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'g'/y. "T, C 4 <o 



TOTI'IED STATES OF AMERICA. 







Mi> 



I* 



^' 



THE 



PBINCIPLES AND PRACTICE 



MEDICINE. 



s 



i 



JOHN ^LLIOTSON, M.D., C. 



F.R.S, 



/AlfTAB., 

President of the Royal Medical and Chirurgical Society; 

President of the Phrenological Society; 

Late Professor of the Principles and Practice of Medicine, and of Clinical Medicine, 

and Dean of the Faculty of Medicine, in University-College, London; 

Late Senior Physician to the XJniversity-College-Hospital ; 

Fellow of the Royal College of Physicians ; 

Formerly Physician to Saint Thomas's Hospital, 

And President of the Royal Medical Society of Edinburgh. 



EDITED BY 



NATHANIEL ROGERS, M.D. 

Member, and late President, of the Hunterian Society of Edinburgh ; and Corresponding Member 
of the Medico-Chirurgical Society of Dublin; 



^ 



ALEXANDER COOPER LEE. 



FIRST AMEEICAN, FROM THE SECOND LONDON EDITION, 
GREATLY ENLARGED AND IMPROVED. 



WITH NOTES AND ADDITIONS BY 



THOMAS STEWARDSON, M.D. 

PHYSICIAN TO THE PENNSYLVANIA HOSPITAL. 




PHILADELPHIA: 

CAREY AND HART 

1844. 



ix-^. 



^^.><^ 



"^<eA^ 



Entered according to act of Congress, in the year 1843, by 

CAREY AND HART, 

In the office of the Clerk of the District Court for the Eastern District of Pennsylvania. 



^"yJ-i 9f 



T. K. & P. G. Collins, Primers. 



TO 

HENRY, LORD BROUGHAM, 

BARON BROUGHAM AND VAUX, F.R.S., 
MEMBER OF THE NATIONAL INSTITUTE OF FRANCE; 

THE ABLE, LIBERAL, AND ENLIGHTENED PROMOTER OF KNOWLEDGE 

IN ALL ITS DEPARTMENTS; 

TO WHOM 

THE LITERATURE OF THE COUNTRY IS INDEBTED FOR SOME 

OF ITS BRIGHTEST ORNAMENTS; 

AND 

THE COUNTRY ITSELF FOR SOME OF ITS BEST LAWS ; 

WHOSE EXERTIONS 

THROUGH THE PRESS, AT THE BAR, AND IN THE SENATE, 

HAVE RAISED FOR HIM 

"A MONUMENT MORE DURABLE THAN BRASS;" 

WITH 

PROFOUND ADMIRATION OF HIS TRANSCENDENT TALENTS, BUT STILL GREATER 

RESPECT FOR THEIR APPLICATION, 

THIS VOLUME IS INSCRIBED. 



PREFACE TO THE SECOND EDITION 



When this Work first appeared, it had to compete with several long 
established favourites, and to encounter some deeply-rooted prejudices on 
the part of men who strongly dissented from Dr. Elliotson's views on 
certain subjects. In spite of these obstacles, however, its reception has 
been more flattering than we dared to anticipate. The first impression 
was rapidly exhausted; it became the favourite class-book in the majority 
of our Medical Schools; and even those who were formerly strongly pre- 
judiced against it, have since acknowledged the practical information they 
have derived from its perusal. All this is highly satisfactory; and were 
any additional proof of its sterling worth required, it would be furnished 
by the fact that the Germans have published a translation. 

In entering on the task of preparing for publication a Second Edition, 
we have been stimulated by the success of the first to fresh exertions, in 
order to render it (if possible) still more worthy of the approbation it has 
received. With a view to the accomplishment of this object, we have 
ventured on making certain additions and alterations; which, without 
materially increasing the size of the book, will (as we believe) materially 
enhance its value. Much care and discrimination were necessary in 
making these additions,— both as to the materiel to be selected, and the 
mode of its insertion; otherwise the book would have been injured, rather 
than improved. We have therefore been careful only to remedy obvious 
deficiencies, and to make such other additions as more recent researches 
had rendered necessary. The sources whence this supplementary matter 
has been taken are various; but we have of course been guided, to a 
great extent, by public opinion; — making our selections from those works 
which seemed best entitled to our confidence, for their general accuracy 
and soundness of doctrine. For the purpose of rendering these additions 
as useful as possible, it has been deemed advisable to insert them within 
brackets, in the text; taking care, however, to preserve the continuity of 
the whole; and to acknowledge, in a foot-note, the source whence each 
quotation was derived. Some other illustrative extracts, often very in- 
teresting in a literary point of view, and all bearing on some medical 
observations in the text, have been inserted as foot-notes. 

The alterations that have been made, though few, are such as have 



VI PREFACE TO THE SECOND EDITION. 

been dictated by a desire to consult the convenience of the Reader. The 
subjects have been grouped together, in conformity with Dr. ElUotson's 
own views; and divided into Parts, Books, Chapters, and Sections. Page- 
headings and side-titles have been introduced; and, together with a co- 
pious Index, will (it is hoped) enable the Reader to refer to any particular 
passage with perfect ease. 

These are the alterations we have deemed it necessary to make. In 
the performance of our task, we have been actuated (at every step) by a 
sincere and ardent wish to render the volume worthy of the reputation 
which Dr. Elliotson has so justly acquired, both as a teacher and Physi- 
cian. In working out this design, we have received every assistance from 
the enterprising publisher, who has spared no expense either in the lite- 
rary or the printing department; — being anxious to raise this distinguished 
member of his series of Medical Text-Books to a degree of excellence 
commensurate with the favour it has received. Whatever approbation 
or censure may be bestowed on our labours as Editors, we feel quite 
certain that the valuable materials contained in this book, will always 
meet with the respectful consideration due to genius and industry, when 
directed to the alleviation of human misery. 



PEEMCE OF THE AMERICAN EDITOE. 



. In the last London edition of Dr. Elliotson's Lectures, numerous addi- 
tions have been made, with the view of giving to the work the character 
of a complete Treatise on the Practice of Medicine, suited to the purposes 
of a text-book. Most of these have been retained, whilst at the same time 
the work has been still further enlarged. In particular, it has been thought 
necessary to give a more extended space to the consideration of Remittent 
and Yellow Fevers, which, as the reader will observe, are but cursorily 
treated of by Dr. Elliotson. A separate article, by the American editor, 
has therefore been devoted to each of these affections. His other addi- 
tions, with the exception of a few foot notes, are included within brackets, 
and bear his initials. 

T. S. 
Philadelphia, October 18, 1843. 



CONTENTS 











Pago 


Dedication ........ iii 


Preface .... 








V 


Introduction . . . . 








17 


General Pathology .... 








33 


Section I. Nature of disease 








34 


11. General nosology 








40 


III. iEdology 








42 


IV. Semeiology . 








49 


V. General treatment of diseases 






66 


VI. Methodical nosology 






.. 69 


PART I. 











GENERAL DISEASES. 



Chapter I. Inflammation .... 

Section I. General definition 

II. Appearances after death 

III. Pathology of inflammation 

a. Microscopic condition of the capillaries 
h. Pathological changes in the state of the 

IV. Course of common inflammation 
V. Results of inflammation 

VI. Varieties of inflammation 
VII. Causes of inflammation 
VIII. Diagnosis and prognosis of inflammation 
IX. Treatment of inflammation 
a. Active inflammation 
h. Atonic and passive inflammation 

c. Chronic inflammation 

d. Terminations of inflammation 

e. Specific inflammation 

Chapter II. Haemorrhage .... 

III. Profluvia ..... 

IV. Dropsy ..... 
Section I. General pathology of dropsy 

II. Acute or febrile dropsy 

III. Renal dropsy 

a. Morbid appearances of the kidney 
h. Signs of renal dropsy during life 



capillar 



les 



71 
73 

79 

82 

83 

85 

87 

94 

106 

112 

117 

118 

118 

130 

131 

133 

135 

136 

144 

146 

147 

154 

156 

156 

158 



CONTENTS. 









Page 


c. Characters of the urine in renal dropsy . . 159 


d. Changes in the blood in renal dropsy 




162 


e. Complications of renal dropsy 




163 


Section IV. Cardiac dropsy 






166 


V. General treatment of dropsy- 






171 


Chapter V. Deficient secretions 






175 


VI. Changes of structure 






176 


Section I. Induration . . 






176 


II. Softening .... 






178 


III. Hypertrophy ... 






180 


IV. Atrophy .... 






183 


Chapter VII. Transformations of structure 






184 


VIII. New formations . 






189 


Section I. Tubercles 






190 


II. Carcinoma 






195 


«. Scirrhus, or carcinoma simplex 






197 


b. Encephaloid disease 






203 


c. Carcinoma alveolare 






206 


III. Melanosis 






210 


IV. Kirrhonosis . 






214 


PART II. 









UNIVERSAL DISEASES. 



Chapter I. Anaemia . . . . . 






217 


II. Chlorosis . . . . . 






218 


III. Scurvy . . 






225 


IV. Intermittent fever . . . . 






233 


Section I. Symptoms and varieties . 






234 


II. Complications and effects 






240 


III. Causes 






243 


a. Predisposing causes . 






243 


- b. Exciting cause 






245 


c. Proximate cause 






266 


IV. Diagnosis and prognosis . 






268 


V. Treatment 






269 


a. During the paroxysm 

b. During the intermission 






270 

272 


Chapter V. Continued fever 






284 


Section I. Symptoms and prognosis 






284 


II. Local complications . 






290 


III. Morbid appearances . 






292 


IV. Diagnosis and prognosis 






296 


V. Causes 






298 


a. Remote causes 






298 


b. Contagion 






299 


c. Proximate cause . 






316 


VI. Treatment 






320 


Chapter VI. Remittent fever 






332 


" " (Dr. Stewardson) 






338 


Yellow fever ( " *' ) 






354 



CONTENTS. 



XI 



PART III. 
LOCAL DISEASES. 



BOOK I.—CUTANEOUS DISEASES 

Chapter I. Papulse 

Section I. Strophulus 
II. Lichen 
III. Prurigo 
Chapter II. Exanthemata 
Section I. Roseola 

II. Erythema 

III. Urticaria 

IV. Rubeola 
V. Scarlatina 

VI. Erysipelas 
Chapter III. Squamae . 

Section I. Pityriasis 
II. Lepra 
III. Psoriasis 
Chapter IV. Vesiculse . 
Section I. Miliaria 
II. Herpes 

III. Eczema 

IV. Scabies 

V. Pompholyx 
Chapter V. Pustulae 

Division L Chronic pustular eruptions 
Section I. Impetigo 
II. Ecthyma 

III. Rupia 

IV. Porrigo 
Division 2. Acute pustular diseases 

V. Variola 
VI. Vaccinia 
VII. Varicella 
Division 3. Tubercular eruptions 
VIII. Acne 
IX. Sycosis 
Division 4. Boils . 
X. Plague 

XI. Malignant Pustule 
XII. Equinia 

a. Appearances and varieties in the lower animals 

b. Appearances and varieties in man 
Chapter VI. Purpura . 

VII. Discolorations of the skin . 
VIII. Organic diseases of the skin 
Section I. Lupus 

II. Elephantiasis 

III. Ichthyosis 

IV. Framboesia 
Chapter IX. Diseases of the appendages of the skin 

X. Diseased secretions of the skin 



Pagre 
363 

366 

367 

369 

370 

374 

374 

375 

377 

381 

387 

397 

402 

403 

404 

406 

408 

408 

410 

411 

412 

415 

417 

417 

417 

419 

420 

421 

425 

425 

438 

445 

446 

446 

448 

448 

449 

455 

456 

461 

462 

466 

467 

469 

469 

470 

472 

474 

475 

476 



XU CONTENTS. 




BOOK II.— DISEASES OF TEE NERVOUS SYSTEM . 


Page 

477 


Chapter I. Phrenilis 


481 


Section I. Symptoms ..... 


482 


II. Milder forms .... 


484 


III. Morbid appearances . . . 


486 


IV. Causes ..... 


491 


V. Diagnosis . ; . . . 


493 


VI. Prognosis . . . . . 


497 


VII. Treatment . . . . . 


498 


Chapter II. Hydrocephalus . . . . . 


500 


Section I. Acute hydrocephalus .... 


501 


II. Chronic hydrocephalus 


507 


Chapter III. Apoplexy ...... 


512 


Section I. Symptoms ..... 


512 


II. Morbid appearances .... 


515 


III. Causes 


518 


a. Predisposing causes 


518 


h. Exciting causes .... 


519 


IV. Treatment ..... 


522 


Chapter IV. Cerebral affections from remote causes 


526 


Section I. Cerebral symptoms from intestinal irritation . 


526 


II. Cerebral symptoms from exhaustion . 


526 


a. Spurious hydrocephalus . . . , 


528 


h. Apoplexia exsanguinea . . . . 


529 


III. Effects of a shock, mental or physical 


530 


IV. Delirium tremens . . . . . 


531 


V. Cerebral symptoms from chlorosis, &c. 


535 


Chapter V. Tumours in the brain . . . . . 


536 


VI. Atiections of the intellect . . . . . 


538 


Section I. Malformations of the brain . . . . 


538 


II. Idiocy ...... 


540 


III. Insanity ...... 


546 


a. Varieties ...... 


546 


h. Symptoms and progress . . . . 


560 


c. Morbid appearances . . . , 


562 


d. Causes ...... 


568 


e. Diagnosis and prognosis . . . . 


573 


/. Treatment . . . . . 


575 


1. Physical treatmeyit . . . . 


575 


2. Moral management . . . . 


577 


Chapter VII. Affections of the spinal cord . . . . 


583 


Section I. Spinal irritation . . . . . 


584 


II. Inflammation within the spine 


588 


III. Spinal ajfoplexy 


590 


IV. Spina bifida ...... 


590 


Chapter VIII. Convulsions . . . , 


591 


IX. Epilepsy ...... 


51;'3 


Section I. Progress and varieties . . . . 


593 


II. Causes ...... 


601 


III. Morbid appearances . . . . . 


603 


IV. Diagnosis and prognosis . . , . 


604 


V. Treatment ...... 


605 


Chapter X. Hysteria ....... 


609 


Section I. Catalepsy ...... 


615 


II. Trance . . . . . . 


618 



CONTENTS. 








Xlll 


Section III. Lethargy . . . ... .619 


Chapter XT. Diseases of motion 








620 


Section I. Paralysis agitans 








620 


II. Chorea 








623 


III. I^eaping ague 








626 


Chapter XII. Tetanus 








628 


Section I. Symptoms and progress 








623 


II. Causes 








630 


III. Diagnosis and prognosis 








633 


IV. Treatment 








633 


Chapter XIII. Hydrophobia 








637 


Section I. Symptoms and progress 








637 


II. Pathology and causes 








641 


III. Diagnosis 








647 


IV. Treatment . . 








649 


Chapter XIV. Neuralgia 








652 


XV. Paralysis 








659 


Section I. Hemiplegia . 








664 


II. Paraplegia 








673 


III. General treatment of paralysis 






674 


IV. Local palsies 


- 






676 



BOOK m.— DISEASES OF THE RESPIRATORY ORGANS 



683 



Chapter I. Bronchocele 

IL Affections of the mouth and throat . 
Section I. Parotitis 
II. Tonsillitis 

III. Stricture of the cesophagus 

IV. Inflammation of the mouth 

a. Pustules in the mouth 

b. Jlphthse 

c. Stomatitis mercurialis 

d. Stomatitis ulcerosa 
V. Gangrsena oris 

VI. Fetid breath . 
VII. Ear-ache 
Chapter III. Diagnosis of pulmonary diseases . 
Section I. Examination by sight and touch 
II. Percussion 
in. Auscultation . 

a. Auscultation of the respiration 
J). Auscultation of the voice . 
c. Pleural friction- sound 
IV. General remarks 
Chapter IV. Diseases of the larynx and trachea 
Section I. Acute laryngitis 

II. Chronic laryngitis 
m. Croup 

IV. Organic affections of the larynx and trachea 
V. Catarrh 
VI. Spasmodic affections of the larynx 

a. Laryngismus strididus 

b. Nervous affections of the larynx in the adult 



683 

690 
690 
691 
694 
695 
695 
695 
696 
697 
698 
700 
701 
701 
703 
703 
707 
709 
713 
714 
715 
716 
716 
721 
724 
730 
730 
733 
733 
735 



XIV 



CONTENTS. 



Chapter V. Bronchitis . 

Section I. Acute bronchitis 

II. Asthenic bronchitis 

III. Chronic bronchitis 

IV. Effects of chronic bronchitis 

a. Dilatation of the air-tubes 

b. Diminution of the air-tubes 

c. Dilatation of the air-cells , 
Chapter VI. Pneumonia 

VII. Gangrene of the lungs 
VIII. Haemoptysis 

Section I. Haemorrhage from the air-passages 
II. Haemorrhage from the air-cells 
III. Treatment of haemoptysis 
Chapter IX. Functional diseases of the lungs 
Section I. Asthma 

II. Hooping-cough 
Chapter X. Phthisis pulmonalis 

Section I. Pathology of phthisis 

II. Symptoms and progress of phthisis 

III. Diagnosis and prognosis of phthisis 

IV. Causes of phthisis 
V. Treatment of phthisis 

Chapter XI. Diseases of the pleura 
Section I. Acute pleuritis 

II. Chronic pleuritis 

III. Hydrothorax 

IV. Pneumato-thorax 
V. Hydro-pneumato-thorax 

VI. Organic affections of the pleura 

BOOK IV,— DISEASES OF THE HEART 

Chapter I. Pericarditis .... 

II. Disease of the lining membrane of the heart 
Section I. General inflammation of the membrane 
II. Diseases of the valves 

III. Effects of diseased valves on the circulation 

IV. General symptoms of obstructed circulation 
Chapter III. Disease of the substance of the heart 

Section I. Carditis .... 

II. Hypertrophy and dilatation 

III. Aneurism of the heart 

IV. Chronic changes, the result of inflammation 
V. Rupture of the heart . 

VI. Structural diseases of the heart 
VII. Neuralgia of the heart 
Vni. Angina pectoris 
Chapter IV. Diseases of the aorta 

Section I. Aortitis .... 

II. Aneurism of the aorta 



Pagfe 
7a7 
737 
741 
742 
747 
747 
748 
749 
751 
759 
761 
762 
763 
767 
768 
768 
780 
785 
786 
788 
796 
797 
800 
807 
807 
810 
816 
817 
818 
822 



824 

824 
831 
831 

833 
835 
846 
851 
851 
852 
858 
861 
862 
864 
866 
866 
868 
868 
868 



BOOK V.~DISEASES OF THE CHYLOPOIETIC VISCERA . 873 

Chapter I. Diseases of the periton&um ..... 873 
Section I. Peritonitis ...... 873 



CONTENTS. 






xv 


Pa^e 
Section II. Enlargement of the mesenteric glands . . . 876 


III. Ascites .... 






877 


IV. Organic diseases of the peritonaeum . 






879 


Chapter II. Diseases of the pancreas 






882 


III. Diseases of the spleen . • . 






883 


IV. Diseases of the liver 






885 


Section I. Hepatitis 






885 


II. Structural diseases of the liver 






888 


III. Jaundice 






891 


IV. Biliary calculi 






896 


V. Diseases of the gall-bladder . 






898 


Chapter V. Pathology of the stomach and intestines 






898 


VI. Diseases of the stomach 






904 


Section I. Acute gastritis 






904 


II. Chronic gastritis 






907 


a. Ulceration of the stomach 






908 


b. Rupture of the stomach 






908 


III. Structural diseases of the stomach 






910 


IV. Haematemesis . . 






912 


Chapter VII. Diseases of the intestines . 






913 


Section I. Enteritis 






913 


II. Colic 






915 


III. Paralysis after lead-colic 






918 


IV. Intus-susception 






919 


V. Dysentery ... 






920 


VI. Diarrhoea 






926 


VII. Discharge of fatty matters 






. 930 


A^III. Gastro-intestinal concretions . 






932 


Chapter VIIL Cholera 






935 


Section I. English cholera 






935 


Cholera infantum (Dr. Stewardson) 






937 


Epidemic cholera 






938 


Chapter IX. Disorders of the digestive organs . 






944 


Section I. Symptoms 






945 


II. Causes 






949 


HI. Treatment 






951 


Chapter X. Worms .... 






959 


Section I. Ectozoa 






959 


II. Entozoa 






960 



BOOK VI.— DISEASES OF THE URINARY ORGANS 



969 



Chapter I. Diseases of the kidney 
Section I. Nephritis 
II. Haematuria 
HI. Organic diseases of the kidney 
Chapter II. Functional disorders of the kidney . 
Section I. Ischuria 
II. Diabetes 

HI. Excess of urea in the urine . 
IV. Serum, chyle, and fat in the urine 
Chapter HI. Calculous diseases 

Section I. Urinary sediments 

a. Amorphous sediments 

b. Crystallized sediments 



969 
969 
970 
972 
974 
974 
976 
985 
986 
987 
987 
988 
990 



XVI 



CONTENTS. 









Page 


Section II. Urinary calculi . . . . .991 


III. Calculous diathesis 






994 


a. Lithic-acid diathesis 






995 


b. Oxalate-of-lime diathesis . 






997 


c. Cystic-oxide diathesis 






998 


d. Phosphatic diathesis 






999 


IV. Calculi in the bladder 






1001 


Chapter IV. Diseases of the bladder 






1004 


Section I. Cystitis 






1004 


II. Cystorrhcea . 






1004 


III. Structural diseases of the bladder 






1005 


IV. Paralysis of the bladder 






1006 


V. Disease of the prostate 






1006 



BOOK VII.— DISEASES OF THE FIBROUS TISSUES 



1008 



Chapter I. Gout 

II. Rheumatism 



1008 
1013 



THE 



PRINCIPLES AND PRACTICE 



OF 



MEDICINE. 



INTRODUCTION. 



The Art of Medicine is to be perfected, I conceive, by improvements in our 
knowledge of the nature of diseases, by improvements in diagnosis, and by im- 
provements in our acquaintance with remedies and their application. 

Anatomy. — Improvements in our knowledge of the nature of diseases must be 
obtained through the cultivation of Anatomy and Physiology, and of Morbid Ana- 
tomy and Morbid Physiology ; or, in other words, from an acquaintance with the 
derangements that take place in structure and function, it is evident that no one 
can be acquainted with a disease, unless he is acquainted, more or less, with the 
part diseased, — -its situation, form and structure ; and the more accurate and minute 
his acquaintance with these, the greater, casteris paribus, will generally be his 
knowledge of the nature of its lesions. I say ^^cmteris paribus;^^ iDecause a know- 
ledge of mere Anatomy, however accurate and minute, does not imply a knowledge 
of disease (its symptoms, history, and causes), or skill in treating it; — any more 
than a knowledge of the alphabet, and the ability to read, imply a literary charac- 
ter: and nothing can be more absurd than for the public to presume that a man is 
a good practitioner, merely because he is a good anatomist. An anatomist is not 
necessarily even a physiologist; and Mery was accustomed to say, — "We anato- 
mists are like the porters of Paris; who are all well acquainted with all its streets, 
as well as all its lanes and alleys, but know nothing of what passes within the 
.houses."* The most assiduous examination of only the dead body, can disclose 
but little of the functions and properties of the living. The structure of the brain 
would never teach us that it is the organ of feeling and thought; or of the kidney, 
that it produces a fluid containing lithic acid and urea. The sympathy existing 
between the nasal membrane and diaphragm, and between the kidneys and surface; 
the curious phenomena resulting from contagions and malaria; the various morbid 
actions to which various parts are liable (the innumerable diseases of the nervous 
system, for instance); the susceptibility of various parts to the operation of various 
agents during health (such as of the mouth to the operation of mercury, and of the 
'stomach to that of ipecacuanha); the peculiar power of certain substances over cer- 
tain diseases (as of quinina over intermittent fever); — all this would never be sus- 
pected at the dissecting-table. And I cannot refrain from remarking, that for any 
one to pride himself upon his knowledge of established Anatomy, would be ex- 
ceedingly weak; as it requires no preparatory philosophical education, and no in- 

aRees's CyclopiBdia; Article "Mery.'*' 
VOL. I. — 2 



18 INTRODUCTION. 

tellectnal exertion; but rtierely the possession of eyes and memory, and a willinsf- 
riess to em ploy them. Dr. M'Culloch, in his powerful, thonah (1 must be pardoned 
in saying) occasionally extravag'ant, work, apologizes for not arranging liis cases 
anatomically; on the ground that it would have savoured of pedantry; — "a small 
pedantry," he says, '-far too common; as if any man could not make himself mas- 
ter of Hutnan Anatomy in a few weeks, as well as of any other tangible and de- 
monstrable substances."'' But if it would be laughable for any one to pride himself 
on his knowledge of Anatomy, it is culpable in a physician not to be a good anato- 
mist. Oiherwise he cannot comprehend the phenomena of many diseases. He 
cannot, for example, understand why, in partial paralysis of the head, sometimes 
only certain muscles cease to obey the will; — wliy loss of sensation sometimes oc- 
curs alone, and why to only a certain extent; — why the pain of the neuralgia takes 
a particular course; — or why, in disease of the heart, unusual varieties of sound 
and impulse are obseivable in particular portions of the cardiac region. He cannot 
possess any but the most superficial knowledge of Morbid Anatomy; the cultiva- 
tion of the far greater and more important part of which is peculiarly the duty of 
the physician, who treats the chief morbid states of the' most important organs of 
the body; and not of the surjreon, who does not even witness their symptoms. He 
will, therefore, either neglect to complete the investigation of his unsuccessful cases, 
by examination after death, or be unable to appreciate what presents itself, and 
perhaps be indebted to an active surgeon for information. He cannot otherwise 
be a good physioloaist; for, although Anatomy alone will seldom teach the opera- 
tions of an organ, these can manifestly not be known, unless the organ i;self is un- 
derstood. 

Physiology. — The importance of Physiology requires no argument in its sup- 
port; for, except in obvious structural or mechanical changes, the symptoms of 
disease are chiefly Morbid Physiology; and therefore, to quote the familiar passage 
of Galen, — "The magnitude of a disease is proportionate to its deviation from the 
natural state; and he only knows the extent of the deviation who knows exactly 
what is the natural state." Et^ oaov yd^ l^ictaiaL ty^? ^vcJecoj sxaatovi si^ tosovto xai 
fisysOov^ vjxBi. To 8'6gov ^^latatai, yvujvav 6vvat6v fMOvqi ta to xa-ta ^vGiv^ axpijSCoi 
STiiata/jiiva).^ And again, Mtj 8vvars9av ruva xa'kCj^ Id&aaOat ta vo^rnxata, Ti^lv b'kov to\) 
(jtO|ita-r'oj iriKSxi'^aaeai f^ •fi^on^.'' Wilhotit a thorough acquaintance with both the 
natural structure and the functions, a thousand highly interesting deviations will 
never be recognised in the cases which come daily before us. 

Pathology. — If such is the importance of Anatomy and Physiology to every 
physician, it will not be disputed that, in order to advance our knowdedge of the 
nature of diseases, these sciences should be improved to the utmost. But however 
necessary these foundations (Anatomy and Physiology), the grand source of this 
knowledge is the observation of the phenomena of diseases, — their symptoms, his- 
tory, and causes (in other words. Pathology), and of their structural lesions (in 
other words, Morbid Anatomy). No one expresses a doubt respecting the import- 
ance of Pathology; — the importance of observing the symptoms, and tracing the 
history of diseases; and of investigating their pecidiarities, analogies, and causes. 
Yet, in all this, how liable are we to error! How patient and searching an eye is 
required to note all the phenomena of a disease; — to perceive what is essential to 
its existence, and what is only Incidental! How profound a judgment to reason 
upon these phenomena, and to investigate their causes; — to discern the analogies 
between alTections which, at first sight, are perfecdy distinct! And, at the same 
time, how cool should be the judgment duly to appreciate all fanciful analogies, all 

a"Mar.sb Fever and Neuralgia;" Volume 2; Page 104. 

••"As is the degree of devi<Uion from nature, so is the magnitude at which the disease 
arrives; but the amount of this derangement can be ascertained only by him who is accu- 
rately acquainted with the natural slate." — ^^MeLhodus Medendi ad Glauconem.;^ Liber 1; 
Caput I. 

c "Ii is impossible for any one to cure diseases perfectly, without having previously well 
examined the constitution of the whole body." — ^'Metkodus Medendi;'^ Liber Ij Caput 1. 



INTRODUCTION. 19 

hypolhelical suggestions! Exactly the same difficiiUles surround Morbid Anato- 
my; but in its case they are alleged, by some, as rbjeclions to its prost^cution. But 
how could any affection beneath the surface of the body have been understood, 
without an ocular investigation of the parts affected? How could pain in the chest, 
dyspnosa, cough, and pyrexia, have bren known as signs of inflammation of the 
kings or their membranes, unless the examination of persons who died under these 
symptoms, had proved such a lesion to be frequendy their cause? If knowledge 
can be thus obtained, why not obtain the utmost possible? True it is, that inci- 
dental morbid appearances have often been mistaken as necessary and constant; and 
that some even pretty constant appearances have often been absurdly announced as 
the essence of the disease, when they were merely its effect, or (at the utmost) only 
among the number of its piienomena. Equally true it is, that chang-es after dealk 
have been mistaken for morbid appearances; as was pointed out by Dr. John Davy 
in the case of redness from imbibition of blood.* But such errors, surely, afford no 
reason for neglecting careful and extensive examinations of diseased parts, and draw- 
ing just inferences as to the connection of the change of colour or structure with 
the (Hsease; — they supply no reason for not cultivating so ample a field of know- 
ledge scientifically. If a disease be accompanied by a change of structure or appear- 
ance ivit/im the body, surely this change, as a fact in the disease, is worthy of 
notice; — as worthy as visible changes in the skin, the mouth, or the eyes; which 
changes are always carefully described by these objectors, even when merely se- 
condary effects; though they differ from the Aicts of Morbid Anatomy, only in the 
accident of bemg coornisable without dissection; while they are not a whit more 
necessary to a perfect history of a disease, and are much less in number; — owing to 
the circumstance of nearly all our organs being concealed from view. After some 
diseases, indeed, no change of structure or appearance is discernible. But even 
here, extensive anatomical investigation is important; for it often prevents us from 
forming groundless hypotheses, as to the seat and nature of such affections. Hy- 
drophobia might be referred to the stomach, were it not that the red patches, which 
are sometimes seen in this organ after the disease, are frequently not to be detected. 
Tetanus might be thought always to arise from inflammation of the spinal marrow, 
were not this part frequently found free from inflammation in tetanic patients. It 
discloses to us a fact which we might otherwise have doubtetl; — that diseases may 
be only functional, as well as structural; — that, in the words of one of the most in- 
telligent and industrious cultivators of Pathology and Morbid Anatomy (Dr. Andral), 
— "it is one of the most serious errors to which the ill-directed study of Morbid 
Anatomy can lead, to admit no other alteration in the economy, than those which 
are discoverable by the scalpel."^ We learn, in short, to form a just estimate of 
Morbid Anatomy; — that it is an important part of the basis, but by no means the 
^'main basis" of Pathology. 

Diagnosis of Diseases. — But if our art is to be perfected by a better acquaint- 
ance with the nature of diseases, it is not less to be perfected by improvements in 
distinguisliing them; — by improvements in diagnosis. '^ 'I'he diseases of the lungs 
and their membranes, are as well understood as any of the body; yet the best prac- 
titioners continually fail in distinguishing them. They often fail, for instance, to 
distinguish one form of chronic bronchitis from hydrothorax; the treatment of which 
diseases may be totally different. So important is diagnosis, that it has become a 
proverbial saying, — "The knowledge of a disease is half the cure." Diagnosis also 

' "Transactions of the Medical and Chinirgical Society of London;" Volume 10; Page 89. 

""Clinique Medicale;" Tome 3; Page 510. 
_ <= On ihis subject we beg to refer the reader to Dr. Marshall Hall's "Treatise on Diagno- 
sis." It is now incorporated with his "Principles of the Theory and Praciice of Medicine.** 
Dr. Cowan, in his "Bedside Manual of Physical Diagnosis," lias given, in a very portable 
form, the phy?>ical signs of the diseases which affect the folluwing important parts:— 1. Lungs 
and Pleura. 2. Pleart and Pericardium. 3. Vascular System. 4. Abdomen, Osseous Sys- 
tem, and Auditory Apparatus. The physical signs are chiefly furni.shcd by auscultation and 
percussion. 



20 INTRODUCTION. 

is to be improved, not only by a better acquaintance with the symptoms and history 
of diseases, but by a better acquaintance with Morbid Anatomy; so that the cor- 
respondence between symptoms and local lesions may be established, and tlius the 
affection clearly ascertained. As HealtJiy Anatomy is the foundation of Morbid 
Anatomy, and Physiology is the foundation of Pathology, the importance of these 
also to improvements in diagnosis is apparent. 

Laennec's Discoveries. — The discoveries made by Laennec with respect to dis- 
eases of the heart and lungs,* are great enough to entitle him to all the honours which 
have ever been acquired in our profession. He has enabled us to judge of diseases, 
which are otherwise often not distinguishable with certainty, or even at all; and 
this with an accuracy inconceivable to those who are unacquainted with his inves- 
tigations. He has enabled us to distinguish diseases of the heart, which were for- 
merly, and are sldl, too often either all expressed by the easy term — "disease of the 
heart," — without any specification of the part of this complicated organ affected; 
or are as often passed over entirely; — the case being mistaken for hydrothorax, or 
some pulmonary affection. He has also enabled us to distinguish diseases of the 
lungs which, in many cases, could not be pronounced upon with accuracy; and 
others of which the diagnosis was always uncertain. Moreover, we can point out 
the very part afTected. 

But Laennec's discoveries are objected to on the very ground of their accuracy. 
We are asked — "C?n bono?'''' ("Of what use are they?") The answer is plain. It 
is universally allowed that every disease should be described, and its nature ascer- 
tained, as accurately as possible. Now, with every advance in accuracy of descrip- 
tion, and in knowledge of the source of symptoms, diagnosis imperceptibly and 
inevitably becomes more accurate. To condemn accurate diagnosis, therefore, is to 
condemn accurate knowledge^ — to rest satisfied with imperfect information, when 
industry would give us more; — to admire ignorance, when knowledge is wiihin 
our reach. 

The art of diagnosis ought to be universally cultivated, without reference to its 
utility ni particular instances. It is part of our science; every part must be culti- 
vated for the perfection of the whole; and what may not be practically useful to- 
day, may become so to-morrow. How many discoveries in Chemistry and Phy- 
sics appeared, at first, to be objects of mere curiosity; but have afterwards been 
applied to the most important purposes! Plato possessed so exalted a feeling for 
science on its own account, that he considered the applications of geometry to prac- 
tical purposes, as far inferior to its philosophy;'' and those who may see no reason 
for being so deeply enamoured of science as that, must allow that there is every 
reason to remember the words of Jesus, the son of Sirach: — "None may say — 
'What is this?' — 'Wherefore is that?' — for, at time convenient, they shall all be 
sought out."*" In improving diagnosis, it is impossible to discover only what is ob- 
viously useful. The research nmst be made generally; and what is at once useful, 
and what is not, must turn up together. In the diseases of other organs, we 
always aim at accuracy of diagnosis, without any hope of utility. When a solid 
tumour exists in the abdomen, we endeavour to ascertain whether it is the liver, the 

» See his celebrated Treatise, entitled— "De TAuscultation Mediate; ou Traite du Diag- 
nostic des Maladies des Poumonsetdu Cceur; fonde principalement sur ce Nouveau Moyen 
d'Exploration." ("Treatise on the Diagnosis of Diseases of the Lungs and Heart; chiefly 
founded on a New Mode of Investigation,— Mediate Auscultation.") This work is princi- 
pally known lo the English reader through the medium of Dr. Forbes's Translation; — a 
work which is enriched with many valuable notes. 

^ Olnovv el fxh ov^Iav avayna^ii Qiaa-acrQcti^ TT^OiTiiJtEi, el Je yivea-iv, ov TT^oa-mei. wc yao TT^Arrovreg rs nal 

TTavrct ovTM <Ji>9eyyofjt.svoi' to S"' Ij-ti ttou rclv to /i*,a6rifxa yvclos-ioo:; I'vsKa fiTirn^evofxevov. — ITOAITEIA. Liber 

vii. ("We must not, therefore, if compelled to eoniemplate, on the one hand, an actual being, 
say — 'It is fitting;' and if we contemplate, on the one hand, the origin of that being, say — 
*It is.not fitting;' for they speak as intriguing advocates, who utter all their speeches with a 
sinister design;— squaring, stretching, adding, and asseverating without scruple; but every 
scientific pursuit is cultivated for the sake of knowledge.") 
e "Ecclesiasticus;" Chapter 39; Verse 17, 



INTRODUCTION. 21 

spleen, the pylorus, an ovarium, a new formation, or something else; although the 
treatment would probably be the same in all. 

Auscultation and Percussion.— ^uX therein immediate utility in the discoveries 
of Avenbrugger* and Laennec. No one will pretend that, in chronic diseases of 
the chest — with the exception, perhaps, of phthisis — ihe diagnosis is generally 
satisfactory. Before I adopted auscultation, I frequently discovered disease of the 
heart after death, where I had not previously suspected it; and frequently found 
the organ sound, when I had supposed it diseased. When I was correct in ex- 
pecting to see organic affection of the heart, I was often wrong as to the precise 
nature of the lesion. Too often has auscultation at once revealed to me disease of 
the heart, when, by good practitioners, no affection of the heart, or even of the 
chest, had been suspected; or where the case had been named "nervous palpita- 
tion" or "asthma;" — where the lungs had been regarded as the seat of the malady; 
or where the case had been treated with the most violent remedies for hydrothorax. 
Repeatedly have I seen chronic bronchitis with extreme congestion in the lungs 
mistaken for hydrothorax; and this was imavoidable, when percussion and auscul- 
tation were omitted; because the symptoms were precisely the same, with the 
exception of those which percussion and auscultation could alone disclose. Inflam- 
mation of the substance of the lungs often takes place during other diseases, 
without being obvious before death to any but the auscultator and percussor. 
Without the aid of the ear, who can distinguish emphysema of the lungs, or, in 
every case, pneumato-thorax?^ Both may be readily mistaken for hydrothorax. 
The symptoms may be a pallid face, purple lips, orthopnoga, sudden starting from 
sleep to the waking state, a small and intermitting pulse, cold extremities, and 
swollen feet. The remedies of hydrothorax may appear indicated; but the ear will 
discover, on percussion, a hollow sound — far too hollow a sound — in the chest, at 
its very lowest parts; while there is, in the first case, little respiratory murmur, 
and in the second none at all, — at the very place where the hollow sound is heard. 
Nothing but the ear can show the nature of these cases. Nothing but the ear can 
distinguish them from each other. Without the ear, no case (^an be known with 
certainty to be one of hydrothorax, — however marked the symptoms. 

It has more than once happened to me, to be unable to form any opinion as to 
the nature of a disease, without auricular examination. Patients have complained 
of mere debility and loss of flesh, with slight general ailment; and have declared 
themselves free from all local symptoms: — so that nothing but the most random 
guess could be made at their disease, A minute examination of them has disco- 
vered nothing wrong, or nothing materially wrong, in the performance of the 
functions of the head, chest, or abdomen; but, on percussing the chest, the sound 
proved as dead in some part as if the thigh had been struck; and, applying the 
stethoscope, no respiration has been heard, or the voice has rushed through the 
instrument, or an unnatural sound has been heard in the heart; and thus the whole 
mystery has been at once cleared up. In truth, the exact state of the functions of 
the lungs and heart cannot be ascertained, except by the ear; and without an exami- 
nation by its aid, no one is warranted in declaring these functions healthy. I once 

> Avenbrugger's discovery was percussion; and his work on that subject, first given to the 
world in 1761, wasentilled — "Inventum Novum, ex Percussione Thoracis Humani, ut Signo, 
Abstrusos Interni Pectoris Morbos Deiegendi." ("A new Discovery for delecting Obscure 
Diseases of the Chest, by means of Percussion.") A translation of it is given in " Original 
Cases, with Dissections and Observations, illustrating the Use of the Stethoscope and Per- 
cussion in the Diagnosis of Diseases of the Chest. By John Forbes, M. D., Physician to 
the Chichester Dispensary." 

** The name "j9?ie%m<?-thorax," adopted from Itard bv Laennec, is evidently improper. 
Such compound words are always made from the dative singular; — the finsl letter being 
changed into o, if it be any other vowel. We thus have " wier^-gestation," '' cerebros\>\x\^\,'" 
and " hemato-ce\e." The genitive and dative of al.ua (blood) are ai'^a-ro;, alfxart. The geni- 
tive and dative of mivfxa. {air) are TrvEUiwaro?, miufxan] and the compound word should be 
";me?mai5o- thorax." Indeed, we already have "■ fneMviatom]p'kolos''' to signify a person with 
an umbilical hernia; and, what is still closer, we have the word '■'■ 'pneumatocele''' 



22 INTRODUCTION. 

admitted a man into St. Thomas's Hospital, without any friend to give an account 
of him; and so deaf and stupid, that he could scarcely jjive any himself. He com- 
plained merely of occasional coldness, heat, and sweaiing, with debility; declared 
he had been ill but two or tliree weeks; and ascribed his complaint to sleeping in a 
damp bed at Gravesend. The case resembled remittent fever more than any thing 
else; and I treated it wiih sulphate of quinine. The symptoms of remittent fever 
yielded; but the debility reniained, and even increased. 1 investigated the case 
minutely. There were no symptoms of phthisis, or of any other local disease, 
except convexity of the nails; but, on striking the chest, I found the right superior 
part give a dead sound; and in the centre of this I heard pectoriloquism. The case 
was then regarded as one of abundant tubercular deposition in the right lung, with 
an excavation in its centre; and the autopsy showed that the diagnosis was correct. 
The diagnosis, it is true, did not lead to a cure; but it prevented me from plaguing 
the patient wiih medicines, from aji erroneous idea of the nature and seat of the 
disease; and it enabled me to give a correct prognosis. Even when there can exist 
no doubt in the mind of an able practitioner, as to the seat and nature of t'he disease, 
auscultation may prove a useful aid. In consultation, aiiother practitioner, from a 
peculiar bias towards the heart, may consider the symptoms to arise from that 
organ; although they are evidently pulmonic, perhaps even phthisical; and vice 
versa. Or perhaps he may refer unquestionable symptoms of organic pectoral 
disease in general, to the liver, or the digestive organs (according to the reigning 
folly of the day); as is done, continually, with affections of the head and spine. It 
may be impossible clearly to refute him by the ordinary means of diagnosis; and 
yet auscultaiion may furnish some symptoms so decisive as to silence him. 

Auscultation, however, can never justify us in the least neglect of the general 
symptoms and history of a disease. This would indeed be unphilosophical; for 
the symptoms of auscultation, are but one set among a number of others. But if 
it would be unphilosophical to neglect the general symptoms, it would be equally 
so to despise tiiose which present themselves to the ear. If the functions of the 
heart and lungs are naturally performed with peculiar sounds, and if in diseases the 
sounds are altered, these deviations surely demand equal attention with those which 
are discernible by the other senses. Surely the physician requires all his senses 
for the acquisition of knowledge; as much as other prosecutors of natural science. 
We employ our eyes to discern the countenance and general aspect of our patients; 
the changes of the pectoral, intestinal, and renal secretions; and alterations in the 
colour, size, and figure of various parts. We employ our touch to examine the 
pulse; and to ascertain the preternatural presence of fluid, preternatural enlarge- 
ment, diminuiion, or induration. Our smell gives us information as to the depraved 
secretions of fever, as to suppuration, and as to gangrene. In diabetes, some have 
even recourse to the sense of taste. Nay, certain symptoms observable by the ear 
only, are always carefully dwelt upon. Borborygmi, for instance, enter into the 
definition of hysteria; and all the varieties of cough and wheezing are described. 
Why, then, should such sounds as are elicited by striking the chest, or require the 
ear to be brought either into contact with it, or into connection with it by means of 
a solid medium, be despised? The celebrated Hook not only did not despise the 
ear as an inlet of knowledge, but looked forward to the invention of acoustic instru- 
ments, which would enable it to make important discoveries. Indeed, he almost 
prophesied the stethoscoj)e. " There may be a possibility," says he, "of disco- 
vering the internal motions and actions of bodies by the sound they make. Who 
knows but that, as in a watch we may hear the beating of the balance, and the 
running of the wheels, and the striking of the hammers, and the grating of the 
teeth, and multitudes of other noises, — who knows, I say, but that it may be pos- 
sible to discover the motions of the intern-al parts of bodies (whether ani/uai, vege- 
table, or mineral) by the sound they make; — that one may discover the works 
performed in the several offices and shops of a man's body; and thereby discover 
what engine is out of order, what works are going on at several times, and lie still 
at others, and the like. I could proceed further; but methinks I could hardly for- 



OS- 

seetu- 
ot 
e an 



INTRODUCTION. 23 

bear to blush, when I consider how the most part of men will look upon this. But 
yet, again, I liave this encouragement;— -not to ihink all these thing-s utterly imp 
sible, thouah never so much derided by the generality of men, and never so sec. 
ingly mad, foolish, and fantastic; — that, as the thinking them impossible cann 
much improve my knowledge, so the believing them possible may perhaps be l.. 
occasion for taking notice of such things as another would pass by withotit regard, 
as useless. And somewhat more of encouragement I have also from experience; — 
that I have been able to hear, very plaiidy, the beatinij of a man's heart; and 'lis 
common to hear the motion of the wind, to and fro, in the ffuls and other small 
vessels. The stopping in the lungs is easily discovered by the wheezing. As to 
the motion of the parts one amongst another, [in order] to their becoming sensible, 
they require either that their motions be increased, or that the organ [of hearing] 
be made more nice and powerful, to sensate and distinguish them as they are; for 
the doing of both which, I think it not impossible but that, in many cases, there 
may be helps found.""* 

Far be it from the defenders of auscultation and percussion to assert, that the 
diatjnosis of thoracic diseases can never be doubtful. Skill in auscultation requires 
much application; and, even with the greatest, doubt will frequently exist. The 
stethoscope does not render the parietes ol the chest transparent. Percussion and 
auscultation merely open a new set of symptoms to our notice; and, as diagnosis 
is certain in proportion to the number and nature of the facts on which it is founded, 
and the percussor and auscultator, with all the same means of judging as his oppo- 
nents, possesses others in addition, he is better qualified to form an opinion; and, 
though he may sometimes still regret his want of certainty, he knows that by 
shutting his ears, — by levelling himself with his opponents, he augments his un- 
certainty a hundred-fold.'* 

The alleged errors of those who practise auscultation, are no arguments against 
it. Many tales of this description, like those of the errors of phrenologists, have, 
when traced to their origin, proved inaccurate, or even altogeUier destitute of truth; 
and eagerly to catch at them would betray a mind hoping that no fresh knowledge 
is to be attained. Persoiis, it must be remembered, who have no skill will pretend 
to it; and the skilful will sometimes give a hasty judgment; but, as in the case of 
Phrenology, nature is open to us all. Let us examine for ourselves — examine 
carefully and patiently; — not anxious to Und auscultation a deception, but hoping 
to find the promise of new information fulfilled; — not unwilling to learn because we 
are no longer in static pupillari (" in the rank of pupils"); — not so higli in our own 
estimation, as to feel indisposed to be taught by others; — not unphilosophical 
enough to have a hostile opinion upon a matter which observation must decide; — 
not guilty of the inconsistency of lamenting the imperfection of our art, and whining 
about its sad claim to the tide of a conjectural art, while we are too indolent to 
investigate a method which professes to remove much of its uncertainty, is recom- 
mended by men of the greatest talent and the most intense application to the study 
of their profession, bears upon itself the stamp of probability, and the results of 
which are capable of being proved physically necessary.^ 

^ " Method of improving Natural Philosophy." Posthumous Work--; Pagp 30. 

^ Dr. Andral — who nowhere shows a disposition to overrate the value of auscultation, 
and is a highly-informed praciical phvsician of the soundest judgment — savs, in the preface 
to the second part of his " Clinique Medicale,"— " Thanks especiall}^ to the wonderful dis- 
covery of Professor Laennec, the diagnosis of a great number of thoracic affections may be 
frequently established with as much accuracy as that of the least complicated luxation, or 
the simplest fracture. There is a certain number of pneumonic inflammations, in which we 
are able to follow the different phases of the alteration of the lungs, and their return to the 
healthy state, with as strict precision as the eye externally follows the different periods of the 
cicatrization of a wound. There are affections of the heart, in which the nature of the 
organic lesion may be determined by the sense of hearing, almost as accurately as the state of 
a cutaneous tumour may be ascertained bv the eye, or the stale of the neck of the womb by 
the touch. Clinical observation, however, meets with many cases in which diagnosis is 
very obscure; and others, in which the very nature of the afl'eciion is still a matter of dis- 
pute.'' 

« I said, upon another occasion, that "the greatest discoveries have generally been at first 



24 INTRODUCTION. 

Therapeutics. — With respect to the third mode in which I conceive that our art 
must be perfected, — improvements in our knowledge of remedies and their appU- 
cation, — I must be brief. Much remains to be accomplished in the discovery, both 
of the virtues of medicines already in use, and of new medicines, or such modifi- 

ridiculed, and their author?, no less than all the truest benefactors of the human race, have 
been ' despised and rejected of men.' (' Prophecies of Isaiah;' Chapter 53; Verse 3.) 

' Romulus, et Liber Pater, et cum Castore Pollux, 
Dum terras hominumque colunt genus, aspera bella, 
Componunt, agros assignant, oppida condunt, 
Ploravere suis non respondere favorem 
Speratum meritis.' 

('Romulus, and Bacchus, and Castor, and Pollux, while dwelling among men, brought 
to a successful issue many difiicult wars, distributed territories, and built cities; but they 
found that the gratitude excited, was not equal to the benefits conferred.' — Horace's' Epistles;' 
Book 2; Epistle 1; Lines 5, 7, 8, 9, and 10.) 

" Let us remember that Harvey, whose memory we honour, was dishonoured at first by 
his cotemporaries, for the discovery which immortalized his name;— that he lost his prac- 
tice, and — so far from finding comfort among his brethren — left the country, and was lam- 
pooned from one end of Europe to the other; and that no English physician who had attained 
the age of forty at the time, ever (to the end of life) acknowledged the circulaiion of the 
blood. Let us remember that Sydenham, whose memory also we honour, was called a quack 
and a murderer by many of his cotemporaries; whose names, whatever bustle they made 
during their existence, have never once been mentioned since their death. Let us remember 
that the discovery of the lacteals was at first rejected with contempt; — that Bartholin, in a 
letter, says, — ' There is not one among the doctors of Montpellier who acknowledges the 
lacteal vessels; — so wedded are they to the authority of Galen; for which they contend as 
though 'pro aris et focis' ('for their altars and homes,') and disregard the experiments of 
the moderns.' Let us remember that even old Harvey, when the thoracic duct was after- 
wards discovered, could not at once loosen himself from the bonds of early prejudice, and 
give up the prevailing belief that the lacteals all terminated in the liver; and that the very 
Bartholin who saw the folly of the Montpellier doctors, never believed in the exclusive office 
of the thoracic duct. Let us remember that, if the illustrious father of our modern philoso- 
phy, Lord Bacon, was not vilified and imprisoned (like Galileo) for announcing truth, he 
was represented by Cecil to Elizabeth, when she thought of making him her Solicitor- 
General, as ' a man of mere speculation;'— as one wholly given up to philosophical inquiries, 
— new, indeed, and amusing; hnt fanciful av^d unsound; and therefore more likely to distract 
her affairs, than to serve her carefully and with proper judgment.' 

"In ancient limes, Horace saw his odes despised, because they were new. The public, 
he said, — ' 

-' Nisi quae terris seraota, suisque 



Temporibus defuncta videt, fastidit, et odit.' 

('Neglects and dislikes every thing which does not relate to times long since passed away.' 
— Horace's ' Epistles;' Book 2; Epistle 1; Lines 21 and 22.) 

' Est vetus atque probus, centum qui perficit annos.' 

(' He is ancient and excellent who has been dead a hundred years.' — Horace's ' Epistles;^ 
Book 2; Epistle 1; Line 39.) 

" But, like the illustrious Gall, Laennec is no more: — 

' Extinctus amabitur idem.' 

(* He himself, when dead, will be beloved.' — Horace's ' Epistles;' Book 2; Epistle 1; 
Line 14.)" 

I cannot forbear from making the following extract from the first volume of Gall's work 
"sur les Ponctions du Cerveau:" — 

" The followers of the different schools of philosophy among the Greeks, accused each 
other of impiety and perjury. The people, in their turn, detested the philosophers; and 
accused those who investigated principles, with presumptuously encroaching upon the 
lights of the Deity. The novelty of Pythagoras's opinions caused his banishment from 
Athens; those of Anaxngoras threw him info prison; the Abderites treated Deraocritus as a 
madman, because he dissected dead bodies, in order to discover the cause of insanity; and 
Socrates, for demonstraiing the unity of God, was condemned to drink hemlock. 

" The same scandal has been renewed at all times, and in all nations. Many of those 
who, in the fourteenth century, distinguished themselves by their knowledge of natural 
things, were put to death as magicians. Galileo, for proving the earth's motion, was impri- 
soned at the age of seventy. Those who first maintained the influence of climate upon the 
intellectual character of nations, were suspected of materialism. 



INTRODUCTION. • 25 

cations of old ones as almost entitle them to the epithet " new." Every advance 
in our knowledge of the essential nature of diseases^, will (no doubt) enable us to 
improve our application of remedies upon general principles; — to improve our 
"general indications." But without any additional knowledge of the nature of 
diseases, cautious trials — guided by the best analogy we may discern, or by some 
fortuitous occurrence — will enable us (if we are disposed to labour) to effect much 
in extending our knowledge of the powers of particular remedies over particular 
diseases. Lord Bacon^ regrets that physicians apply themselves so exclusively to 

" Universally, nature treats new truths and their discoverers in a singular but uniform 
manner. With whsLt indignation and animosity have the greatest benefits been rejected! 
We may instance potatoes, Peruvian bark, vaccination, &c. As soon as Varolius made 
his anatomical discoveries, he was decried by Sylvius as the most infamous and ignorant 
madman. Vesanum, litterarum imperitissmntvi, arrogantissimum, caluviniaforem maledi- 
centissimum, rerum omnium ignarissimum, transfugam, impium, ingratum, monsirum igno- 
rantice^ impietatis exemplar perniciosissimum, quod pesiiientiali halitu Europam venenata <^c. 
(' Mad, very deficient in learning, most arrogant, most slanderous calumniator, ignorant of 
every thing, a turn-coat, impious, ungrateful, a monster of ignorance, a most pernicious 
example of impiety, which poisons Europe with its pestilential breath,' &c.) Varolius was 
reproached with dazzling his auditors by a seductive eloquence; and with artificially effect- 
ing the prolongation of the optic nerves as far as the thalami. Harvey, for maintaining the 
circulation of the blood, was treated as a visionary; and depravity went so far as to attempt 
his ruin with James and Charles the First. When it was no longer possible to shorten the 
optic nerve, or to arrest the course of the blood in its vessels, the honour of these discoveries 
was all at once given to Hippocrates. The physical truths announced by Linneeus, Buffon, 
the pious philosopher Bonnet, and George Le Roy, were represented as impieties likely to 
ruin religion and morality. Even the virtuous and generous Lavaier was treated as a 
fatalist and materialist. Everywhere do fatalism and materialism, placed before the sanc- 
tuary of truth, make the world retire. Everywhere do those upon whose judgment the 
public relies, not merely ascribe to the author of a discovery the absurdities of their own pre- 
judices; but they even renounce established truths, if contrary to their purposes; and revive 
ancient errors, if calculated to ruin the man who is in their way. 

" This is a faithful picture of what has happened to me. I hiave, therefore, some reason 
to be proud of having experienced the same lot as men to whom the world is indebted for 
so great a mass of knowledge. It seems that nature has subjected all truths lo persecution, 
in order to establish them the more firmly; for he who can snatch one from her, always 
presents a front of brass to the darts hurled against him, and has always force enough to 
defend and establish it. History shows us that all the efforts and sophisms which are 
directed against a truth once drawn from darkness, falllikedust blown by the winds against 
a rock. 

" The instances of Aristotle and Descartes should particularly be quoted, when we wish 
to display the influence of prejudice upon the good or bad fortune of new doctrines. The 
opponents of Aristotle burnt his books. Afterwards, however, the books of Ramus, who 
had written against Aristotle, were burnt; the opponents of the philosopher of Stagira were 
declared heretics; and it was even forbidden by law to dispute his doctrines, under pain of 
being sent to the galleys. There is now no longer any discussion about the philosophy 
of Aristotle. Descartes was persecuted because he taught the innateness of ideas; and the 
University of Paris burnt his books. He had written the most sublime thoughts upon the 
existence of God; but Voet, his enemy, accused him of atheism. Afterwards, this same uni- 
versity declared itself in favour of innate ideas; and when Locke and Condillac attacked 
innate ideas, the cry of materialism and fatalism resounded on all sides. 

" Thus, the same opinions have at one time been regarded as dangerous because they were 
new, and at another as useful because they were ancient. We must, therefore, pity man- 
kind; and conclude that the opinions of cotemporaries as to the truth or error, and dangerous 
or innocent tendencies of a doctrine, are very suspicious; and that the author of a discovery 
should be anxious only to ascertain whether he has really discovered a truth or not." 
(Page 221.) 

Gall might have added, in the words of Professor Plavfair, that — notwithstanding " the 
splendour of Newton's discoveries, the beauty, the simplicity, and grandeur of the system 
they unfolded, and the demonstrative evidence by which that system was supported — the 
Cartesian system of vortices kept its ground for more than thirty years, after the publication 
of those discoveries;" and that actually "the Newtonian philosophy first entered the Uni- 
versity of Cambridge under the protection of the Cartesian," by a stratagem on the part of 
Dr. Samuel Clark; who quietly explained the views of Newton, without any appearance of 
argument or controversy, in the form of notes to a new translation which he published of the 
French Cartesian work, long established as a text-book by the tutors of the University. 
_ Dr. Chambers, speaking of the first reception of the Newtonian philosophy, says — "autho- 
rity scowled upon it, taste was disgusted by it, and fashion was ashamed of it." 

a " Inslauratio Magna."— First Part. 



26 INTRODUCTION. 

general indications; — neglecting the peculiar properties of remedies in particular 
diseases. '• Medici liiijusce aelatis," he says, "licet genetales intentiones curatio- 
num lion male persequantur; particulares tamen medicinas quae ad curationes mor- 
borum singuh)rum proprietate qnadam spectant, aut non bene norunt, aut non 
relio^iose observant."* He remarks that they merely go on, in their prescriptions, 
" addendo, et demendo, et mutando, ciica medicinas, prout iis libitum fueril; et 
fere, pharmacopoeonirn more, quid pro quo substiiuendo;'"' and he advises that 
some physicians "et eruditione et praclica insignes, opus aliquod conficiant de 
medicinis probatis et experimentalibus ad morhos particulares."*' 

Such experimentai facts, however insulated tliey may at first appear, gradually 
arranire themselves with otliers into general principles; and thus what is, at first, 
little better than empiricisin, becomes science. I confess that I look wilh more 
hope to this source of improvement, than to any other. "^ 

Medicfd Education in England. — -From the want of a University, Medicine 
and Surgery were, for along time, scarcely taught in London at all; — notwithstand- 
ing the am[)le means presented by the population and the hospitals. The student 
was compelled to travel to France, Holland, Italy, or (in later times) to Germany 
or Scotland, for the purposse of acquiring a true professional education; for our own 
two Universities neglected almost entirely to teach medicine. It is doubtful whether 
this arose from the want of anatomical and clinical means, the hopelessness of ri- 
valling the great continental and Scottish schools, or the idea that their proper end 
was to teach general knowledge, — to impart only what all educated persons should 
know; or from the circumstances mentioned in a powerful and remarkable article 
upon the Universities of England, in the one hundred and sixth number of the "Ed- 
inburgh Review:" — the ascendency of the Colleges over the University; — tlie sub- 
version of the professorial system by the tutorial. "Time was," says the reviewer, 
"when the Colleges did not exist, and the University was there; and were the 

' " Physicians of the present day, it is probable, may fulfil the general indications of cure 
not inefficiently; but the particular medicines which, by some special properly, are fitted for 
the cure of particular diseases, they either do not well know, or do not sufficiently regard." 

^ "Adding, diminishing, and changing medicines, as freelv as possible; and generally, 
according to the custom of apothecaries, substituting one drug for another of similar value." 

c " Eminent both for learning and experience, should prepare a work on the approved and 
the doubtful medicines, adapted to particular diseases." 

d To such investigations, theref^ore, I have sedulously applied myself; and those of my 
results which were successful, are before the profession: — 1. Cases illustrative of the Effi- 
cacy of Hydrocyanic Acid in affections of the Stomach; with a General Report upon its 
Medical Powers. 11. Some Facts respecting the Inertness of ordinary Antimonial Powder. 
III. The Use of Opium in Dinbetes; and the Necessity of Varying the Doses of Medicines, 
in Various Circumstances. The foregoing were published, inthe year 1820, in one octavo 
volume. IV. Nine Papers, published in the 12th, r3th, Ibih, 16th, 'and l8ih volumes of the 
Medico-Chirurgical Transactions, on the following subjects:— 1. The Medical Properties 
of Cluinine (Volume 12, Page 543). 2. The Use of the Sub-Carbonate of Iron in Chorea, 
and its General Properties (Volume 13, Pages 2G3 and 464). 3. The use of Sub-Carbonate 
of Iron in Tetanus (Volume 1.5, Page 161). 4. The Use of Sulphate of Copper in Chronic 
Diarrhoea (Volume 13, Page 451). 5. Rupture of the Stomach (Volume 13, Page 26). 6. 
Fallopian-Tube Pregnancy (Volume 13, Page 51). 7, Glanders communicated from the 
Horse to the Human Subject (Volume 16, Page 171). 8. The Discharge of Fatly Matters 
from the Alimentary Canal and Urinary Passages (Volume 18, Page 67). 9. Additional 
Facts respecting Glanders in the Human Subject (Volume 18, Page 201). V. Lumlevan 
Lectures on "The Recent Improvements in the Art of Distinguishing the Various Diseases 
of the Heart." VI. Two Papers in the "Cyclopasdia of Practical Medicine:"— 1. Acupunc- 
ture (Volume 1, Page 32). 2. Neuralgia (Volume 3, Page 165). Vlf. A Paper on Acu- 
puncture, in the "Cyclopsedia of Praclica! Surgery" (Volume 1, Page 44). 

I make this statement for the purpose of easy reference; as some of my friends wish me 
to collect into one volume these, — -the whole of my professional attempts, except the English 
edition of Blumenbich's Physiology, and an Introductory Lecture upon Siaie-Medicine 
[delivered in iVIr. Grainger's Theatre, Southwark, on Thursday, November 1, 1821]; and I 
feel disinclined to follow their advice. [To the above list we may add Dr. Elliolson's Edin- 
burgh Thesis (on Inflammation); his "Address delivered at the Opening of the Medical 
Session, in the University of London, Ociober 1, 1832;" and a Letter "'o the Gentlemen who 
composed Dr. Elliolson's Class of the Practice of Medicine, in University College."— 
(March 4, 1839,)] 



INTRODUCTION. 27 

Colleges again abolished, the University would remain entire." When "the Uni- 
versity was paramount, tlie cycle of instruction was distributed among a bodv of 
teachers, all professedly cliosen from merit, and eac!i concentrating liis ability on a 
single object;*' and "the whole youiii of equal standnig in the University, were daily 
collected into large classes under the same professor;" whereas '-vhe Colienes and 
Halls are now elevated into so many litde Universities;" into whidi "the students 
are distributed (with little regard to ability or standing) among some fifty tutors," 
who are "chosen from the fellows;" notwilhsiandmg that "the fellowships were 
not founded for the purposes of teaching," and that "the fellow rarely owes his 
eligibility to merit alone, but, in the immense majority of cases, to fortuitous cir- 
cumstances."^ 

Establishment of Medical Lectures in LGndon. — The opportunities of teaching 
Anatomy, Surgery, and Medicine, in London, however, became at length too great 
lo be entirely thrown away, and the surgeons of the hospitals began to deliver lec- 
tures on x4natomy and Surgery, and afterwards the physicians uj)on Medicine, 
These lectures were of limited extent; nor, for a time, were systems of courses de- 
livered, — so as to constitute regular schools. The time, the tiouble, and the ex- 
pense of travelling to a University of medical reputation, rendered the emolument 
fairly to be expected on establishment in practice too high for the mass of the peo- 
ple to afford; a!id as population increased, and more practitioners were demanded, 
home medical instruction was sought after by greater numbers every year; — and 
this the more, as any one could practise without the license or authority of any 
University. 

Establishment of Medical Schools. — The lectures improved, and at length re- 
gular schools were established; yet, as they were all private, and could confer no 
privileges or honours, those who required degrees went to the old celebrated schools; 
while those whose only resource was the private schools, had too limited pecu- 
niary means to devote much above a year to public study; so that these metropo- 
litan schools remained scanty and superficial. The whole of Anatomy, Physiology, 
and Morbid Anatomy together, was disposed of in a coiiise of little more than three 
months; the Practice of Medicine, and the science of Chemistry, each in the same 
period, wiih only a lecture of one liour's duration three times a week. Much of 
General Pathology, and Forensic Medicine, was altoo^ether omitted; the whole of 
Medical Police likewise, and the literature of the profession, were passed over. It 
was left for the University of London^ to be bold enough to establisli courses of six 
months' duration; in which full scope would be afforded to the professors of laying' 
before the student the whole body of medical science; to add the charms of varied 
illustration; to inculcate in^portant points earnestly and repeatedly; and to introduce 
the student to an acquaintance wiih medical literature. 

Advantages of Lectures.— The mode of instruction by lecture, though by no 
means sufficient of itself, is in my opinion of high importance. When a whole 
subject can be taught in a solitary course of lectures, and the exhibition of nothing 
is required, — so that a mere delivery of stateuient constitutes the whole task of the 
professor, — there can be no doubt that a good work, containing all the same infor- 
mation, might be studied in private with equal benefit; and, indeed, with this 
greater advantage; — that it would probably, after costing less, remain in the pos- 
session of the student, to be consulted by him whenever he might think fit. But 
when a circle of instruction is required, — when the subjects are numerous, and 
demand many courses of lectures, and many professors, — the student cannot be 
committed to himself. Without lectures he wordd become (almost to a certainty) 
bewildered; — studying at irregular intervals, wandering from one subject to another, 
and getting little fruit from any; whereas the attendance on various lectures, at 
slated hours, creates an excitement and an interest, as well as a regularity of habile 
which aie of incalculable utility. 

- "Edinburgh Review," June, 1831; Volume 53: Pages 386, 387, 394, and 395, 
»> Now called "Universiiv-Coilege," 



28 INTRODUCTION. 

Draioings and Specimens. — In our science and art, however, lectures are, on 
another account, of superior advantage, — indeed indispensable. One part of the 
office of every medical lecturer, is to describe objects of sense. The attempt to 
learn Anatomy, Physiology, Chemistry, Materia Medica, or Botany, would be 
ridiculous, without the inspection of the material objects, and the principal phe- 
nomena. Of the Practice of Medicine and the Practice of Surgery, the same is 
true. No professor, either of the one or of the other, can give his pupils a full idea 
of the phenomena of diseases, or of the administration of remedial means, unless he 
lefer to patients exhibiting the various phenomena of disease, and subjected to the 
exercise of our art. As cases, however, cannot be had at pleasure, so as regularly 
to illustrate a systematic course of lectures, it is indispensable to deliver the general 
description and history of diseases and their treatment, in a distinct course; and to 
afford the ilUistrations from life in a totally separate manner, as they incidentally 
present themselves in a collection of patients. It is, therefore, essential that there 
should be both a general course, and clinical instruction. Yet, m the general course, 
material illustration is botli possible and necessary. Representations of the various 
morbid changes (by copious and well-executed drawings, engravings, and models), 
and actual specimens of these changes, and all the material products of disease, it 
is the duty of a teacher to present and explain; although, when I was a student in 
Edinburgh, the professor of Medicine never exhibited a single drawing, or a mor- 
bid specimen. 

Hospitals and Dispensaries. — For the other great mode of instruction in the 
Practice of Medicine and Surgery, an hospital is imperiously necessary. A dis- 
pensary must always be a miserable substitute for an hospital. No medical Uni- 
versity would grant the decree of Doctor in Medicine, to any who had frequented 
merely a dispensary. At die latter the majority of patients are so little in lisposed, 
as to be able to go about. When seen, they necessarily pass in rapid review 
before the practitioner; — giving him an opportunity of showing how practice may 
be despatched, rather than how disease should be investigated: for if the time de- 
manded for the scientific and patient investigation of each case, and for demonstra- 
tion and explanation to the pupil, were given, the poor creatures would be com- 
pelled to lose, in attending at the charity, far more time than their condition in life 
or their strength would allow. There is, besides, among the patients of a dispen- 
sary, no certainty that medicine is regularly taken; — no possibility of fixing their 
diet; — no certainty of their continuing to attend, so that each case may be regularly 
followed up to its conclusion; — no possibility of making daily observations. When 
cases are severe, and the patients confined at home, there is not only the same un- 
certainly of strict attention to the injunctions respecting medicines and diet, but the 
student must lose a great deal of time in running from one house to another: and 
the physician or surgeon will not visit all such patients daily with his pupils; and, 
indeed, his pupils cannot accompany him in these visits, with any degree of regu- 
larity. In an hospital the patients are compelled to obey every injunction; and, 
being under the same roof, they may be seen at pleasure any hour of the day, with- 
out loss of time; so that long and repeated observation of their cases is easy. 

When death occurs to a dispensary-patient, and an examination is permitted, the 
student loses still more time: for he must not only go to the house of the family, 
but prepare the body; and afterwards reinstate it; and, in all probability, will sel- 
dom be accompanied by the physician or surgeon. At hospitals the examination takes 
place without any loss of time; the student has nowhere to go; servants prepare, 
and sew up, and wash the body; and the physician or surgeon usually superintends 
the inspection. So superior are the advantages of hospitals, that, as I have already 
remarked, certificates of attendance upon them are required at all medical Universi- 
ties, previously to examination for the doctorate; and although certificates of attend- 
ance at dispensaries are admitted by the Apothecaries' Company of London, and 
may be obtained at a cheaper rate than those of hospitals, the majority of English 
medical students voluntarily enter themselves to the medical practice of hospitals. 

The inferiority of dispensaries is, indeed, acknowledged by their medical officers, 



INTRODUCTION. 29 

in the greater cheapness of their terms; and the Apothecaries' Company declare 
it, in their demand of a longer attendance at them then at hospitals. It is, there- 
fore, much to be lamented that the Apothecaries' Company admit dispensary-attend- 
ance at all; since if, of the short period enjoyed by the medical pupil for the public 
study of his profession, a certain portion is necessarily devoted to the observation of 
cases, that portion should evidendy be spent in witnessing them in what is acknow- 
ledged to be the most efficient manner; and if eighteen months can be spared for at- 
tendance on dispensary-pr^cUce, they can be spared for witnessing hospital-prdiCiice. 
Tliose who cannot see the necessity of hospital-attendance, for the purpose of 
observing, without loss of time, the most important diseases, their minute investiga- 
tion, and accurate and unrestrained treatment by the physician,— cannot but admit 
the necessity of hospital-attendance for the purpose of witnessing the great acci- 
dents, and operations of surgery. The College of Surgeons receives no certificates 
of attendance upon the surgical practice of dispensaries. If, thereore, the student 
must attend an hospital for half his experience, it is indisputably best that he should 
acquire the other half within the same wails. 

I will not scruple to add,, that I think the student pays too much for hospital- 
attendance in London; that the entrance should not be to medical or surgical practice, 
alone, but to the whole range of the hospital; and that the sum which is paid to 
witness the surgical practice only, would be a sufficient remuneration for the sur- 
geons and physicians together; and I should rejoice to see the most meritorious 
among the senior students, rewarded gratuitously with the appointments of dressers 
to the surgeons, as well as of clinical assistants to the physicians. 

Without an hospital, the professors who teach the practical part of the profes- 
sion, not only are deprived of the means of properly instructing their pupils, but 
lose the great advantage of proving to them the truth of their statements, and the 
propriety of their precepts. One great source of my pleasure in teaching at St. 
Thomas's Hospital, was the opportunity of showing the pupils that I practised 
what I inculcated; — of rendering probable, or even proving to them, that what I 
advanced was true; and of referring from time to time, for illustrations of my 
descriptions, to cases which they had witnessed with me in the institution. 

The last argument I will urge in favour of hospitals is, that they are also dispen- 
saries. They have a dispensary-department, in which patients are attended to 
the same amount as at mere dispensaries. Besides all the inmates of St. Thomas's, 
the greater part of ten thousand out-patients are attended; and, although none are 
visited at home, this might readily be done without any farther trouble or expense, 
by the senior and best informed students; to whom such a trust would be an 
incalculable benefit. 

Large and Small Hospitals. — For the greater part of these important objects, 
a small hospital would be sufficient; — a hundred medical, and a hundred surgical 
beds. This number of well-selected cases, assiduously studied, would answer all 
ordinary purposes, as well as the four hundred and fifty-eight beds of St. Thomas's; 
— one half of the cases in which are imperfectly, or not at all known, to the pupils. 
An hospital of this extent might, I am inclined to believe, be conducted at less 
expense than is generally imagined. An important advantage, however, is insep- 
arable from a large hospital; — not that of affording a large number of examples 
of the same affections, but of giving a probability of the occurrence of the more 
rare; — nay, of the rarest diseases, accidents, and operations, during the period 
every student frequents it. Besides the opportunity of becoming fully acquainted 
with all the ordinary cases of Medicine and Surgery, it is indispensable to a full 
and perfect education, that instances of every disease and accident which he may 
afterwards have to treat, should be witnessed by the student. 

The most elaborate description of a disease, or mechanical derangement, not 
only falls short of conveying an adequate idea, but the conception gradually fades 
away; or, if retained, is frequently not recalled when, after a lapse of* time, the 
disease so described chances to occur, and probably we do not recognise it till 
another person names the nature of the affection; or, if we suspect its nature, we 



30 INTROBTTCTION, 

siill have onr doubts. On tlie oshpr hand, if diseases or accidents have once been 
seen, — '* oculis suhjecta fidelibus,"^ when ihey again {)resent themselves, they 
are immediately recognised. 

A strikmg exemphiicalion of these remarks came under my observation vv^hen 
a student. A poor man, labouring under true scurvy, applied lo a surgeon on 
account of the horrid slate of his mouih;— his gums being swollen, spongy, and 
bleeding; his teeth loose, and his breath offensive. The surgeon, not having seen 
a case of scurvy, supposed the disease of the gums arose from a bad state of the 
teeth; and extracted several in succession. He was then sent to another, of high 
eminence and enormous practice, who pronounced it a case of fungus ha^malodes 
of the gums; and admitted him into his iiospital; — intending to resign him to his 
fate. Being visited, however, by a practitioner who had witnessed scurvy at a 
naval hospital, the nature of the disease was at once recognised; some lemon-juice, 
fresh meat, and vegetables were prescribed; and he was well in a week or two. 'I'he 
surgeons, who were not aware of the nature of the complaint, were well-informed 
men; and the disease was one which all have heard of, and the leading symptoms 
of which are universally known. But, though formerly very prevalent and fatal 
in London, it is now uncommon; and thus, from not having witnessed it, these 
two gentlemen committed a serious error. It is also of great importance to the 
student, that he should have witnessed all the rarer accidents and surgical operations; 
and for this purpose a large hospital is indispensable. 

General Education of Medical Men. — While I rejoice in the establishment of 
an English School of Medicine in this city,'' on a plan which, if well conducted, 
will render it equal to any, and far superior to most others, in the civilized world, 
I rejoice also that the School in question, forms part of a University. Nothing is 
more to be desired, than that those who go forth into the world to practise the 
healing art, should be men of excellent education. In most countries of the Con- 
tinent this is the case. The great body of practitioners there, receive a general 
education at a University, previously to commencing the study of their profession. 
They in truth receive what ought to be the education of a physician; and they are 
physicians. In this country, those who carry on the great mass of practice, — 
those who, in addition to their original occupation of apothecary, have risen to 
the office, though not to the name, of physicians, — are indebted chiefly to their 
own exertions, for even their professional knowledge and skill. All the lectures, 
excepting perhaps those on Anatomy and Surgery, have been too scanty and 
superficial; and the clinical instruction has been conducted too generally in a most 
careless manner; so that clinical lectures were actually unknown in London a {e\v 
years ago; and an extremely small number of those whose business in life was to 
practice medicine, ever thought of entering to the medical practice of an hospital, 
or even of a dispensary. No proper systematic method of practical instruction, 
whether medical or surgical,- — no plan for intrusting the students with the charge 
of patients, is even yet established; and no better education is given by parents 
to those children intended for medical practitioners, than to those whom they des- 
tine for trade; and when the best part of general education should begin, the youth, 
with all his capabilities of literary and philosophical attainment, is hurried ofT to 
mix draughts and weigh powders, during the greater part of the day, for several 
years. The portion of time thus consumed, ami the sum of money thus expended, 
would enable the youth of our profession to attain every acquirement of a high 
education. The young men who come to our schools, to prepare themselves for 
general practitioners, are, in the majority of instances, as gentlemanly in their 
sentiments and manners, as intelligent and anxious to learn every thing that their 
instructors are disposed to teach them, as are those sent to Oxford or Cambridge, 
— as are young men of whatever station in society, and in the previous enjoyment 
of whatever advantages. 1 trust that, ere long, the five years' apprenticeship to 

• " Submitted to the faithful eyes.^'— Horace, on the Poetical Art; Line 181. 
»» London. 



learn the business of the dispenser will be abr)Iished; and the youth will acquire a 
gfood classical education, a knowledge of the three great continental languages 
(French, German, and Italian), and no inconsiderable acquaintance with Mathe- 
matics, Physics, and Mental Philosophy. By a change of plan, and by practi- 
cable facilities, I am confident that all this may be accomr>rished with no great 
increase of expense; and the young practitioner be ready for the commencement 
of his active career, at the age of two or three-and-twenty; and no one will deny, 
that a given expenditure of money and of time, ought to be made to produce the 
greatest possible advantages. I hope that the Apothecaries' Company will, one 
day, rather require from those young gentlemen who go before them, testimonials 
of having received a respectable classical and malhemaiical education, and of being 
able to read the Germ.an, French and Italian writers in the originals, with the 
possession of a share of Physics and Mental Philosophy; than of having consumed 
five years, when the mind thirsts most ardently for knowledge, in drug-mixing, 
or such poor and desultory instruction as a private practitioner has time to bestow; 
and which must be as nothing before they begin, systematically and practically, to 
learn Anatomy, Physiology, and Chemistry, at a public school. 

An eminent scientific professor at Utrecht, in a pamphlet published in English 
by Mr. Faraday, in answer to Mr. Babbage's complaint that science is on the 
decline among us, says: — "There are countries in Europe where no young man 
could think of studying medicine, Mathematics, or Natural Science, with the help 
of Latin only; and without being prepared, before entering the University, with a 
sufficient knowledge of German, English, and French. 'J'he ignorance of foreign 
science in England, cannot be attributed to want of zeal, but to a defect in English 
education, — the ignorance of foreign languages. 

If it be alleged that an improvement in education, will make the general practi- 
tioner equal in knowledge to the physician, — "Then," it may be answered, "so 
much the better." I have no desire that the importance of physicians should be 
maintained by the depression of the general practitioner. If the physician is to con- 
tinue as superior to the general practitioner as he formerly was, he must progress 
in the same proportion; he must not think of preventing the advance of the general 
practitioner; he must also step forward himself, to maintain his advantage. The 
physician who devotes himself to a limited sphere, and whose means allow him to 
appropriate more time than the general practitioner to his literary and scientific 
education, and to the subsequent study of his profession; and who— -exempt, while 
in practice, from the toils of Midwifery, and the distractions which beset the ordi- 
nary practitioner — employs those advantages as his sense of duty may dictate, — he 
will thus acquire every reasonable ascendancy; and general practitioners will gladly 
avail themselves of his assistance, and recognise him as the supporter of the re- 
spectability of the profession. The mass of the middle classes of society, has begun 
a great movement in the acquisition of knowledge, in the discovery of rights, in ihe 
correction of absurdities, and in virtue and liberality of sentiment. The higher 
orders see the impossibility of arresting this progress; and tides and decorations 
will no longer command notice, unless supported by real excellence. Among the 
higher raid\s there are some who, so far from viewing this upward movement with 
dread, step forward to promote it. So ought physicians to act towards the general 
practitioner; — to make every effort to improve his general education, and profes- 
sional knowledge. In f\ict, all those who lecture or practise at public institutions, 
act (whether they will or not) contrary to the narrow views of interest; for ihey 
are occupied in imparting knowledge to the rising generation of general practition- 
ers; — occupied in endeavouring to make them as learned as themselves. 

In me such narrow views would be the height of baseness, and would be the 
height of ingratitude; for I hesitate not to avow, — I rejoice in this public opportu- 
nity of declaring, that to the general practitioners of England, Scotland, and Ireland, 
I am indebted for success in my profession. When I commenced my profess^ional 
career, I determined upon seeking for success by working hard: and by conducting 
myself as well as the infirmiiy of human nature would allow. 1 determined, how- 



S2 INTRODUCTION. 

ever long I might wait for success, never to fawn npon and run after my superiors, 
nor to stoop meanly to my inferiors; never to intrigue for an advantage, nor to em- 
ploy trumpery artifices for making myself known to the public. For many years 
I toiled; and saw most of my contemporaries, —nay, of my juniors (who worked 
less, but were wiser in their generation) pass by me. I published work after work, 
- — edition after edition; and paper after paper was honoured with a place in the 
Transactions of tlie first Medical Society in Europe.* I was physician to a large 
metropolitan hospital; and had attended there, and gratuitously out of doors, above 
twenty thousand patients. But in vain. In the year 1828 my profession was no 
more lucrative to me than in 1818, and was as short of my actual expenses. At 
that time the *' Lancet" was pleased, now and then, to publish a clinical lecture, de- 
livered by me at St. Thomas's;'' and my practice at once doubled. The following 
year it published the greater part as I delivered them;*' and my practice doubled 
again. Next season,* the "Lancet" published them all; the "Medical Gazette"® 
followed its example; and my practice doubled a tliird time. This astonished me 
the more, as my clinical lectures wer€ generally delivered with litde or no premedi* 
tation; while all that I published myself had cost me great labour, many a headache, 
and much " midnight-oil." It was through tlie general practitioners, in the large 
majority of instances, and throujjh general practitioners (for the most part) with 
whom I had not the honour of any acquaintance, that the publication of those 
lectures accomplished my success. To the body of general practitioners, there- 
fore, I owe a debt of gratitude. They have called me forth spontaneously, from 
no interested motive; and I cannot exert myself too much in the education of their 
successors. 

Books. — Young men are generally frightened on hearing the almost countless 
names of medical authors: or on beholding the array of volumes in public profes- 
sional libraries; and a melancholy, amounting even to despair, has seized many an 
upright and inquiring youthful mind. Should any one be suffering from this anxiety, 
let him take comfort from my sincere assurance, that very few of these volumes need 
ever be opened. The greater part are full of absurd hypotheses, narratives at present 
comparatively unimportant, and exploded practice. Many are little more than 
copies and compilations from others; and the real good that exists in them all, is to 
be found in the best modern treatises. Except authors and teachers, few can have 
a necessity, in the whole course of their lives, for poring over these ponderous 
tomes. Students, indeed, I am thoroughly persuaded, should never read any but 
elementary works; and their whole library cannot, with any propriety, amount to 
twenty volumes. One good work on Anatomy, one on Physiology, one on Che- 
mistry, one on Botany, one on Materia Medica, one on Midwifery, one on the 
Practice of Medicine, one on Surgery, and one upon State-Medicine, should, in my 
opinion, constitute nearly the whole of a student's library. The design of his 
education is to fill his head, not with opinions and strange facts, but with solid 
truth; and if, after three or four years' close study, with the assistance of a regular 
attendance on lectures on all these subjects, and of unwearied observation in the 
wards and in the dissecting-room, he fully comprehends the contents of these few 
works, and deposits them in the storehouse of his memory, he will have done well, 
and will be prepared to practise his profession with honour. 

" " The Medical and Chi'rurgical Society of London." See Volumes 12j 13, 15, 16, and 
18 oflheir " Transactions." 
b See the " Lancet" for the Session 1828-9. 
c See the two volumes of the "Lancet" for 1829-30. 
d The season 1830-31. 
t See Volumes 7 and 8 of the " Medical Gazette." 



33 



GENERAL PATHOLOGY 



General Law of Mutability . — It appears to be a law of the universe, that every- 
thing shall undergo incessant change. Whether the universe be eternal or not; — 
whether we believe it has existed (according to the opinions of some ancient phi- 
losophers) from eternity, and is to exist to eternity; or whether we are so to under- 
stand Scripture, as tliat not only the arrangement of all things, but all things them- 
selves, had a beginning, and must have an end, — however this may be, while the 
universe is in existence, it appears to be the law of the Creator that every thing in 
it shall undergo incessant change. 

Both the animate and the inanimate world are in this predicament. The most 
minute aggregate of matter, and the largest material bodies, appear only destined 
for certain periods of continuation in their existing state. With respect to our own 
earth, we see that countries are continually lessened and destroyed by the encroach- 
ments of the sea and by eruptions; and, on the other hand, from similar circum- 
stances, other countries are produced. It is probable, therefore, that the appearance 
of the earth at present, is totally different from what it once was, and that after a 
period it will be totally different from what it now is. Even with respect to other 
worlds, there is every reason for astronomers to believe, th?.t many have been de- 
stroyed ; and that some worlds which are now seen, are but fragments of others 
which have been broken to pieces. 

Period of Existence Limited. — With respect to the animated part of the cre- 
ation, every vegetable, — every animal, has but a limited period destined for its 
existence. This period varies exceedingly; for some animals are destined to live 
but a few hours, while others, again, appear to live for centuries. 

But besides this definite period, every animated being is liable to be cut off long 
before its natural period arrives. Animals and vegetables are all exposed to violence 
of every description; — not only to mechanical violence, but to the destructive opera- 
tion of a thousand causes; and to disturbance from the cessation of the circum 
stances which are necessary to their existence. One animal is destined to devour 
another while in its prime; nay, to destroy the element of what would be the young 
(the eggs, for example) of another; and myriads of insects are continually destroy- 
ed in storms. Constantly, therefore, the limit which Providence appears to have 
placed to every thing is curtailed. Every animal and vegetable is subject to be cut 
short long before that limit is reached; so that there appears to be a perpetual strug- 
gling throughout nature; — the Creator having, on the one hand, in-vested every ani- 
mated being (whether vegetable or animal) with a power to exist for a certain time, 
and to resist injurious agencies; and having provided, on the other hand, injurious 
agencies without number, to injure and to cut it off before its time. 

It has been said by some philosophers that, looking at man, one would suppose 
he was destined to live to all eternity; — that, at first sight, such a machine as the 
human body, unless destroyed by external violence, would appear capable of lasting 
for ever. And by experience alone we are taught the contrary. "Primo statini 
aspectu, talis machina, nisi forte causa aliqufi externa corriipta vel Ircsa, in omnc opvum 
durabilis videtur. Etquidem sola experientiacontrarium doceniur."* However, there 
is nothing in the appearance of the human machine which would lead us to suppose 

» Gregory's "Conspectus Medicinoe Theoreticoe." Book 1; Paragraph 1'3. 
VOL. I. — 3 



34 GENERAL PATHOLOGY. 

that it could last forever. Whatever we know of nature, can be learned only from 
experience; and it would be as correct to say, that because it is summer we should 
believe it will be summer forever, or hecause it is day we should believe it will be 
day for ever, unless we have contrary experience, as it would be to say, that the 
human machine in itself appears capable of lasting for ever. We can learn nothing 
from taking a partial view of things; for it is impossible to form a judgment of na- 
ture, except by taking a continuous and enlarged view. It would also be contrary 
to all analogy, to suppose that the human machine is capable of lasting to eternity. 



SECTION I.— THE NATURE OF DISEASE. 

Positive Causes of Death, — With respect to the injurious circumstances which 
are positive, and to which animals are exposed, and by which they may be cut off 
before their full period has arrived, they are those, in the first place, of mechanical 
violence; in the second, those of a specific nature. Many animals and many 
vegetables contain within them materials, which are destructive to the life of others. 

Negative Causes of Death. — Animals are liable to be destroyed, also, from a 
want of suitable external circumstances; for a series of actions is incessantly going 
on in every animated machine, and those actions are maintained by external cir- 
cumstances; — such as by a certain degree of temperature, by a certain surrounding 
atmosphere, and by a certain supply of matter to be taken into the mouth or 
stomach, or some equivalent organ. The deprivation of any of these may put a 
stop to existence, or impair it; and, on the other hand, the excess of some of them 
will have the same effect. The excess of food may destroy or injure life; and the 
excess of heat may cause serious injury, or absolutely consume the body. Besides 
this, the depraved quality of those external matters which are necessary to the con- 
tinuance of life, will have an injurious effect. This is well illustrated by the effect 
of bad food. 

Temperature. — One of the most common causes, — indeed, I may say, the most 
common cause of diseases, is a deviation with respect to external temperature. A 
certain degree of heat is required for the support of life; and a deviation in that par- 
ticular is the most common cause of the diseases which we observe in this country. 
An excessive degree of heat produces one set of effects; an excessive degree of cold 
produces another; and an alternation of the two — from the body being suddenly 
exposed first to the one and then to the other (more especially if this exposure be 
partial) — is attended by the most serious effects. The greater number of diseases 
are inflammatory; and the most common cause of inflammation is sudden alterna- 
tions, or other unfavourable circumstances, with regard to temperature. 

Jlir. — Bad air is also a common cause of disease; but this does not arise from 
the want of oxygen in particular, as has been imagined; but from the presence of 
certain substances of deleterious quality. I believe it is found, that the quantity of 
oxygen in the air is the same in almost every country and in every situation; and 
it is the presence of other things, in addition to the oxygen, which produces the 
injurious effect. We see the effect of the bad quality of the air in unhealthy situa- 
tions, where persons are sallow and bloated, and carry about with them marks of 
disease, visible enough to others who come from a healthy spot, although not al- 
lowed to exist by the parties themselves; — simply for this reason, — that, being so 
accustomed to what they witness, they conceive it to be their nature. 

Food and Labour. — The ill effects of unwholesome food are seen every day. 
The body is rendered feeble; and when this takes place, whether from bad air or 
bad food, it becomes an easy prey to any other cause of disease which may present 
itself. Want of the rest necessary for the refreshment of the body, has also the 
effect of producing disease. Excessive action, too, either of the mind or any part 
of the body, has likewise the same tendency. 

Thus, disease is continually produced from mechanical violence, from the pre- 
sence of injurious agents, and from errors in regard to those agents which are abso- 



GENERAL PATHOLOGY. 35 

liiteiy necessary to the support of life; — whether the errors be those of excess, 
deprivation of proper quantity, or depreciation of quality. 

Hereditary Taint. — This, however, is not all. When a disease has been 
induced, it frequently happens that a tendency to that disease is transmitted to the 
offspring' of the sufferer; so that it requires no exposure of such offspring to the 
particular cause of the disease, in order to become its victim; but at a certain period 
of life, unless placed in very happy circumstances, — and perhaps in spite of the 
happiest circumstances possible, — the disease under which the parent laboured 
appears in the child, or in a still later offspring; and possibly cannot be controlled. 
Again: independently of the inherent disposition to disease, and tlie external circum- 
stances to which the offspring is exposed, original malformation of certain parts of 
the body so disorders its functions, that sooner or later disease, which may end in 
death, makes its appearance. 

Derangement of Functions. — When disease takes place, the functions of the 
body suffer disturbance. A series of actions is continually taking place in the body; 
and some of these, when " disease" (so called) occurs, become deranged. The 
circulation of the blood is altered; more is accumulated in some parts than there 
should be, and less in others. Tlie temperature of the body is altered; it is too hot 
either partially or generally, or it is too cold. The feelings of the body are altered; 
they become too acute or too dull, or they become otherwise wrong. The strength 
of the body likewise is changed; in some few instances it is increased, but in the 
great majority it is impaired. What was done naturally in the body before this 
change took place, is now done either too little, or too much, or in a depraved 
manner. The products of the body are likewise altered. The sweat is not natural 
in its quality, any more than in its quantity; the urine, and the secretions poured 
forth from the intestines, become altered in quality; and 1 have no doubt that the 
excretion from the bronchial tubes, also, is changed in its constituent proportions. 
At last, not merely are the actions of the body, and the products excreted from it 
altered, but even the very substance of the body itself will become changed. 

Extent of Derangement. — With respect, however, to all the changes I have just 
enumerated, they mustevidendy be in a certain intensity, — a certain degree of them 
must exist, for us to say that disease is present. A change, although (stricdy speak- 
ing) a disease, may be so inconsiderable, that one would be laughed at for calling it 
by that name. A slight spot upon the surface, — a single point no larger than a flea- 
bite, no one would think of calling " a disease;" and yet, if there were a larger 
number of these, though the only difference consisted in amount (the nature and 
degree of each being exactly the same), we should not hesitate to say that disease 
was present. Therefore, when a deviation with respect to function or structure takes 
place, there must be a certain extent of it, or a certain intensity of it (one or the 
other), to justify us in saying it is really a disease. Logically and strictly speaking, 
disease is said to be "an aberration of function or structure of one or more organs 
from a sound state." You will find this mentioned in some books, as the definition 
of a disease. But this is hardly sufficient; because, with respect to structure, and 
even with respect Xo function, a part may be sound, and yet be in a state of disease. 
A part may grow to a much greater size than natural, — there may be diseased 
bulk of the organ, although the structure is healthy. This is a rare occurrence; 
but sometimes it does take place. Generally, where there is increased bulk 
there is diseased structure; but it is possible for a part to be enormously large, with- 
out being altered in structure; and yet the person may be said to be labouring 
under disease. A person with an enormous liver, or brain, though no unheallliy 
change could be discovered in its texture, would nevertheless be pronounced to be 
in a state of disease. So with respect to the fluids; they also sufler very great 
changes, and yet there may be no fault of function. In the disease called "annemia,"* 
where the blood is deficient in quantity, the disease may really be quite independ- 
ent of any fault of the body itself. A mere want of nourishment may cause the 

» From ay (privative) without; and al/xtf, blood. 



36 GENERAL PATHOLOGY. 

blood to be of a diseased quality; — that is to say, not to contain its natural elements, 
but to be very watery, — to be thin and pale (the whole body becominjr white or 
tallowy in appearance); and yet no function can be said to be diseased, — at least 
excepting through this want of nourishment. The body is ready to do all that is 
required of it, if proper food be given. This definition of disease, therefore, is 
more or less exceptionable. Besides: in a large number of diseases, the quality of 
\\\e fluids is altered; and it is essential to a correct definition, that this should be 
taken into account. 

With respect to the extent of aifection which is necessary to exist in order to 
constitute a disease, there must be a great difference in various individuals; for the 
health of different persons is exceedingly various. What is health to one man, 
would be disease in another; just as the degree of strength which is natural to a 
delicate person, would be considered downright weakness in another. To obviate 
any difficulty of this kind, we sometimes find added to the definition of disease 
which I have already given, — "rendering assistance necessary." The definition 
given in Dr. Gregory's " Conspectus" is: — "A disease is present, when the cus- 
tomary actions of the body are either altogether impeded, or performed with diffi- 
culty and pain." ("Morbus adest, quum corpus tanlum a statu sano deflexerit, ut 
solitae actiones vel prorsus impediantur, vel aegre aut cum dolore perficiantur."'' 

Definition of Disease. — Disease, therefore, may generally (perhaps) be defined 
to be, — " an aberration of function, or structure, or size, of one or more organs; 
or of the quality of the fluids, from the sound state; renderingassistance necessary." 

Pathology, Definition of. — This, however, it may be remarked, is only a defi- 
nition of disease in general; I shall make some further remarks upon the definition 
of each particular disease hereafter. Diseases, therefore, are neither more nor less 
than alterations in the physiology or anatomy of the body; — in other words, morbid 
physiology, and morbid anatomy. This morbid state of physiognomy," and this 
morbid state of anatomy, *" are together called " Pathology." The doctrine of dis- 
eases, whether as it regards function or composition, is called "pathology."** There 
is an inclination, in the present day, to limit the word '■^pathology'''' to morbid ana- 
tomy. That, however, I think, is quite unjustifiable; for pathology is the doctrine 
of disease, whether it relates to function, or structure, or both. Pathology, there- 
fore, is an unhealthy state (if I may so speak) of physiology and of anatomy; — the 
composition of the fluids, as well as function, being comprehended under the term 
'■''physiology;'^ — size, as well as structure, being comprehended under the term 
"anatomy." 

Functional and Structural Diseases. — Diseases are often divided into those 
which are "functional," and those which are "structural;" but it is very common 
for the one to terminate in the other; — for diseases which are at first purely func- 
tional, to become at last structural. At any rate, many organic diseases do not at 
first exhibit themselves as such, but are ushered in by a change of function. It is 
possible that a minute change of structure may exist, long before it is discovered; 
and that minute change is enough lo explain the alteration of function; but many 
diseases exist long, to all appearance, as mere functional disturbance, before they 
become structural. Many diseases remain functional, — at least they go through 
their course as a disturbance of function, never affecting the structure; but struc- 
tural diseases almost always disturb function. It is evident that if the structure of 
an organ which is to perform a certain duty be much altered, that duty cannot be 
well discharired. 

Organic Diseases. — Structural diseases are sometimes called "organic." I be- 
lieve that the words ^'structuraP' and ^'•organic'' are used synonymously, to ex- 
press those diseases which consist in a change of composition and arrangement of 
the organ itself, and not a mere alteration in the mode in which it does its duty. 

" Gregory's "Conspectus Medicinae Theoreiicse;" Chapter 1; Paragraph 24. 

b From <;>u3-tf, nature; and Xoj/oc, a discourse. 

c From ava, about; and re^va;, to cut. 

^ From '7raQoi;j a disease; and Xoj/oj, a discourse. 



GENERAL PATHOLOGY. 37 

Perhaps the worJ ^^ organic''* is preferable to the word ^'•structural;'''' and for this 
reason, — that some diseases of this description do not appear to consist in any 
alteration of structure, but merely in a diminution or an excess of bulk. Now in 
those cases (which, though they are rare, nevertheless do sometimps occur) where 
an org-an wastes, or becomes larger than natural, and yet appears otherwise liealthy, 
the affection cannot exactly be called "structural;" — the word " org-a/iic" better ap- 
plies to them; and therefore, altogether, the term "•organic"''' may be preferred to 
^'•structuraiy 

Disorders and Diseases. — There has been an attempt by some to call the one 
set of complaints, supposed to be merely functional, — "disorders;" and the others, 
which are structural or organic, — "diseases." For instance: they call dyspepsia, 
or diabetes, a "disorder;" and ulceration or cancer of the stomach, or ulceration of 
the kidneys, a "disease." This plan, however, is not generally adopted. It might 
be very well if all persons agreed to adopt the terms in this sense. But that is not 
the case: indeed, so far from it, that, in most books, the expression "organic or 
structural disease''"' occurs; which would not be necessary if every one adopted the 
word '■^lisease'''' to signify in itself a structural affection. Nay, so extensively is 
the word ^'•disease"''' emploved by some persons, that even accidents (as dislocations 
or fractures) are called "disease." You will find, in Cullen's "Nosology," that 
dislocation and fracture are arranged under the class of "Local Diseases. ''''^ 'i'he 
word ^'disease,"" then, is used by some nosologists very extensively. They em- 
ploy it to signify accidents, mechanical affections, dislocations, ^ hernia,'^ and every 
thing of that description; and it is used by almost all writers to signify both func- 
tional and structural affections. I shall, therefore, use the word '•Hlisease"'"' to signify, 
not organic affections exclusively, but all depraved conditions, whether functional 
or organic. 

Local and General Diseases. — Disease may be considered according as it is local 
or general. Some diseases affect only one part, and others are supposed to affect 
the whole system. Fever, for example, was formerly supposed to be an affection 
of the general system, without the preponderance of disease in any individual 
organ. The libours of Louis, Cruveilhier, and Bright, however, have conclusively 
established the fact, that proper typhus, in every instance, presents a disease of the 
intestinal glands, more especially those of Peyer; while, with regard to fevers of a 
less malignant character, it is by no means proved whether they consist in a general 
disturbance only, or whether they depend upon a more local action for their cause. 
I can entertain no doubt, however, that there are such things as general diseases; 
and it appears to me that scurvy is of this description, for every fluid of the body 
seems vitiated; — at least the blood throughout the body is so, and all the solids 
appear to be in a similar state. There is no one part of the body that can be fixed 
upon as the seat of the malady. So with respect to ague. I cannot discover any 
reason for ascribing the disease to any one part of the frame; and I therefore think 
that it also is an instance of a general affection. 

Acute and Chronic Diseases. — Diseases are also different from each other 
according as they are acute^ or chronic.^ Some diseases come on suddenly, last 
usually but for a short time, terminate either in health or death, — 

*' Cita mors venit aut victoria laeta/'f 

» They constitute Orders 7 (Ectopise, from sxTOTrof, out o/;7Z«ce)and 8(Dyaly5es, from haXw^ 
to dissolve) of Glass 4. A complete view and explanation of all the Classes, Orders, Genera, 
Species, and Varieties in Cullen's System, may be obtained at a a^lance, by means of a "Sy- 
nopsis of Cullen's Nosology," published on a single sheet, by Butler, St. Thomas's Street, 
Southwark. 

^ From Jjc, out of; and "locus," a place. 

<= From £pvo;, a branch; — alluding to its protrusion. 

p From " actio, " to sharpen. 

e From xi°'^°'i time. 

f " A quick death or a happy victory arrives." — Horace's " Satires;'' Book 1; Satire Ij 
Line 8. 



38 GENERAL PATHOLOGY. 

and are called acute. Other diseases last for a long time — perhaps coming on 
slowly; but whether they come on slowly or suddenly, if they last for a long time, 
they are called chronic. Acute diseases, however, will sometimes, instead of ter- 
minating in health or death, become chronic; — that is, become less violent in degree, 
and go on for a length of time. Diseases, therefore, are to be considered acute or 
chronic according to their duration. 

Active and Passive Diseases. — Diseases are also considered, by some, accord- 
ing as they are active or passive; — that is to say, according as they are attended 
with a degree of violence or excitement of the system, or no excitement at all. Some 
persons (indeed a large number) use the terms " active'^ and '^ passive,''^ and " acute'''' 
and " chronic^'''' synonymously; but this is an error which ought particularly to be 
guarded against. It does not follow because a disease is acute, — that is to say, exists 
for a short time, and then terminates, — that it is necessarily attended by violent symp- 
toms; nor does it follow, because it lasts for a length of time, that these symptoms 
should not be active. This is illustrated, every day, in the case of rheumatism. It is 
daily spoken of as " acute" or " chronic," and " active" or " passive;" — the terra 
"acM^e" being used indifferently with '^active,^^ and " chronic'^ with '•'passive.''^ In 
the chronic form of the affection, therefore, a person would not think at first of apply- 
ing those remedies which, in an acute attack, would be beneficial; — taking it for 
granted that, as the disease is chronic, there is no violence; but that a slowness of mis- 
chief is going on, and that the remedies for the active acute state are improper. But 
we see, every day, cases of rheumatism which, although they have lasted for six or 
twelve months, or even longer, are still attended with all the symptoms of an acute 
disease; — that is, attended by heat of the parts, if not by quickness of pulse; and 
if blood be taken away, it appears buffed. It would, therefore, be a serious error 
to consider "«c/zye" and '■'passive,^'' as synonymous terms with ^^ acute''' and 
^^ chronicf^ because, in acute diseases, the word ''^ acute'' refers simply to their 
short duration; and, in chronic diseases, the word " chronic'^ simply to their long 
duration; whereas the word " active''^ refers to the violent disturbance going on in 
the system or part, and the word ^^ passive''^ to slow changes, — changes not of a 
violent description. A chronic disease may be active; and an acute affection may 
be passive. A person with an acute affection may lose all his powers, and the 
whole functions of the body may go on in the most languid way. Therefore 
*' acute" and "chronic" are one kind of state, " active" and " passive" are another. 
An acute affection cannot be chronic^ but it may he passive; and a chronic affection 
cannot be acute, but it may be active. 

Continued, Remittent, and Intermittent Diseases. — ^^Diseases differ, also, accord- 
ing to their uniformity of duration. Some continue with uniform tenor during 
their whole course, — without any very great deviation from the beginning to the 
end; these are called " continued." Others, again, undergo a very great remission 
at regular periods, or at least pretty regular periods; — the symptoms not going off 
entirely till the disease ceases altogether, but undergoing such a relaxation of severity 
at such periods, as to acquire a character from this circumstance; — when they are 
called "remittent." Wliile others, again, will cease entirely from time to tim.e 
(generally, too, at stated times), and recur again at certain intervals, so long as the 
person is affected with them; these are called " intermittent." These varieties are 
particularly seen in the case of fever. Fever may hold a pretty uniform course; — 
never ceasing at all, or particularly diminishing, during the twenty-four hours, till 
its close; and then we call it " continued fever." It may last lor a day, a week, 
or several weeks. Tn other cases, tliere is a sudden diminution in the degree of 
heat, violence of pulse, thirst, and all the other symptoms, at a certain period in 
the twenty-four hours, and perhaps at longer intervals; but they do not cease 
entirely: such is the character of " remittent fever." Others, again, cease entirely. 
Tile patient will be attacked at a certain hour, be ilia certain number of hours; and 
then recover perfectly, with the exception perhaps of languor: the disease then 
receives the name of ^'•intermittent fever." 

Continuent and Periodical Diseases. — Many persons speak of " continued" 



GENERAL PATHOLOGY. 39 

disease, as distinct from "remittent;" and it is so common that we are justified in 
using- the distinction; but some make a nicer distinction, and use the word " con- 
tinued'''' to inchide both " continuenV^ (whicli preserves the same tenor to the end), 
and " remittenf^ (wliich, although it never ceases, yet relaxes from time to time). 
If intermittent diseases recur and disappear at regular intervals, then they are 
called "periodical." A periodical disease is necessarily intermittent; but an inter- 
mittent disease is not necessarily periodical. Intermittent embraces the circum- 
stance of simple intermission, no matter when or how; but it embraces also regu- 
lar intermission, — periodical disease. The presence of a disease which is inter- 
mittent, is called the " paroxysm,"* or "exacerbation"'' (these being considered 
synonymous terms); and the interval which occurs between them, is called the 
" intermission;" or, in case of febrile disease, the period of apyrexia,*" — the period 
of the absence of pyrexia.* I fear being troublesome in mentioning the meaning 
of so many terms; but it is absolutely necessary that they should be understood, 
before proceeding to treat of particular diseases. 

Diseases differ, therefore, according as they affect function or structure; and as to 
whether they be local, or general; acute, or chronic; active, or passive; continued, 
remittent, or intermittent. 

Nature, Causes, and Seats of Diseases. — Diseases likewise differ in their true 
inherent nature, independendy of any other circumstances. They differ also as to 
their causes. Some are produced merely by an aberration as to some of the cir- 
cumstances which are necessary to the support of life; such as the excess of tem- 
perature or food, or a deprivation of food or air, or a diminution of food or air. 
Others, again, are produced by specific causes, — by the agency of particular sub- 
stances, the nature of which cannot be comprehended. Such, for example, is ague, 
which is produced only by a certain exhalation; and such is small-pox; and such 
are all those diseases which acknowledge a peculiar specific poison for their cause. 
Diseases difl'er likewise, according to the organ which they affect. There are some 
diseases which can affect almost every organ in the body. Inflammation is one 
which affects every part of the frame wliich has vessels; but there are certain 
diseases that can only ailect particular organs. The tendency to produce gall-stones, 
can affect no other part than the biliary system. In addition, therefore, to all the 
circumstances previously mentioned, diseases differ as they affect any part of the 
body at large, or are necessarily confined in their operation to particular organs. 

Explanation of Terms. — I must now enter a little more minutely into the expla- 
nation of certain expressions, which will be used frequently hereafter; otherwise I 
am in danger of -being misunderstood. The whole doctrine of disease is called, 
collectively, " General Pathology." Pathology is the science of disease, — " aegroti 
hominis scientise;"^ while physiology is the science of health. General Pathology 
is commonly said to embrace four particulars : — 1. General Nosology;^ or, an 
account of diseases in general, and of their differences. 2. An account of the causes 
of disease; which is called " setiology."^ 3. The symptoms of disease; which is 
called " semeiology,'"* or, " symptomatology."' 4. The treatment of disease; which 
is called " therapeia."*^ There is, however, not only a general but especial patho- 
logy, which respects particular diseases; and if the epithet ^' methodicar^ he 
attached to " nosology,'''' an arrangement of diseases is meant; — a classification of 
the various affections to which we are liable. 

* From TTet^o^uva), to aggravate. 

b From " exacerbo," to be become violent. 

<= FVom a. without; and irv^t^ia, fever. 

^ From trv^, fire. 

« " The science which relates to a sick man." 

^From ves-oj, a disease; and Xcysf, a discourse. 

e From atna., a cause; and \oyoi;, a discourse. 

^ From a-ifxiiov, a sign; and "koyor, a discourse. 

' From e-vfATCTtotxa., <ru/ut.rrTeafxaro;,a symptom; and Xcyof , a discouTse. 

•^ From fligarrtuw, to heal. 



40 GENERAL PATHOLOGY, 



SECTION II.—GENERAL NOSOLOGY. 

I shall first speak of what is called " general nosology," or the consideration of 
diseases in general. These may be either local or general; bnt even when local, 
they seldom continue so without producing more or less general effects. Diseases 
vary in their symptoms, and in their course, according to the texture which they 
affect. The body consists of a certain number of textures; — the various parts of 
the frame may be resolved into a certain number of particular " tissues," as ihey 
are called. Now, some diseases affect certain textures; and others affect other tex- 
tures; and the symptoms of diseases, and their course, are influenced very much 
by the texture which is thus affected. To take inflammation, for example: we shall 
find that the symptoms are very different when it affects a serous membrane, froni 
what they are when it affects a mucous membrane. Again: the symptoms are very 
different when it affects the skin, or when it affects a bone. The symptoms of 
disease, too, and the course of diseases, vary exceedingly according to the organ 
Diseases may not only attack a particular organ, but they may attack a particular 
texture in a particular organ, or they may attack all the textures of an organ. Now, 
when they attack any particular organ, the importance of that organ to the economy, 
the function which it performs in health, and the various relations of that organ, 
greatly influence the symptoms. For example: inflammation which may be of no 
consequence in the finger, may (though only to the same extent) be fatal when 
seated in the stomach; a lltfle ulceration, of not the slightest importance on the 
hand, may produce death if it occur in the stomach; an affection in the brain, or 
in the heart, may be productive of very different results, — a very different degree 
of danger, from what it would if seated in many other parts. 

Increased and Diminished Action. — Diseases vary exceedingly, likewise, in 
proportion as they are attended by excessive or diminished action. Some diseases 
are characterized by an inordinate, violent action of the part; — the natural state of 
the part seems augmented. Whatever is done in health, is done ten times more in 
disease; — at least for a time; till the strength is exhausted, or the state gradually 
subsides into health. Other diseases are characterized from the beginning, or nearly 
so, by a great diminution of action. The natural functions of the part decline ex- 
ceedingly; so that depression is the character of the disease. If the affected part 
be, in ordinary circumstances, possessed of much sensibility, (the general surface, 
for example,) the progress of disease in it is characterized by a very acute sensation 
of pain. If the part be one the function of which is motion, the latter may become 
very intense; and convulsions may occur as the consequence. On the other hand, 
we may have a diminution of feeling, — perfect torpor, — insensibility; and such an 
absence of all power of motion, that the part is useless to the individual. Again: 
if ihe part be one which secretes, the secretion may be in excess; and if it cannot 
escape we have dropsy. The secretion, on the other hand, may be exceedingly 
diminished; so that, in the case of the kidneys, no urine can be formed; and, in 
the case of the skin, the siirface shall be perfecUy dry. 

Changes of Size and Consistence. — Some diseases, among structural affections, 
are attended by a great dilatation of the part; — the part becoming much dilated, 
beyond its natural extent. On the other hand, in some diseases, the parts become 
contracted and diminished. In some diseases, the parts become exceedingly hard- 
ened; so that from being naturally soft, they become as firm as cartilage;* and are 
sometimes converted into absolute bone. Again: very firm parts will occasionally 
become perfectly soft; and bone will become as pliable as muscle.'' I have seen 
the liver become softened down to a pulp, in the course (to all appearance) of three 
days. Again: diseased parts will become exceedingly full, — distended with fluid; 

* From"carni]ago;" — from"caro, carnis," yZe.^A. 

^ From " musculus," the diminuiive of " mus," a mouse;— from the resemblance lo that ani- 
mal when flayed. 



GENERAL PATHOLOGY. 41 

and this may be either general or local. It may be either local congestion,* or uni- 
versal plethora^ of the body. In other instances, the parts become devoid of fluid, 
and shrink; and this is observed also generally or locally. Alterations of texture 
likewise take place, and alterations in the quality of the fluids. The texture, — to 
say nothing of induration, softening, hypertrophy, or atrophy, — the texture of the 
parts sometimes becomes perfectly diflferent from what it is observed to be in the 
state of health. So with respect to the fluids, they will frequently be formed of a 
character totally dissimilar from what they should be. The urine is sometimes any 
thing but genuine urine; and the bile is sometimes so pale, that we can scarcely 
recognise it as bile; and so with respect to the blood itself; it is sometimes very 
litde more than a reddish watery fluid. 

Hereditary^ Congenital, and Acquired Diseases, — The foregoing are important 
and essential diff'erences in disease. There are, however, many other vareilies, 
which are considered more or less accidental; — that is to say, which do not aflfect 
the nature and course of the disease. Some diseases are " hereditary," for exam- 
ple; and this will not at all influence the nature of their course of duration; but 
some diseases may be hereditary in the particular individual; while other diseases 
are not hereditary; — not transmitted from parent or ancestor to ofl'spring and pos- 
terity, but still are born in the individual. They seem to be implanted in him at 
his first formation; and then they are called only " connate'"" or " congenital."* A 
disease which is connate, or congenital, may be hereditary; but it is not necessa- 
rily so. All diseases which are neither hereditary, nor connate or congenital, are 
said to be *' acquired." 

Primary and Secondary Diseases. — Then diseases, — to speak still of acci- 
dental varieties, — are sometimes " primary," and sometimes "secondary." Some- 
times the disease which occurs is the first; but sometimes, after one disease has 
taken place, it is joined by another; — that is to say, it exists with another, or gives 
such a predisposition that another is produced; but it is of no consequence to the 
nature of a disease, whether it is primary or secondary. 

Sporadic, Endemic, and Epidemic Diseases.'— Agn'm: diseases are sometimes 
said to be " sporadic,"^ sometimes " endemic,"^ sometimes " epidemic."^ A dis- 
ease is said to be sporadic, when it occurs from an accidental circumstance occur- 
ring to any particular individual; — when it is a solitary accidental case. Hence, 
when a person, from exposure to cold, suff*ers inflammation of the lungs or intes- 
tines, he is said to labour under a sporadic disease. These are insulated cases, 
—having no connection with each other; — not having any general prevailing cause. 
But if diseases occur from some general and temporary cause affecting a whole 
population, then they are said to be epidemic. "Sporadic" and "epidemic," 
therefore, stand contrasted with each other; — diseases of the former class being 
those which occur occasionally and accidentally, from some peculiar circumstance 
happening to the individual; while epidemic diseases are those which aflTect a large 
mass of persons, from some general prevailing cause. Again: diseases are some- 
times said to be endemic; — that is to say, when they do not arise from any gene- 
ral influence at a particular time, pervading a population, but when they spring 
from certain causes fixed and inherent to a certain place; — when certain places 
in which people reside, send forth causes of disease, to which all persons who 
come to that spot are liable, but from which persons do not suffer unless they go 
there. This is the distinction between " mdemic" and " fjoulemic" diseases; — 
the former being confined to the inhabitants of a particular spot; and the latter 
being those which arise from a general cause, taking place only from time to time, 
and pervading, not a particular spot, but a considerable population. 

* From "congero/'^fl accumulate. 
^ FromTrXrj^M, to JiU. 

« From " con," 2vith; and " nascor," to be born. 

* From " con," with; and " genitus," born. 
e From a-Trei^oo, to sow. 

t From £Vy among; and J>)yuof, the people. 
K From iTTt, upon; and ^fxo;, the people. 



42 GENERAL PATHOLOGY, 

Contagious and Non- Contagions Diseases, — Another difference in diseases — • 
not at all affecting their nature, their course or their treatment — is, that they may 
arise from a common cause, or from a specific contagion. Some diseases are con- 
tagious, and some are not; but the symptoms do not vary in their essential nature; 
so that we are continually very much in doubt, as to whether a certain disease is 
contagious or not. There is nothing in the disease itself, to make us say that it 
must necessarily be contagious: and the greatest disputes are carried on, as to 
whether a particular affection is or is not contagious. 

Period and Seat of Diseases. — Diseases have likewise been distinguished 
according to the time of the year at which they occur; so that we have vernal, 
summer, autumnal, and winter affections; — vernales, sestivi^ autumnales, and hyS' 
males. Other accidental differences of disease arise from their seat; — whether 
internal or external; and then, again, as to whether they are fixed, or whether they 
wander. If they cease in one particular part, and appear in another, they are said to 
be " metastatic,"* or "retrograde,'"' or " retrocedent."" If disease suddenly cease 
in one psrt, and another become affected, a metastasis, or change of place, is said 
to have occurred. 

Severity of Diseases, — Diseases differ according to their severity. Some are 
exceedingly severe, others are light; — some are said to be mdd, and others are said 
to be malignant. Those which are said to be of a malignant character, however 
mild they may be in appearance, are sure to baffle all the resources of our art, unless 
we can eradicate the affected part by a surgical operation; which sometimes is, 
but sometimes is not, possible. The word " malignant,''^ however, is sometimes 
employed simply to denote a certain degree of severity; — it is a term of rather 
indefinite meaning. Small-pox is said sometimes to be "mild," and sometimes 
" malignant;" and, again, a sore which is of a cancerous nature, — however trifling 
the pain attending at first, but which is sure to go on to ulceration, violent pain, 
and (at last) destruction of the part, — is also said to be "malignant." 

Duration of Diseases. — Diseases vary likewise as to their duration. If they 
be exceedingly short, — so as to terminate within four days, — they are called by 
Latin authors " acutissimi;" but if they terminate within seven days, then they 
are called " peracuti." We have no English words to signify the difference 
between these two durations. If they terminate within fourteen days, they are 
called " acute;" if they run on to twenty days, then you will find authors calling 
them " sub-acute;" and some are so nice in their terms, that if they last forty days 
they call them " acuti decidui;" and all that run on above that period are called 
" chronic." It is sufficient, perhaps, to remember, that an acute disease is con- 
sidered to be one which terminates within fourteen days — a sub-acute one which 
terminates within tioenty; if the disease extend to or above twenty days, we may 
consider it chronic; — at least, I fancy a patient would think we were justified in 
so denominating it. 

SECTION III.— ETIOLOGY. 

Classification of Causes. — The causes of disease are generally divided by authors 
into two; — the " remote" and the " proximate." The remote causes, again, are 
divided by systematic writers into two more; — " predisposing" and exciting." 
The word " cause,'''' however, is in these cases used in a totally different sense. 
When we speak of " remote causes," a very different idea presents itself, than 
when we speak of "joroa:zwa^e causes;" — in fact, the cause of the disease, properly 
speaking, can only be remote. The remote cause, for example, of fever may be 
bad food, and the depressing passions; and the exciting cause may be, according to 
some, a specific contagion. Now the remote causes of the first description are 

^ From (xiSisrrDfA,i, to translate. 

b From " retro," backward; and " gradus," a step. ^ 

« From " retrocedo," to go bade. 



GENERAL PATHOLOGY. 43 

called *' predisposing;" they render the body liahle to become the prey of some- 
thing, wfiich has a tendency to excite the disease. The exciting cause of the dis- 
ease might have had no effect, unless the body had been predisposed; and liie pre- 
disposition might not have had the effect, unless the exciting canse had occurred. 
A circumstance, therefore, which inclines the body to become the subject of disease, 
is called, ^^ s. predisposing cause" ("causa prsedisponens'"^)'^ that which actually 
excites the disease, " an exciting cause" (causa excitans); and both together are 
called " remote causes" (causae remotse). They are called remote, I presume, be- 
cause they are a little distance from the disease itself; and because the proximate 
cause is, to all intents and purposes, close to and all but the actual disease. In one 
sense, indeed, it is the disease itself. 

Proximate Cause. — The application of this term (" proximate") gives rise to a 
great deal of confusion to the student. He would imagine that disease could be 
nothing more than disease; and to call the disease " the proximate cause," would 
be thought absurd; but the reason of this I will explain. In defining any particu- 
lar disease, we are obliged to take into our definition only what we observe; — ^just 
as the naturalist defines any flower, or any mineralogical specimen, by merely tak- 
ing what is the object of sense, and describing it with all the marks together; and 
thus we have what is called the "definition of a disease." For example: in jaun- 
dice we take together the yellowness of the skin, the yellowness of ihe eyes, the 
yellowness of the nails, the whiteness of the fasces, and the high colour of the urine; 
and say that the patient certainly has jaundice. The jaundice is not the disease, 
strictly speaking; but the collection of symptoms under which the patient labours, is 
called "jaundice." Thus the word "•disease''' is applied by nosologists, not to the 
single c«*^se of all these symptoms, but to the collection oi sym^ioms. Take epilepsy: 
a person falls down foaming at the mouth; struggling in every limb; perfectly uncon-^ 
scions; and afterwards, when he ceases to foam and struggle, he lies senseless; — 
such a person is said to labour under epilepsy. These particular symptoms, blended 
together, occurring in succession, are called "epilepsy." Now in Cullen's, and other 
methodical nosologies, the disease is defined according to mere symptoms; — all opin- 
ion, — all ca\ise, is excluded. They take merely the symptoms, and call them the 
disease. It is perfectly right that it should be so. But these symptoms must have a 
cause; — there must be a cause for this disturbance in epilepsy; — there must be a 
cause for the bile going into the blood in jaundice, appearing in the urine, and not 
being able to find its way to the faeces.^ The cause of the epilepsy, or of the jaun- 
dice, is the circumstance that produces all these effects; and that is considered to 
be the " proximate cause." If the epilepsy arose from a piece of bone depressed 
upon the brain, we should say the proximate cause of the epilepsy was the spicu- 
lum of bone. If the bile were obstructed because a calculus was impacted in the 
hepatic" duct, we should say the impaction of the calculus was the proximate cause 
of the jaundice. The proximate cause, therefore, is in fact the disease itself; — the 
actual disease from which the symptoms arise. The remote causes are those that 
predispose to the disease, or actually excite it; ihe proximate cause is the circum- 
stance to which the predisposing and exciting causes have given rise; and this 
circumstance, when present, produces all the external symptoms, — the visible 
changes. 

But the word "rfzsease," when we come to any specific affection, is (in a noso- 
logical sense) applied merely to a set of symptoms; — to that which we can com- 
prehend, — which is discernible; and, as nosologists, we should not apply the word 
"c?isert.9e" to the cause of all these symptoms; but should call it the '-' proximate 
canse.''^ When speaking as pathologists, however, and not as nosologists, persons 
inquire, — " What is the actual disea'se in this epilepsy? — What is the actual disease 
in this jaundice? Is it an enlarged pancreas pressing upon the ducts? Is it a cal- 
culus sticking there? Is the disease a contraction of the sides of the ducts, or what 
is it?" But that is a different sense of the word " disease;'^ and it is necessary to 

■ From " feex, fgecis," dregs. ^ From r.Trap, fiirarof, the liver. 



44 GENERAL PATHOLOGY. 

State that the term is employed by methodical nosologists, and must be so by me, 
to signify a collection of symptoms; and not the true cause, which is at the bottom 
of those symptoms; for though we might be inclined to say that this was the real 
disease, yet it is not so considered, but has received the appellation — ^'-proximate 
cause..^'' 

I trust that the explanation now given, will hereafter prevent any confusion which 
naight otherwise arise. From an imperfect understanding of this matter, persons 
quibble about what is, and what is not, disease. It is necessary to know that a 
set of symptoms, following in a certain order, or united in a certain collection, is 
called " a disease;" and the immediate cause of ail these symptoms, — which some 
say is the real disease, is called by the best writers "the proximate cause."* 

Occasional or Procatarctic Causes. — Exciting causes are, by some authors, 
called ^'occasionaV or ^' procatarctic.''^^ Generally, in England, we say " predispos- 
ing," and "exciting;" but in foreign books a variety of other names are employed. 

Predisposing Causes. — With regard to {he predisposing causes of disease, they 
depend upon a very great number of circumstances. Each particular age, for 
example, is predisposed to particular affections. The child is predisposed to one 
kind of disease, the youth to another, the adidt to another, and the old man to a 
very different set. Climate, also, causes a great difference in the disposition to 
disease;*^ the season of tiie year, likewise, has a great efi'ect; the habit of the indi- 
vidual, as to temperance and sobriety, and as to a natural or unnatural and artificial 
course of life, has a peculiar influence. All these circumstances cause a predispo- 
sition to different affections. In regard to some diseases, there is not so much a 
predisposition required, as a ivant ol indisposition. Almost every one, for instance, 
will take the small-pox, the measles, and the hooping-cough: so that we can hardly 
say that there is a predisposition to these dise^ises. The cases in which they do 
not occur are rare exceptions; and we are more justified in saying, that the person 
is indisposed to them, when these diseases will not occur in spite of the presence 
of contagion, than that those who catch them are predisposed to them: — that is to 
say, by nature we are all more or less liable to them; and it would be almost an 
abuse of terms to say that we were predisposed to them. All that appears to be 
requisite is, that there should be no indisposition to them. 

Exciting Causes. — With respect to the exciting causes of disease, they have 
been generally classed in three orders. 1. Those which excite or stimulate. 2. 
Those which depress or debilitate. 3. Those which exert a physical or phisco- 
chemical action. Heat, and excess in wine, are stijnulating causes of disease: the 
depressing passions, and an excessive loss of blood, may be instanced as debili- 
tating causes of disease; and these debilitating causes are spoken of, by some Italian 
authors, as contra-stimulating causes. Many causes, however, cannot be said 
either to depress or stimulate solely; they exert a peculiar action, which is not to 
be thus explained. It is something we do not understand. For example: malaiia,* 
which produces ajrue, is a certain agent perfectly unknown to us, except so far as 
regards the situation in which it is produced. Malaria produces a set of symptoms 

* The proximate causes of disease consist in alterations either in the structure or in the 
functions of parts; and are therefore divided into organic and functional. The organic 
proximate causes may be divided into four classes: — 1. Inflammation and Fever. 2. Deposi- 
tions. 3, Gangrene, 4. Displacements. Deposiiions are of four kinds: — 1. Natural Tissues 
in excess, 2. Preternatural Tissues. 3. Natural Fluids in excess, 4. Preternatural Fluids. 
Displacements are of seven kinds: — 1. Intus-susception. 2. Hernia. 3. Prolapus. 4, Ex- 
tra-uterine Conception. 5, Miscarriage. 6. Fracture, 7. Dislocation. The functional 
proximate causes may be divided into three classes; — 1, Spasms, and other examples oi' in- 
creased action. 2. Convulsions, and other exp.mp\es of irregular action. 3. Palsies, and 
other examples of diminished action, — Dr. Fletcher. 

*> From TT^onaret^x'^y ^^ S^ before. 

c In hot countries the skin and the liver are more liable to disease, and the lungs and the 
kidneys in cold; because these have, respectively, more to do in a hot and in a cold climate. 
— J9r' Fletcher. 4 

<» The Italian name of an intermittent, endemic in the Pontine marshes. 



GENERAL PATHOLOGr. 45 

of SO peculiar a nature, thai we cannot say it is a mere depressive or contra-stimu- 
lating ao'ent; — that is to say, though the first symptoms of ague produced by it are 
those of extreme debility, yet if we weaken the body to the same extent in various 
ways (as by bleeding and other means), we do not produce that train of symptoms 
known to us as intermittent fever. We have, then, " stimulating," " depressing," 
and " physical," or " chemical" causes; — sometimes called " stimulantes," " contra- 
stiraulantes," and " irritantes." We must not, in medicine, be very nice about the 
etymology of our woids, — that is to say, we must employ words of a certain mean- 
ing, so as to be clearly understood; but we shall find words signifying something 
very diff'erent from what their etymology would lead us to suppose. Nor is this 
remark confined to medicine; it applies equally to anatomy; and our only object 
should be to employ language intelligible among ourselves; — to know what ideas 
are meant to be conveyed, when certain expressions are used.* 

An exciting cause may become ?i predisposing; and a predisposing^ an exciting. 
For instance: malaria excites ague. But a person who has been exposed to malaria, 
may not have ague till he accidentally gets wet through; and then this excites the 
disease, to which the malaria had only predisposed him. Again: if a predisposition 
continue to increase, disease will happen without any exciting cause. Plethora 
of the head may increase till a fit of apoplexy occurs; — witliout stooping, over- 
loading the stomach, or any common exciting causes.^ 

Non-jSaturals. — Among the most common causes of disease, are aberrations 
with regard to six particular circumstances, which have been very strangely called 
" non-naturals." The air we breathe, the food and drink which we take, the reten- 
tions and excretions, motion and rest, sleep and watching, and the various passions 
of the mind (which are all natural enough), are called by old writers "non-naturals;"° 
and others, seeino- the strangeness of this expression, have called them " things 
necessary to life;" — that is to say, things which are necessary in order to the con- 
tinuance of our existence. The great source of disease is, — an aberration of all 
these from that state which conduces to health. With respect to air, for example: 
vitiation produces a variety of diseases; such as fevers, and many others. Our 
health must depend much upon the wholesomeness of our food and drinks and 
upon a proper quantity of them. The body cannot bear more than a certain degree 
of exertion; many diseases, therefore, arise from fatigue. On the other hand, 
excessive rest and indolence produce a collection of fluids in various parts of the 
body, — stagnation, plethora, fatal dropsy, and various organic diseases. So with 
respect to sleep and rest, alternations are absolutely necessary; and we every day 
see persons who, for want of sleep, become the victims of fever, and gradually of 
the most destructive diseases. Again, with respect to the passions of the mind; — 
there is scarcely a disease (with the exception of those that depend upon contagion) 
to which they do not give rise; nor is there any one part of the body, in fact, ex- 
empted from disease through the passions of the mind. No one can imagine what 
a vast number of diseases, not only functional but organic, arise simply from un- 
pleasant emotions of the mind; — that is to say, from grief and deep-rooted sorrow, 
from violent anger, from rej^ret and chagrin, and all those feelings which are of an 
unpleasant character. On the other hand, it is also to be reniembeied, that emo- 
tions of the most agreeable kind, — excessive joy, for instance, — may have an efl'ect 
almost as injurious as those which are of an opposite character. 

^ir. — With respect to the first of these non-naturals, the air, it may injure the 

* This is a very good object, but it ought not to be the onlij object aimed at. The " ex- 
pressions used" should, as nearly as possible, correspond with the "ideas meant to be con- 
veyed." 

^ " Predisposing" causes are ahvays internal; " exciting" cau^es may be either internal 
or external. Sleep (which, in excess, produces disease) is aa example of an internal excit- 
ing cause.— Dr. Fletcher. 

c tjo called, because they do not enter into the composition of the body; but, ai the same 
lime, are necessary to its exiblence. 



4^ * GENERAL PATHOLOGY. 

body by its weight or levity,-— by the various electrical qualities which it may 
possess, — by its temperature, dryness, and moisture. Various winds produce, 
upon the human body, effects of the most curious kind; — according to the countries, 
or districts, or parts, over which they pass. With respect to temperature, it 
injures the body not only by its height or lowness, but also by its vicissitudes; and 
not only so, but according to its partial or general application to the body. A tem- 
perature that would do no harm if it were continued, would be productive of serious 
mischief if it suddenly succeeded an opposite temperature. A temperature which 
would do no harm if applied throughout the body, frequently does great harm if 
partially applied. Every body knows the danger of suddenly cooling, if the body 
be over-heated and fatigued; and of a draught applied to any one part of the body. 
Under this head, also, may be mentioned various effluvia and odours; as they are 
transmitted through the air. 

Food and Drink.— -V^pon food and drink, another source of disease, I need say 
but very little; they may be injurious either by their quantity or quality. 

Retained Secretions;— Plethora. — The great thing here alluded to by old authors, 
is the blood; and it was supposed formerly, that it might greatly injure the body 
mechanically by its excess, either absolute or relative: so tliat" plethora" formerly 
occupied a very prominent part among the causes of disease. Some curious dis- 
tinctions are made by old authors on the subject of plethora. They call it " absolute" 
or "true," or ^^advires^^^ or '^ad vasa,^^^ when the quantity of blood was absolute- 
ly in excess. They called it "apparens" when the blood was in its natural quantity, 
but expanded; — believing that it might be expanded by heat, and thus a temporary 
plethora be induced. When there was no actual increase of blood, — when the blood 
was not expanded improperly by heat, but the space in which it moved had become 
too small, this was called " relative plethora," or "plethora ad spatiumf'^ — where 
the vessels, it was supposed, became contracted, and the blood was merely in ex- 
cess, as compared with the contracted space. Plethora, however, may either be 
general or local. A local plethora is what, in modern language, is called an inflam- 
mation or congestion, — just as the case may be. When the blood is really in excess, 
I believe that it is generally of too rich a quality; that there is too little of its watery 
portion, and too much of the crassamentum."^ 

Inanition. — The opposite of plethora, is inanition. This is a state which is 
induced by excessive discharges, or from the want of food; so that the blood which 
was in the body is let out, or the blood which naturally escapes in the various ex- 
cretions, is not replaced. Anaemia (bloodlessness; or, more properly, a watery 
state of the blood) will arise from a state of the system that is not at all understood; 
in which, although food is taken, nourishment is but very sparingly extracted from 
it. Cases of this description are seen continually: chlorosis is one of this kind. 
But the blood certainly is sometimes in fault with regard to its constituents; not 
merely as to whether it is too rich or too poor, but — as would appear by some ex- 
periments of a friend of mine (Dr. Stevens), and of Dr. Clanny — by the saline 
ingredients erring in quantity; so that the blood, in many cases of disease, is abso- 
lutely deficient in its saline particles.^ It is evident, however, that diseases of the 
soli-ds themselves will sometimes cause these aberrations of the blood; so that the 
blood itself is not the cause of the disease. It may become an instrument of farther 
disease; though disease of the solids originally gave rise to the aberration of the 
vital fluid. 

U)idue Excretions. — With respect, however, to the excreta, it may easily be 
conceived how excessive discharges occasion various diseases. The excessive dis- 
charge may consist of blood, of bile, of secretion from the alimentary canal (faeces), 

a " Relatively to strength." « " Relatively to the space." 

*» "Relatively to the vessels." ^ prynn " crassus," tMck. 

e See " Observations on the Healthy and Diseased Properties of the Blood; by William 

Stevens, M, D.;" and " Hyperanthraxis, or the Cholera of Sunderland; by William Reid 

Clanny, M. D." 



GENERAL PATHOLOGY. 47 

of urine, of perspiration, of saliva (seldom, however, doing much harm), or of semen. 
These are the fluids which particularly escape from the body, and the escape of 
which may do harm. But with regard to that last-mentioned (semen), although 
one must suppose that the excessive loss of the fluid must of itself be injurious, yet 
it is very certain that the mode in which that fluid is lost, exerts a very great influ- 
ence upon the constitution. 

Exercise. — With regard to ^notion and rest, I need not point out the ill efTects 
of sluggishness on the one hand, or of fatigue on the other. Nor need I make any 
remarks with respect to sleep and watching^ for they come under the same head 
as " motion" and "rest;" — sleep and watching being to the brain, what repose and 
motion are to the rest of the body. 

Mental Emotions. — With respect to the passions of the rnind, I mentioned that 
they are a frightful source of disease; — much more so than is commonly imagined. 
An immense number of cases of disease of the heart, and disease within the abdo- 
men,* as well as of the brain itself, arise (I am certain) from unpleasant passions of 
the mind. It is not only unpleasant passions, however, that affect the body inju- 
riously; violent emotions of the most pleasurable kind, will sometimes operate in 
the same way. History relates many accounts of persons who have died from 
excessive joy. 

Poisons. — Besides those circumstances which I have just mentioned, the body 
is liable to injury from two very common sources; one of which is poison of various 
sorts;" which poison may enter the system by the surface, by the breath through 
the medium of the lungs, or by being swallowed. It is a very curious fact, however, 
that many poisons which act offensively when admitted into the body one way, 
have no effect when admitted in another; for it is an established fcict, that the poison 
of hydrophobia, or of a serpent, may be swallowed with the most perfect impunity. 

Mechanical Injuries. — In addition to poison, the body suffers much from me- 
chanical injuries; which, of course, may affect almost any part of the body.*" 

Predisposing Causes; — ^ge and Sex. — Among the causes of disease which 
chiefly act by giving a predisposition, we may mention that of age. All periods 
of life are subject to their own diseases; whether we divide them with Shakspeare 
into seven,** or with those authors who mention five,^ or those who mention more. 
We rarely see gout in an infant; nor is it common for old persona to have the symp- 
toms of acute hydrocephalus. In short, every age seems marked out as particu- 
larly liable to be, if not destroyed, at least impaired, by particular diseases. The 
same is the case with respect to sex. Hysteria, which occurs only now and then 
in the male, occurs far more frequently in the female; and even when there is no 
reason to suppose an affection of the uterus. Of course, there are certain diseases 
which can affect but one sex. 

Temperaments. — Disease depends much upon temperament.' We are all of 
some temperament, or some combination of temperaments; but excess of one tem- 

* From " abdo," to conceal; — as the abdomen conceals the viscera within it. 

•^ Dr. Chrisiison divides poisons into three classes. — 1, Irritant. 2. Narcotic. 3. Narcotico- 
Acrid. Orfila has four. — 1. Irritant. 2. Narcotic. 3. Narcotico- Acrid. 4. Septic, or 
Putrefiant. Dr. Fletcher divides them into six classes: — 1. Acrid. 2. Corrosive. 3. Nar- 
cotic. 4. Narcotico-Acrid. 5. Astringent. 6. Septic. The reader is referred to his " Phy- 
siological Classificaiion of Poisons," published as a Chart, by Butler, St. Thomas's street, 
Soul h war k. 

«= The following are the principal causes which, either by their presence, by their excess, 
or hy ih^ir deJiciencT/, may excite disease:— 1. Caloric. 2. Light. 3. Electricity. 4. Air. 

5. Contagious and infectious Miasms. G. Aliment. 7. Poisons, either swallowed or inocu- 
lated. 8. Pressure. 9. Blows. 10. Wounds. 11. Exercise. 12. Retained Secretions. 13. 
Sympathy. 14. Passions. 15. Sleep.— /?r. Fletcher. 

'^1. The Infant. 2. The School-Boy. 3. The Lover. 4. The Soldier. 5. The Justice. 

6. The Pantaloon. 7. Second Childishness. See " As you like it ;" Act 2; Scene 7. 

" 1. Infancy; from birtii to seven years. 2. Boyhood; from seven to sixteen. 3. Adolescence; 
from sixteen to twenty-five. 4. Adult Age; from ticenty-fivc lo fifty. 5. Old Age; I'lvm fifty 
years to death.— Dr. Fletcher. 

^ From " lempero," to mix together. 



48 GENERAL PATHOLOGr. 

perament gives a great liability to disease. The usual divisions of temperaments 
are four: — 1. Sanguineous. 2. Melancholic. 3. Phlegmatic. 4. Choleric. The 
sanguineous is marked by smoothness of ?kin, softness of hair, a quick pulse, 
a warm surface, great excitability of the vi'hole frame, and generally a fair skin 
with florid complexion. The melancholic, on the other hand, is marked by a 
slow pulse, a dark swarthy complexion, dark and strong hair, and less suscepti- 
bility of emotion, — that is to say, of sudden violent emotion; although, when cer- 
tain emotions take place, they are said to be more continued. The phlegmatic 
is marked by torpidity, paleness, and flabbiness. The choleric is characterized by 
reddish hair, and great excitability. However, these divisions, made by the 
ancients, are not so much attended to now. We often see these temperaments 
strongly marked; but they are also, at other times, variously combined. 

An attempt has been made, within these few years, to divide temperaments dif- 
ferently; namely, according to the activity of particular parts. For instance: some 
persons have the chief activity in the head. They have a large intellectual develop- 
ment of the head, as some people say; and theirs would be called, perhaps, " the 
cerebral temperament." Others, again, have a large broad chest, with a considerable 
development of all the muscles; and this is called "the thoracic, or muscular temper- 
ament." Again: others are sluggish, — prone to eating and drinking, with protuberant 
abdomens; and are said to have " the abdominal temperament." It is rather an 
abuse of terms to call these states "temperaments;" for I think the word ''tempera- 
ment''^ rather refers to a constitution and character of the frame altogether. Yet 
there is no doubt that these divisions occur; for you see some persons all intellect; 
others all muscle and chest; and some portly, with their large abdomens and lean 
pates; — their heads suffering in proportion to the predominant size of the abdomen. 
In truth. Dr. Thomas entitles his work, — "Physiologie des Temperaments ou 
Constitutions.''^ 

Whether we call these conditions " temperaments" or not, it is well to know 
that these persons will suffer various diseases, according to the divisions under 
which they come; — as in the case of those who are of a sanguineous, phlegmatic, 
choleric, or melancholic temperament. They will be particularly liable to diseases 
of the head, if they be of the cerebral conformation; they will be subject to affec- 
tions of the chest, — not of a phthisical, but of an inflammatory kind, — if they have 
a full thorax; and they will be subject to various hepatic, and other abdominal 
diseases, if the abdomen gain the sway. It is worth while to attend to this other 
division of temperaments; although, perhaps, the term itself may be objectionable. 

Peculiarities. — Besides original temperament, acquired peculiarities take place 
by a long residence in a particular climate. By long residence in a particular 
spot, certain dispositions of the body are engendered; and a second nature, if I 
may so style it, is prochiced. The various occupations of life have the same effect; 
— the various trades have their various diseases. On this subject I cannot point 
out better works than Ramazini's* and Thackrali's.** Custom and habit — whether 
referable to trade or situation, or action, or any other circumstance — have also a very 
great effect in producing or preventing the cure of disease. For example: if a 
person who is in the habit of dram-drinking has a sore, nothing is more common 
than to observe, that in spite of the best surgical treatment, tlie healing process 
will not commence till the person is allowed his dram. After surgical operations, 
persons have been known to sink, through ignorance (on the part of the surgeon) 
of tlie general habits of the patient. Even death has occurred after operations, 
from the sudden abstraction of stimuli, to which the patient had been previously 
accustomed; whereas if he had been allowed his ordinary dram, the probability 
is that he would have recovered. This has been strikingly shown in other cases, 
where the knowledge was happily attained; and a good allowance of gin, after 
some severe accident, has caused every thing to go on well, though the patient at 

* " Treatise on the Diseases of Artificers," translated by Dr. James. 
^ " Effects of Arts, Trades and Professions, on Health and Longevity. 



GENERAL PATHOLOGY. 49 

first appeared sinking. Bad habits are, therefore, sometimes to be indulged; 
although they should certainly never be acquired. 

Idiosyncrasies. — Independently of what is called temperament, an individual 
may have a particular disposition, not acquired; it may be born with him, and be 
hereditary. A peculiarity is sometimes so exceedingly singular, — so totally dif- 
ferent from what we observe in other people, that it is called idiosyncrasy.^ It 
is nothing more than a peculiarity, either original or acquired by habit; and some- 
times it is only congenital, while at other times it is hereditary. As an instance 
of this, we sometimes find a person who cannot eat a certain article of food. I 
recollect seeing a young woman who could eat the hardest salt beef, and digest it 
well; but if she took a raspberry, or current, or any other fruit, she was instantly 
thrown into the most violent spasms of the stomach; so that a stranger would have 
fancied her life in danger. These are called idiosyncrasies; and it is of great use 
to knov/ them, because some persons are peculiarly affected by certain remedies; 
and that which is a proper remedy for the disease, may be improper for a particu- 
lar patient.* 

So much, therefore, with respect to the causes of disease in general (general 
setiology). I will now proceed to consider the third branch of General Pathology; 
— the symptoms of disease in general {semeiology or symptomatology). 



SECTION IV.—SEMEIOLOGY, 

Nature of Symptoms. — Symptoms com\ixehew{\ every thing which is observed 
in a patient out of the course of health; — " singul2e quae in ffigro preeter naturam 
observantur res."*' The most evident, and the most constant of these, are put to- 
gether; and are said to constitute the disease. The disease is not the cause of the 
symptoms, but the aggregate of symptoms constitute the disease. I illustrated 
this with respect to jaundice and epilepsy;*^ the outward signs of which are jaundice 
and convulsions, while the inward state is the proximate cause. 

Essential and Accidental Symptoms. — Symptoms may be '' essential" (also 
called " pathognomonic"^), or they may be "accidental." The essential symptoms 
of disease, are those which are necessary to make the disease, — to constitute the 
idea of the disease. We cannot, for instance, suppose a patient to have pleurisy, 
unless there be a degree of feverishness, with sharp pain of the side, increased 
upon respiration, together with cough. These symptoms would be called " the 
essential symptoms of the disease;" yet no one of them would make the disease. 
A patient may have feverishness without pleurisy; or a sharp pain (either muscular 
or neuralgic) in his side without pleurisy; or, again, he may have cough without 
pleurisy. These symptoms, then, are altogether essential to the disease; but no 
one of them constitutes it. If, however, a symptom be so important to the dis- 
ease that the latter cannot be present without it, then it is called " pathognomonic;" 
— a symptom without which we could have no conception of the existence of the 
disease. There are, however, but few of these symptoms. In jaundice, the yel- 
lowness of the skin, of the sclerotica,^ and of the nails, is pathognomonic. With- 
out making any farther inquiry, we may be sure that the patient labours under 
jaundice; but, in general, we make out the disease from the groups of essential 
symptoms, and from taking into consideration every circumstance of the case. 
Besides these symptoms, others are accidental. Many cases have symptoms 

* From j^£o?, peculiar; o-uv, with; and x^etn^, a temperament. 

•» The principal circumsiances which predispose to disease, may be summed up under the 
following heads:—!. Age. 2. Sex. 3. Temperament. 4. Idiosyncrasv. 5. Habit of Body. 
G. Climate. 7. Situation. 8. Season. 9. Diet. 10. Trade or Professioii. 

c Gregory's " Conspectus Medicinaj Theoreticae," Chapter I: Paragraph 2G. 

<J See Page 43. 

e From Trafloc, a disease; and yivxa-KM, to know. 

f From o-xxreoftj, to harden,. 
VOL. I. — 4 



50 GENERAL PATHOLOGr. 

which are not at all necessary to the disease, since it has frequently existed with- 
out them. 

Positive and Negative Symptoms. — You will find symptoms also spoken of as 
*' positive" and " negative;" and it is of great use to attend to the latter. "A nega- 
tive symptom" is, perhaps, an improper expression; as, properly speaking, a 
symptom must be positive. But, from tiie absence of certain circumstances (or 
symptoms) we frequently make out the nature of a disease. If there be two dis- 
eases with certain symptoms common to both, but one of them has a symptom 
which the other never has, then, if that symptom be absent, it enables you to make 
out the true nature of the case. Hence the absence of certain symptoms is frequently 
of as great importance to be attended to, as the presence of others. 

Diagnosis of Diseases. — From ihe presence of the symptoms chiefly, but not 
entirely, we make out the character of the disease; and the determination of the 
character, the name and nature of the disease, is called tlie " diagnosis."* To speak 
again of jaundice:'' from the yellowness of the skin, the whiteness of the fjeces, and 
dark colour of the urine, we make our diagnosis, and say the disease is jaundice; 
although, indeed, we may do so merely from iheyellowness of the skin and of the 
sclerotica. But, frequently, the diagnosis is not easily made out from the symp- 
toms alone. It is necessary to look into the exciting and predisposing causes of 
ihe disease, to ascertain what predisposition the patient is likely to have; also to 
ascertain to what exciting cause he has been exposed; and then — conceiving what 
it is likely would ensue, and observing (as far as possible) what actually has ensued 
— we are enabled to form a much belter conclusion as to the real character of the 
affection. The diagnosis is also materially assisted by attending to the history of 
the case; — not merely observing the symptoms that present themselves to our no- 
tice, but inquiring carefully of the patient the whole story from the beginning. We 
thus ascertiin whether these circumstances confirm what we suppose to be the 
nature of the case. In making out the character of the disease, it is also of great 
importance to learn the effects of any previous treatment that may have been adopt- 
ed. If vigorous treatment has been employed, and has produced no effect what- 
ever, there will be great reason to doubt the propriety of the view which has been 
taken, with respect to the nature of the affection. In making a diagnosis, all these 
points are to be scrupulously attended to. 

It is in making an accurate, careful diagnosis, that the medical practitioner chiefly 
shines. When the nature of a disease is once ascertained, it is no difficult matter 
to treat it. Other qualities of mind are then required; — frequently only courage, 
or mere perseverance; but it is in making a diagnosis, — in ascertaining the character 
of a disease, that the scientific practitioner outshines the inferior. Unfortunately 
this is a point not attended to as it ought to be. Many persons pride themselves 
in being good practitioners; because, without knowing what is the matter, they can 
say what will do good. It is an unscientific way of proceeding; and, even if I 
-could not practise better for making a good diagnosis, still I would be as particular 
on that point as possible, for the sake of observing a good general rule, — for the 
sake of endeavouring to treat the patient belter than I otherwise could, notwithstand- 
ing all my conceit; and for the purpose of being ready to meet any unexpected 
emergency that might arise. A medical man who will not take the trouble to 
establish a diagnosis, is just like a surgeon who will not condescend to learn the 
anatomy of hernia; but who says that he knows if he cuts this way and that way, 
he shall liberate the entangled parts, and accomplish the operation as well as the 
best. I have witnessed this; but, then, what are such men when a difficulty arises? 
They are lost in perplexity, and ^lad to apply to those who know better. It is 
impossible to be too minute in making a ili;ignosis. 

Not only is it necessary to make a diagnosis as to the general character of the 
disease, but also to ascertain what variety of the affection it is (whether it is one 
with strength or weakness); and to weigh the minutest circumstances respecting 

* From liayiywTKoe, to distinguish. ^ See Pages 43 and 49. 



GENERAL PATHOLOGY. 5X 

the case. This is, perhaps, an exercise of patience; but it is a highly gratifyino' 
exercise, especially when it is found that a correct diagnosis has been made. ° 

Prognosis of Diseases. — The judgment formed as to what will happen in a case 
is called '•'•prognosis.''''^ It is quite essential to the formation of a correct progno- 
sis, that an accurate diagnosis should have been previously made; for if the nature 
of the affection be not known, it is difficult to pronounce an opinion as to the pro- 
bable termination. For the sake of making a prognosis, all the symptoms must be 
observed, and the history of the case learned, — exactly as in making a diagnosis; 
but there is something more than that to be done. The direct tendency of the dis- 
ease ought to be known; — the course which the disease is always inclined to run* 
and the course which it is likely to run in the particular individual, according to 
age, — sex, — previous habits, — and all those circumstances which 1 have previously 
mentioned, as to individual peculiarities;'' and in proportion as it is in our power 
to put into practice requisite curative means. There are some cases in which, if 
we were allowed to practise our art freely, we should make a favourable prognosis- 
but in which, our hands being tied, — as they are when others, ill informed or inac- 
tive, are called in over us, — we must give an unfavourable prognosis; — simply be- 
cause the patient must be allowed to die. In making a prognosis, there is frequently 
less skill required than in establishing a diagnosis; for some persons, with a sort 
of tact, will tell whether an individual is in danger or not, without knowino- what 
is the matter with him. Many persons who have no knowledo:e of medicine, or at 
least very little, have such strong perceptions, that — from the aspect of an indi- 
vidual, and from general observations of their own — they are enabled to give a very 
correct prognosis, either favourable or unfavourable. This I know to be the case. 
There are a great many intelligent officers, who — from seeing their men fall around 
them in batde, and sick in hospitals — have become, m one sense of the term, good 
doctors; and though they are not able to cure the disease, or tell what is the matter 
they will be able to give a shrewd and correct guess as to how matters will turn 
out. But although some people, by nature, are well qualified for this, while others 
are not, yet the medical man must be taken as he is; and whether he does or does 
not possess sufficient natural sagacity to make an accuraie prognosis, it is his duty 
to make as careful a diagnosis as he can; — in order that he may make as good a 
prognosis as possible. If his intellect be not of an acute description, yet, by know- 
ing the case, and by the aid of science and minute observation, he will be able to 
form as good an opinion, as the man who, by nature, is qualified for these things; 
and if with science and observation be combined native sagacity, then I need not 
say, that his prognosis will be much superior to that of that of the individual who 
trusts alone to his natural powers. 

Such, therefore, is what is meant by diagnosis, and prognosis ; and I cannot 
too strongly recommend the most careful attention in eslablishino' the former. 
Whether the patient can be cured, or not, it should be a solemn rule to investio-aie 
the case to the utmost. It is only by this plan we can profit ourselves, or Ihat 
those who come after us can profit. If we be not careful, we cannot advance 
science; and the next generation will be none the better for us. 

Diathesis. — There is a term which I have not yet explained, or even mentioned; 
— namely, the word " diathesis.'^'' When the body is particularly predisposed to 
any kind of afl^ection, it is said by some to have that \mY[\cuhr diathesis, or a dispo- 
sition to it. The term, however, is generally limited to two states ; — an inflam- 
matorj'- state; and a state of weakness, or debility, if not of putrescency. One is 
called the " philogistic," or " sthenic" (which means " strong"); and the other the 
" asthenic," or " weak." When, for instance, a person labouring under any par- 
ticular complaint, is in a high state of excitement, with a full and strong pulse, and 
increased heat of body, he is said to have the sthenic"^ or phlogistic'' diailiesis: — in 

■ From TTgo, before; and yivwcrxa, to know, ^ From adevci;, strength. 

^ See Pages 48 aud 49. • From <pX9yi^(Uf to burn. 

e From hariQnfjti, to dispose. 



52 GENERAL PATHOLOGY. 

fact, an active inflammatory state of the body. If, liowever, the state be one of 
debiliiy (so that any disease vvliich is aclually present is attended with weakness), 
and still more if there be extreme collapse, and a disposition to putrescence, then it 
is called the asthenic'' diathesis. I believe, in modern times, these terms are rarely 
used, except when a certain disease is present; so that they really imply, not the 
disposition to disease, but the character of the disease; — as to whether it is actively 
inflammatory (attended by strength), or whether it is attended by weakness. In 
this country, we seldom hear persons use either of these terms, except " phlooristic." 

The word "•diatheses''^ is used by old authors in other senses; — to signify, for 
instance, the general disposition to disease at any particular season; so that the 
constitution of the period was said to be its diathesis. If the disposition of any 
particular season of the year, — not the regular seasons, — were to produce such and 
such kinds of disease, the word " diathesis''^ was applied to that disposition; — to 
the disposition, if I may so speak, of the atmosphere at the time. But, generally 
speaking, the word is used as I have pointed out above. However, sometimes a 
constitutional disposition to certain diseases, when present, is called a diathesis. 
For instance: it is not uncommon, in practice, to hear persons talk of a " scrofulous 
diathesis." Where a person has every look of scrofula, with its actual presence in 
one part, individuals say, — " That is a scrofulous diathesis." A disposition to 
many other kinds of disease, when present, is sometimes called a diathesis; but it 
is the phlogistic diathesis of which mention is most frequently made. This term 
is sometimes used to signify that full state of the body, which would render a 
person very liable to an active inflammatory affection; but is certainly more fre- 
quently limited to that state, when the disease has actually begun. Now and then, 
persons wiih merely a full pulse, are said to be labouring under the phlogistic dia- 
thesis; but that state is characterized more particularly by the word "/)/eMor«," of 
which I lately spoke." 

Let us now consider those symptoms of disease, on which the diagnosis and 
protrnosis are in a great measure to be founded. The symptoms of disease may be 
divided, perhaps, in one point of view, into two kinds; — those which are discover- 
able by the patient only; and those which are discoverable by the by-standers also, 
or by them alone. 

Ujieasy Sensations. — There are some symptoms which a patient alone can 
ascertain; — for example, liis feelings. He it is that feels the pain, and it is a lucky 
circumstance that it is so; for if the doctor felt the pain as well as the patient, there 
are but few who could stand the practising of the profession. We know little about 
the pain, except from the patient's account; and in many cases, in public practice, 
we arc deceived. We have, however, only done our duty in listening to the patient's 
description. 

Pain. — With respect to pain, it is of various kinds: — it may be " sharp," — 
"stabbing," — "darting," — "shooting," — "lancinating." These are all words 
used by patients. At other times the pain is not of this character, but dull; and 
then we call it an " ache;" and sometimes patients add the word "/?fi5m;" — making^ 
it "aching pain." Sometimes pain is described as "throbbing" and "pulsating;" 
and patients also complain of " pricking" pain, — as though a number of needles 
were being pressed into them. These things are all of great importance to be 
attended to, because they frequently show the seat of the afl^ection; and according 
as a patient describes his pain to be sharp or dull, throbbing or pricking, so we 
frequently ascertain whether he is telling the truth or not; because the probability 
is, that it will be of a particular character; and we may ascertain whether his ac- 
count agrees with what we should, a priori, expect liim to describe. We some 
times hear pain spoken of as " smarting:" and, in some affections of the abdomen, 
a patient complains of " broiling" pain. It appears to be a high degree of smarting, 
with a sense of burning. 

If pain be increased by pressure, or by the application of stimulants, then we 

* From a, without', and a^inq^ strength. •» See Page 46. 



GENERAL PATHOLOGY. 53 

say there is "tenderness;" but perhaps the word ^Henderness*^ is more properly 
restricted to pain increased upon mechanical pressure. There are othei feelings 
continually described by patients; as, for instance, a feeling- of '* dead weight." 
This is particularly the case with respect to the head. "NVe sometimes hear persons 
complain of " fuhiess," — as if a part were excessively full; and now and then this 
sensation rises to such a pitch, that the part feels as if it would burst; and then we 
call it a feeling of " tension." A feeling of tension, appears to be a high degree of 
a feeling oi fulness. Now and then, patients complain of a sensation of " pins and 
needles;" which is very different from the sensation of pricking pain, — as if needles 
were being run in; it is as if the pins and needles were rather blunt. It meiely 
gives the lowest sensation of this kind, — not amounting to pain. " Pricking" pain 
is of a very different character; — for instance, that which people frequendy complain 
of from inflammation of the urethra, in gonorrhoea. They experience a pricking 
pain along the urethra. But the sensation experienced when the hands and feet 
are "asleep," is not called ;?am, — patients say they feel as if pins and needles were 
there. You will frequently hear persons declare, that they have an indescribable 
uneasiness in a part, — a sensation which nearly drives them mad ; but they will 
not allow it to be pain. 1 have known this sensation occur in different parts of the 
body. I recollect one lady who had it in the neck; so that she was obliged to walk 
about the room, followed by a servant rubbing her neck, night and day. Unless 
this was done, the sensation nearly deprived her of her senses; and her countenance 
betrayed the greatest distress. You will find other sensations spoken of by patients; 
— a " creeping," a " crawling," or a feeling as if water were trickling down them. 
There are also symptoms which approach nearly to pain, — " itching" and " ting- 
ling;" which may be almost insupportable. Tingling is a high degree, 1 imagine, 
of what is called "itching," united with a sense of " pricking." With regard to 
other sensations, there is nausea felt in one part, — the stomach; and now and then 
persons have an excessive sensibility of one particular sense, — of the eye or the ear, 
for instance. 

Exhaustion and Debility. — Besides these symptoms, people have a feeling of 
great exhaustion, or debility; and this is a point strictly to be attended to, in form- 
ing the prognosis in an acute disease; for sometimes it is a fatal symptom. When 
a patient, for example, after inflammation of the bowels, has no pain, but a feeble 
pulse; and complains that he is so weak, that he feels as if he should die, — that he 
never felt such weakness in his life, we may be almost sure he will be dead before 
the next day. On the other hand, this feeling is very deceptive. Women are 
subject to a sinking sensation at the epigastrium. They tell us they feel as if they 
had no inside; and are sure they are about to die; but the feeling is quite delusive. 
In the former case, after an acute disease, from seeing all, or the greater part of the 
symptoms decline, we might judge that the patient would soon get well, and that 
this feeling of weakness was nothing more than might be expected after severe 
indisposition; but we must take into account other symptoms, — particularly the 
weakness of the pulse. But with respect to these females, we find the pulse good; 
and they are able to walk about, notwithstanding all the depressive feelings of 
which they complain. This is a very remarkable circumstance; and I shall find 
it necessary to draw attention to it, when speaking of diseases of the stomach, and 
of hysterical affections. 

Drowsiness, &;c. — Patients, also, can alone be conscious of drowsiness, deficient 
appetite, inordinate appetite, and c/ejorf/yecZ appetite; although, with respect to many 
of these things, we can often, by other circumstances, ascertain whether they are 
telling the truth or not. It is to the patient, likewise, that we must trust for the 
existence of tenesmus'" and of strangury;'' — a frequent desire to go to stool, and a 
painful and frequent desire to make water. 

There are some symptoms, too, which are derived from other senses than those 

» From TEivw, to constringe. 

*• From ff-T^ay^, (7Tfayy9f, a drop; and owpev, urine. 



54 GENERAL PATHOLOGY. 

of general feelings; and these are referable to the ear. Patients will continually 
complain of the most violent " beating pulsation" in their head: and frequently, 
loo, of a "snapping" and "cracking" there. Such symptoms undoubtedly do 
exist, but we can take no cognizance of them. With respect to sight, we must 
depend on the patient's account for the occurrence of flashes of light before the 
eyes; and for the symptom so common in many diseases, — moats floating before the 
eyes; and for double vision, or diplopia;* and likewise for the symptoms of giddi- 
ness or vertigo." On the patient, also, we must depend for symptoms with regard 
to taste. Some have in their mouth a bitter nauseous taste, of which we cannot 
judge. So with respect to smell; — now and then persons experience a most disa- 
greeable odour, which no other person can notice. There was a case of hydro- 
phobia at Guy's Hospital, in which there was an instance of an accidental symptom, 
and that a symptom to be ascertained only by the patient; — the patient experienced 
a most disgusting odour. This occasionally happens in cases of insanity. Now 
and then the smell which the patient perceives, may be noticed by other persons: 
because it arises from some disease within the nose. There are still other symp- 
toms, of which the patient alone can give an account; such as defects in the senses; 
— a loss of sight, of taste, or of hearing. So with respect to many mental circum- 
stances; such as the loss of many desires, and a feeling of strong desires; — for all 
these we must, rely much upon the patient. 

All these are symptoms which the patient alone can know any thing about: 
We all know something about them, because we are more or less ill at some part 
of our lives; but the medical attendant must take the patient's word for these sen- 
sations; — at least he cannot ascertain the existence of them directly. He can only 
ascertain, by other symptoms, whether the patient is probably telling the truth. 

Altered Appearances. — I shall now proceed to consider those symptoms which 
are perceptible to the practitioner also, or to him only. In some writers, " symp- 
toms" and "signs" are distinguished from each other; but I think it mere trifling 
to dwell upon such matters. With respect to those symptoms, however, which 
others observe, of course the patient, for the most part, may observe them likewise. 

In observing the symptoms of disease, it is right to remember that Providence 
has blessed us with five senses; and all these five senses it would be ungrateful, as 
well as unscientific, not to employ. I am lead to speak in this way, on account 
of its being a modern practice to employ the ear extensively. Those who do so 
were formerly laughed at as innovators; — as people who took unnecessary pains, 
and were perhaps attempting a piece of quackery, in order to produce an impression 
on their patients. If nature has blessed us with hearing to observe certain phe- 
nomena around us, there can lie no reason for not employing it, when we come to 
observe the phenomena of disease; and if it be a fact, that there are symptoms of 
the most useful nature cognizable by the ear only, it is our duty to employ our ears 
for the purpose of detecting them. We are bound, I think, to employ all our five 
senses in the investigation of disease. The senses, however, of which we chiefly 
make use, are those of sight, hearing, and touch; but the smell, and in some 
instances even the taste, may be called in to our aid; — the smell, however, much 
more frequently than the taste, li would be as absurd to shut our ears, as to shut 
our eyes; yet, because the extensive employment of hearing has only been intro- 
duced lately, those who were not instructed in this point when they were students, 
are, some of them, too proud to learn in their old age; and are good enough to pity 
us younsjer men. 

As to those symptoms which are cognizable by our various senses, they discover 
themselves in every part of the body, from the head to the foot; but the two parts 
which give the chief symptoms to the sight, and (I may say) to the touch, and the 
chief symptoms not only in reference to themselves but to all other parts of the 
body, are the head and the hand. It has become the custom, in all civilized nations, 
to cover all parts of the body except the face and hands; and these two parts afibrd 

» Fronn JtawXooj, double; and oTTTOjwat, to see. »> From verlo, to turn. 



GENERAL PATHOLOGY. 55 

far more information thfin any others, respecting the state of the body, and respect- 
ing diseases that are present, and not seated in these individual parts, but at a 
distance. It is certainly a striking coincicience; but we must remember, that while 
necessity compels mankind to keep the face, and almost always the hand, uncovered, 
Providence has ordained that these same two parts shall convey the chief information 
to others, respecting our mind and body. 

With respect to the face, we observe that it gives us two sorts of information; — 
first, as a mere portion of the body only, — a portion of the surface which is far 
more affected by every change than any other, excepting the hand, and therefore 
so far as it is face; and, secondly, it gives us another description of information so 
far as it is countenance, — so far as it expresses the state of the mind, and the state 
of the feeling altogether. The observations which we make upon this part of the 
body, then, may be considered as they respect simply yace, and as they respect 
simply countenance. 

Alterations in the face. — With recrard to the face, as really a part of the surface 
of the body, if there be fulness of blood, it is shown particularly there. If we were 
to take the same quantity of surface in any other part of the body, — the abdomen, 
back, or thighs, for instance, — we should not get the same information from the 
part, simply as surface, as we do from the face. If the body be at all full, we see 
it in the face. If the circulation be rapid, and the heat considerable, it is the face 
that shows it; for the cheeks become tinged much sooner than any other part. If 
there be the least degree of coldness, we perceive it in the cheeks, nose, and lips. 
We discover hectic fever in an instant, by the red patch upon the cheek. If the 
patient be labouring under difficulty of breathing, we find the eyes immediately 
suffused, the lips more or less livid, and the whole face frequently of a leaden hue; 
— sometimes, indeed, I have seen it black. If it be jaundice .that the patient labours 
under, we instantly discover it in the face. By one part of the face (the eye) we 
can detect it, long before it appears in any other part of the body, except the hand; 
and when the disease has nearly declined, it is in the face as well as in the hand, 
that it lingers the longest. In the white of the eye we perceive the presence of 
jaundice, before it is apparent anywhere else, tixcept at the root of the nails. If 
the patient be bloodless, it is first discovered in the paleness of the face, the want 
of the usual vermilion of the lips, and the absolute paleness of the tongue. There 
is not a white crust upon the tongue; but it is absolutely blanched. Two of the 
chief marks of scrofula are shown in the face; — the dilated pupil, and the tumid 
under lip. 

From the face altogether, simply as a part of the body, we are able frequendy to 
tell at once that the lungs are affected, or that there is a great disposition to affection 
of the lungs, [t is sometimes impossible to doubt for a moment that, if the patient 
be not labouring under phthisis, it will soon approach. From the peculiar appear- 
ance of the countenance, particularly from the appearance of the eye (its transpa- 
rency), together with the languor of the cheeks, or the flush upon them, — no doubt 
can exist as to the nature of the disposition. And with respect to other parts, we 
can tell that the patient is labouring under organic disease of the abdomen, from the 
look of the cheeks. I do not say it is so always; but the appearance of the face 
is of orreatuse, in enablinof us to detect that condition. 

In organic diseases of the stomach, intestines, and surrounding parts, there is 
often a faint greenish yellow appearance of the face, something like that of a faded 
leaf, with minute vessels; — not forming a patch of red, as in hectic fever; but 
reticulated, like net work, on the cheeks. Where we observe this, there is generally 
some part of the abdomen in a state of organic disease. We discover, in a moment, 
the strength of a patient by his countenance. When attending a case of fever, there 
is frequently no occasion to ask a question: we can tell whether a patient is better 
or worse, by viewing his countenance. So with respect to many other diseases; — 
when the patient is getting either better or worse, we can tell immediately, by his 
face, what change has taken place subsequently to our previous visit. Every body 
makes this observation; and hence, when an individual meets a friend, he tells him 



56 GENERAL PATHOLOGY. 

he looks well, or that he is sorry to see him ill. If the appearance of the face be 
so characteristic of the state of an individual's health, even in the judgment of an 
inexperienced person, how much more so must it be in that of the medical man, 
who studies minutely every shade of change and difference that takes place in each 
particular part. 

Of course, if disease take place in the face locally, it will show itself there as in 
other parts of the frame; — whether it be swelling, mortification, local cutaneous 
disease, or whatever else may happen to it. 

The Tongue. — In the tongue an immense number of symptoms present them- 
selves; and the body cannot labour under inflammation in any part, without the 
tongue becoming affected by it; if there be strength, generally tfie tongue becomes 
white. If there be inflammation within the stomach and intestines, it frequently 
becomes red, — red at the tip, red at the sides, perhaps red all over; and perhaps 
there are red stripes upon it. If the stomach be simply in a state of dyspepsia, 
and the bowels confined, the tongue becomes covered with a yellow thick mucus. 
The indications of the tongue are innumerable; they have been observed from the 
remotest ages; and no one would think of finishing his attention to a patient, with- 
out looking at that organ. The tongue will sometimes become brown; sometimes 
it will become absolutely black. In what are called " putrid" diseases, — where 
there is a high degree of debility, and a disposition to putrescency, — the tongue 
will become black. In other cases it will become glazed throughout, shining, and 
glassy; and in this state it will frequently be cracked. In other diseases, again, — 
as in " delirium tremens," — it is frequently covered by a creamy mucus; — not a 
thick yellow mucus; but a mucus more like cream than any thing else, and so liquid 
that the tongue is moist. The tongue frequently, in paralysis, moves to one side; but 
generally in an opposite direction to that in which the mouth is drawn.* In fever, 
and other diseases, the tremor of the tongue is very characteristic. In general the 
whole body trembles; but the tongue does so particularly. In " paralysis agitans," 
though the person lie still in bed, yet if he put out his tongue, it is seen to be in a 
great degree of tremor. In cases of dyspnoea^ and apoplexy, the tongue is swollen. 
I need not insist upon the great importance of this part of the face or head, — the 
tongue.*' 

The Eye. — Then, again, if we take the eyes. We discover, in a moment, whe- 
ther there is great excitement of the brain going on, by the sparkling of the eyes, 
by their redness and watery appearance. We can discover whether a person has 
headache, by the oppression shown in the eyes; and, in some affections of the 
head, the eyes squint, — are contorted in various ways. Frequently, too, when 
a person is asleep, he does not completely close his eyes; which is often an indi- 
cation of disease. Then, again, the state of the pupil is very characteristic of 
many affections of the head. If we take the eye altogether, there is generally an 
appearance of brilliancy, or of dulness; or, if we take particular parts, there is a 
dilatation of the pupil, or (on the other hand) an extreme contraction; all these 
things it is of the highest importance to observe, because they point out particular 
affections. For example: if we take apoplexy, we usually see the pupil dilated, 
and know that there is great oppression of the brain; but if the pupil be amazingly 
contracted, — reduced to a pin's point, we may almost to a certainty say that 
the patient will die. I do not say it is absolutely certain; because it is wrong 
to speak positively. If a person have taken a large quantity of opium, there is 
generally the same effect produced — a great contraction of the pupil; and where 

> In paralysis of one side of the face, the tongue goes to the diseased ^\(\e]—be\x\^ turned in 
that direction, as on a pivot, by the action of the "genio-hyo-glossus" muscle of the healthy 
side. — Dr. Fletcher. 

*» From Juf, vjith difficulty; and wvtw, to breathe. 
■ c i''he tongue is flat, wiih its anterior extremity rounded, in gastro-enteritis. It is cylin- 
drical and pointed in hectic fever; in which the ''' lobster-tongue" (red, with white papillee) 
sometimes occurs. In scarlatina it is white, with red papillae. In dyspepsia, especially in 
the morning, it is rough and scabrous. — Dr. Fletcher, 



GENERAL PATHOLOGY. 57 

we are not informed with certainty of the patient having taken that narcotic, the 
appearance I have just described will assist materially in forming the diagnosis. 
Then — besides the strabismus,* and open state of the eye during sleep — there are 
contortions in various instances; particularly if a child have convulsions of another 
part of the face, — the muscles of the lower jaw; so that he gnashes and grinds his 
teeth together during sleep, and his eyes roll.'' 

Risus Sardonicus. — There is one set of convulsions about the mouth, mentioned 
under the term ^^ risus sardonicus.'''' It is a horrid sort of grin, which is often seen 
in persons who are about to expire. To me it is the most terrible of sights. It 
has been thought to characterize inflammation of the diaphragm;*" but I do not 
know whether that is the case; — inflammation of the diaphragm is a rare affection. 
It is common, however, for persons at death's door to grin frightfully. The phe- 
nomenon receives its name from a herb, of a poisonous quality, which grows in 
Sardinia; and is said to produce in those who eat it, this horrid contortion of the 
mouth, just before death. 

7%e Orbit. — From the state of the orbits or at least the contents of the orbit 
around the eye, we may judge of the extreme debility, exhaustion, and emaciation 
of the patient. If the parts around the eye become absorbed, the eye sinks back 
in the orbit, and there is produced a hollowness, which is characteristic of extreme 
exhaustion and inanition; and this alone will enable us to say, in a moment, how 
much worse the patient has become. 

Fades Bippocratica. — We likewise see a singular appearance of the counte- 
nance, mentioned by almost every writer, under the title of ^^ fades Hippocratica;'^ 
so called, because Hippocrates gave a most accurate description of it. His de- 
scription is, — " sharpness of the nose; hollowness of the eyes; collapsed state of 
the temples; collapsed and contracted state of the ears; the edges of the nostrils 
everted;** the skin of the forehead firm, tense, and dry; i)aleness of the whole face, 
perhaps even blackness, or a livid and a leaden appearance." These are the 
characteristics of the " facies Hippocratica." It is the usual appearance of the 
face, immediately before death; when the body is at last completely exhausted, 
and life about to be resigned. 

The Teeth. — I may mention (although it is not in regular order) that among 
the symptoms of phthisis, one is taken from the teeth; — not that all phthisical 

* From <7Tgtt^i^o, to squint. 
. ^ The eyes do not close in paralysis, apoplexy, asphyxia, and the " Hippocratic counte- 
nance." An open state of the eyes, therefore, is considered a very bad sign. In tetanus 
the eyes are generally open, both when the patient is asleep and when he is awake; for 
neither the sphincter (" orbicularis palpebrarum") nor the "levator palpebrae superioris" is 
completely relaxed; — so that the eye-lids are always partially separated. In this disease, the 
ball of the eye is fixed; — from contraction of the " recti'' muscles. Ptosis is a palsy of the 
" levator palpebrse superioris." Strabismus occurs in the first stage of apoplexy, in myelitis 
of the upper part of the spinal cord, in amaurosis, in worms, &c. It takes place either from 
defective action of one set of muscles, or from increased action of another set. The direction 
of the eye is upward, in tetanus, because the ^'inferior oblique" muscle acts too much; and 
in paralysis and syncope, because the " superior oblique" acts too little. The eye is too 
moist in tetanus, and the last stage of ophthalmia; it is dry in the first stage of ophthalmia, 
in phrenitis, and in all the diseases of debility. It appears to "flash" in anger, mania, hys- 
teria, and fever. The cause of this appearance is, that the vessels in the interior of the 
eye are dilated, and admit more while blood; so that more light is reflected. The iris is 
said to be convulsed in epilepsy, but I never met with any one who- had seen it; and we are 
not sure that the iris is muscular, — so as to be capable of being convulsed. — Dr. Fletcher. 

<= From ha^ through; and <^^ctrra)^ to divide. 

^ The nostrils are dilated in phrenitis, tetanus, and all diseases of excitement and impeded 
respiration. They arc constricted in asphyxia, and all diseases of depression. This con- 
striction is very remarkable in the " Hippocratic countenance;" which depends on defective 
muscular action. The "hectic countenance" is distinguished from it by redness of the 
cheeks. In all other particulars it resembles the Hippocratic; but depends on a diflerent 
cause; — the absorption of fat. The expansion of the nostrils, in di'spnopa, is not for the 
purpose of admitting more air; for, if that were the case, the mouth would be open. It is 
owing to the great stimulus applied to the portio dura; which sets all the muscles supplied 
by it into energetic action. — Dr. Fletcher. 



58 GENERAL PATHOLOGY. 

patients have the same state of the teeth; but in many there is beautiful whiteness 
of the teeth, with a degree of transparency and brilliancy, comparatively seldom 
seen in persons who are not disposed to phthisis. 

Exanthematic Eruptions in the Face.— I may mention that exanthematic and 
acnle inflammatory canlaneous diseases, show themselves much belter on the face, 
for the most part, than anywhere else. It is on the face, first, that we discover 
a child is going to have the measles. When a child is in a state of pyrexia, and 
we are sure it is going to be ill of something or other, the face will first disclose 
it, if it be the measles. -There we have the running of the eyes, — there we have 
the fulness; and the first papulae that present themselves, are generally seen on 
the face. Most acute cutaneous diseases attack the face among the earliest parts; 
or if they do not, yet the face, if affected, generally discovers the true nature of 
the disease better than any other part; the reason of which is, that the face is much 
more vascular than other parts. The cheeks are more or less inclined to be red, 
in most individuals; and the least feverishness reddens the face, more than any 
other part of the body; and therefore it is that acute cutaneous diseases generally 
show themselves best in that situation. 

Paralysis of the Face. — With respect to the face, simply as a part of the surface 
of the body, we discover paralysis in it more easily than in any other part. If a 
person be sitting still, we cannot tell whether his arm or his leg is paralyzed; but 
if his face be paralyzed, we can generally in an instant discover it, by the part 
aiFected being drawn to the opposite side, and perhaps from the patient's inability 
to swallow his saliva.^ And so with regard to the tongue; — the moment the person 
begins to speak, we frequently can discover the existence of paralysis. 

The Countenance. — The face is particularly indicative of the general state of 
the individual's mind, and of the general state of the strength likewise; and we 
then, perhaps, should rather call it " the countenance;^'' and speak of *' the coun- 
tenance'''' instead of " the /r/ce;"- — ^' ihe countenance^^ being the term generally 
used in reference to the state of the feelings. We can judge directly whether a 
patient is in pain or not, — -whether he is suffering, by the countenance. In colic, 
and in enteritis, the agony is so depicted in the countenance, that we discover in 
an instant that something must be wrong. I need not say that, in insanity, that 
passion of the mind which is predominant, discovers itself in the countenance. 
We may at once detect a good-natured, a furious, a proud, or a desponding maniac. 
We may also discover much by the way in which his head is carried, — to say no- 
thing of his countenance. Those that are proud, carry the head upright; those that'' 
are cast down, carry it the reverse. But the countenance, independently of the 
position of the head, is indicative of the character of tlie disease; — an idiot is almost 
immediately discovered by the expression of his face. We ascertain in a moment, 
by the countenance, what the person's feelings are with respect to strength as well 
as to comfort; and what passions of the mind are predominant. We discover, as 
I before mentioned,'' whether a person is belter by observing his face, — by noticing 
whether it looks fuller; but we also discover much from the expression of the coun- 
tenance. What a vast amount of information, therefore, is given by the face; — 
not only with respect to affections of that particular part, but with respect to all 
other parts of the body. 

The Attitude. — A great deal may be learned of the patient's feelings, by the 
attitude of his body. In fever nothing is a more unfavourable omen, than for a pa- 
tient to be seen lying on his side at first, and gradually getting on his back, till he 
lies altogether supine; but when he also sinks in his bed, the case becomes slill 
more alarming. The reason is simply this: — More muscular strength is required 
in order to lie on the side, than on the back, and to remain in a firm posture than 
to sink down; and therefore, when a patient sinks down, it is an indication that 
his strength is nearly exhausted. We discover a great deal, too, by the restless- 
ness of the whole body. One of the most unfavourable symptoms, in many di^-- 

» Probably from " salitus," salt. ^ See Page 55. 



GENERAL PATHOLOGY, 59 

eases, is extreme restlessness. Restlessness, in women, may arise from mere 
fidgets; but in acute diseases, when great debility has come on, restlessness is often 
one of tlie fatal symptoms. 

The Hand. — But to go to the hand;-— (he part wliich, together with the face, in 
all countries (civilized and uncivilized), is most exposed. In the hand we have 
very great indications; though, certainly, they are not so strong as in the face. 
The hand is one of the extreme parts, and shows the first fall of temperature. It 
is one of the first parts that become cold; — exactly as the nose and ears do in the 
head. I believe the difi^erence between its temperature in fever and in health, is 
often greater than the difference of the temperature of most other parts of the body. 
A cold sweat is shown in the hand, among the earliest parts; and the hectic fever 
which flushes the face, flushes also tlie palm of the hand, and indeed the sole of the 
foot; but it is shown particularly in the palm of the hand, from the greater fineness 
of the integuments. Difficulty of breathing, again, discovers itself by the appear- 
ance of the nails. If, in the difficulty of breathing, we observe a purple hue of the 
lips, a fulness and a leaden colour of the face, and a purplish colour of the eyes, 
we discover likewise a purple hue of the nails, — at least the parts under the nails. 
As I mentioned, in jaundice, that the disease appears first at tlie roots of the nails, 
as well as in the sclerotica; and that after the disease has disappeared from the rest 
of the surfaces, we may discover it still lingering in the system by the yellowness 
observed in the same two parts,* — so I believe that the changes, with respect to 
the eyes and nails, go on pari passii^ in dyspnoBa. The dryness of the hand, its 
mordant heat, its clamminess, its firmness, its softness, the very grasp of the pa- 
tient, — are all significant. If phthisis is often seen in the eye, the ends of the fin- 
gers are no less indicative of it, or of some other internal scrofulous affection. 

Besides all this, it is in the hand that we easily make the most important 
conceivable observations, upon the state of the circulation. It is in the hand, or 
at least at the wrist, that we feel the pulse much more easily than at any other part 
of the body. The same observation might be made anywhere else; but it would 
be done far less accurately, and with far less ease, than at the wrist. With respect 
to all other observations, — about temperature, about heat, about cold, about clam- 
miness, and about sweats, — I think that not only are they all made much more 
accurately in the hand than in any other part, but that the hand appears to be 
affected by these particular symptoms, more than most other parts of the surface 
of the body. 

Volume of the Pulse. — With regard to the /?i«/se, great indications of disease are 
taken from it. The pulse generally is spoken of, in the first place, as " great" or 
"small" ("pulsus magnus," — "pulsus parvus"); it is mentioned likewise as 
""strong" or " weak" (" pulsus validus," — "pulsus debilis"); and as "hard" or 
" soft" (" durus," — " mollis"). A pulse may be large, — may be considerable, 
and yet not hard; a pulse also may be hard, and yet by no means large, — on the 
contrary, exceedingly small. A pulse is not necessarily strong because it is large: 
neither is it necessarily loeak because it is small in volume. If a pulse be both hard 
and large, it is a strong pulse also; if a pulse be small and soft together, then it must 
be considered as iveak. Mere softness may be such as to amount to weakness; and 
if it be exceedingly weak, we may extinguish it by the least pressure of the finger. 
This pulse has been called " pulsus vermicularis;" and (among us) " fluttering," if 
it be also quick. It is a pulse easily recognised in practice; and, in many cases, 
indicates death to be at hand. If a pulse be exceedingly hard, and at the same 
time small, then it has been called " a wiry pulse." A wire is necessarily fine 
and haid; and a pulse which has the same attributes is called "a wiry pulse." 
This is different from a thready pulse; just as thread is different from wire. A 
thready pulse is merely that which is small, soft, and weak; — a vernjicular motion, 
hardly worthy of the name of a pulsation. It is chiefly in violent inllammalions of 
the abdomen, that we have the wiry pulse; however, we must not depend upon the 

■ See Page 54. •> " In similar progression." 



60 GENERAL PATHOLOGY. 

pulse only, in such cases. If there be other symptoms of inflammation of the 
stomach, or intestines, or peritoneum,* we must not say that is not the disease, 
because the pulse is not wiry. 

Bate of the Pulse, — These are qualities of the pulse, with respect to its volume, 
solidity, and force; — large or small, hard or soft, strong or weak. But there are 
other varieties of pulse, taken from its rate. A pulse may be quick, and a pulse 
may be sloiu; there is the " pulsus yre^^^e?^s," and the " pulsus rarus.^' The pulse 
will sometimes go up to 160. Sometimes it will go beyond that; — so that we 
cannot count it, especially if weak. But then we can ascertain the state of the 
circulation by the heart, where we can count 200 and upwards with perfect ease, 
when we cannot count the pulse at the wrist. A distinction is made with regard 
to a frequent pulse, into a " pulsus freqtiens'^ and a " pulsus celer.^^ " Frequcns" 
is where there is a large number of strokes in a given time; and, " celer" is where 
the strokes take place in a short and abrupt manner. " Pulsus frequens^' and 
*' pulsus rarus'^ are opposite to each other; — the former being a rapid, and the lat- 
ter a slow pulse. The opposite of the " pulsus celer'^ is the " pulsus tardus;'' in 
which, whatever number of beats take place, they occur in a gradual manner. In 
England, practitioners call the pulsus celer " a jerking pulse;" — ^'jerking'' and 
*' sharp''' are our terms corresponding to " celer," with regard to the pulse. No 
matter whether it is quick or not, we say it is a sharp or jerking pulse; whereas, 
on the other hand, that which takes place (as it were) deliberately, is called " pul- 
sus tardus." 

Examine the Pulse at both Wrists. — I may mention the great importance of 
feeling the pulse at both wrists. If we feel the pulse at the left wrist only, we 
may often think that the patient, from extreme debility, cannot bear bleeding; but if 
we feel it at the right also, we can frequently form a very different opinion. No- 
thing is more common than for the pulse at the two wrists to vary exceedingly; 
and it is the pulse at the right wrist that, in the greater number of cases, is the 
correct guide. The difference is so great, in so large a number of cases, that it should 
be a general rule to observe both pulses. I have never myself seen the pulses dif- 
ferent in point o( time; but there is a great difference with respect io force. It is 
also certainly right, in. cases of great nicety; — where we are in doubt as to the 
means to be used, — to examine likewise at the heart; and in cases of local disease 
of that organ, it is also right to examine the heart itself; for, in some diseases, we 
have simply, from an affection of the heart, a very violent pulse; — such as would 
lead us to bleed to a great extent. But, in those cases, the pulse is not an indication 
of the general strength of the patient; but receives its character solely from the dis- 
ease of the heart. On the other hand, in some diseases of the heart itself, we find 
a very small pulse; and, on examining the heart, we hear it beat violently; but, 
owing to a diminution in the aperture, the blood escapes in small quantity. 

Irregularity of the Pulse. — I should likewise mention, with respect to the 
pulse, that its rate, size, and force, are sometimes irregular. It will vary in strength 
and size, at different beats; and it will also vary in frequency. We sometimes 
have a pulse merely irregular; — beating always with nearly the same force, but 
at an irregular rate; and that is an " irregular" pulse, in the common acceptation 
of the word. But, besides that, we frequently find it irregular in force, size, and 
frequency; so that it will give a strong pulsation or two; then a number of strokes 
of no strength at all; and, again, it will beat violently. Irregularity, therefore, 
does not refer to frequency only, but likewise to force. Sometimes the pulse 
intermits. 

The Pulse varies according to Jlge. — We must also'remember, as physiologists, 
that the pulse differs in every age, — that the younger we are, ihe more quick is 
the pulse; also that the pulse of the female is quicker than that of the male; and 
that, generally, the inhabitants of a warm climate have a weaker pulse, than tliose 
in a more temperate latitude. It is necessary to take all these things into considera- 

» From TTEft, around; and Tttvw, to stretch. 



GENERAL PATHOLOGY. 61 

tion; because, if we were to find the.pnlse of a child 120, and that of an adult 
labouring under fever likewise 120, we should commit a great error in supposing 
that the child likewise laboured under fever. It is necessary, therefore, to remem- 
ber that the pulse varies according to age, sex, and climate; and that in young 
children it is particularly quick. 1 had an instance of the great use of examining a 
patient in bed, and not being contented without what is contemptuously called " a 
mechanical examination," in an enlargement of the abdomen: — 

Case. — I was called to visit a pregnant lady, about thirty years of age, whose 
pulse was about 80 or 90; but on listening to the abdomen, — she being single, and 
having some disease (as she said), — there was another pulsation, about 128. The 
pulsation did not arise from any of the branches of the iliac arteries; for their pul- 
sations would have been the same as at the wrists. She had a pulse of 80; some- 
thing within her had a pulse of 128; and what that was, I left her to settle by her- 
self. All that I could say was, that if she waited patiently, the whole of the 
disase would come away, to a certainty, in two or three months. 

The pulse has been called, in the most ancient times, "res fallacissima," — the 
most false of all symptoms; but the truth is, «// symptoms are delusive, if taken 
separately: it is the collection which enables us to form our judgment. The varie- 
ties which I have mentioned, are sufficient for all practical purposes, and are the 
only ones that I have observed; but we find, in books, an extreme minuteness on 
this point; and, I think, a great deal of absurd trifling. The Chinese, I understand, 
have made most minute observations on this subject. They describe all sorts of 
pulse; — such as (I dare say) no one ever observed, and no one ever will. 

As to the two parts of the body hitherto mentioned, — the face (or, rather, the 
head altogether), and the hand, our observations upon them are chiefly made by 
sijjht and by touch. The head and the hand, of course, when they themselves are 
affected, give all the symptoms common to other parts of the body. When either 
of these parts is inflamed, the various local symptoms present themselves. It is 
not, however, of local symptoms that I am at present speaking; but of symptoms 
indicating the state of the other parts of the system in general. 

State of the Breath. — However, there is another sense that may be employed 
with respect to the head; and that is the sense of smell. The breath that proceeds 
from the mouth, has sometimes peculiar odours; which, if we do not take pains to 
notice, we are at any rate compelled to observe. 

The Neck. — To proceed, downwards, however; the neck affords a certain de- 
gree of information, but not much. A long^ thin neck is frequently taken, in con- 
junction with other symptoms, as a sign of phthisis; whereas, a short, thick neck 
indicates a disposition to fulness of the head and chest. The pulse in the neck is 
also an indication of different diseases. In many affections of the head, the carotids* 
wUl throb violently, — so as to be seen at a distance; and in many affections of the 
chest, the same circumstance is observed. Here, again, we see the necessity of 
attending to more symptoms than one. A great throbbing of the carotids may 
arise either from an affection of the chest, or of the head; for they both give rise to 
it. The pulsation of the jugulars* is likewise frequently an indication of thoracic 
disease; for a difficulty in the transmission of the blood through the chest, will give 
rise to a great pulsation of the jugulars. I need not say, that the tenderness of the 
neck indicates various diseases. By observing tenderness in that situation, it is fre- 
quently easy to ascertain the existence of disease in the larynx; when, otherwise, 
there might be doubt as to the nature of the affection. 

The Thorax. — With respect to the chest, it affords us a vast source of informa- 
tion. Its size and shape indicate the general constitution. Phthisical patients 
generally have a narrow and flat chest; — contracted in various directions, — shallow 
and flat in front, and narrow at the sides. If a person bo disposed to apoplexy 
(from mere plethora and congestion), and in gouty persons, the chest is disposed 

* From xflfow, to cause to sZc^ep; because the tying of vessels in question produces coma. 
k F.om " jugulum," tke throat; — so called from " jiigum," ayoke: 



62 GENERAL PATHOLOGY. 

to be circular. Frequently the chest is deformed; and frequently it acquires an 
enlargement in various parts, from disease in the pleura. When a collection of 
water or pus (particularly of pus) takes place in the pleura, it is not uncommon to 
find that the sides of the chest have become enlarged. It is, therefore, frequently 
of great importance in thoracic diseases to strip the patient, and look at his chest; 
for we may frequently discover by tlie eye a slight deviation in its two sides, which 
we cannot observe by the touch. A deviation so slight, that it would escape us if 
we resorted to measurement, is frequently perceptible to the eye.^ Of course, the 
touch will give considerable information with respect to tenderness; and also with 
respect to the state of respiration, and the state of the heart, — by the thrill which 
we experience. In some cases of difficulty of respiration, we find under respiration 
a thrill; and in certain obstructions of the heart itself, we find, on pressing over a 
part of the heart, a similar circumstance takes place, — corresponding with the action 
of the heart. In some cases of aneurism'' of the aorta,'' and of diseases of the heart, 
we find by the hand a strong pulsation. 

Respiratory Sounds. — But although the sight and the touch give this informa- 
tion, there is a third sense which imparts especial aid with respect to diseases of 
the chest; and that is hearing. The function of the lungs differs from the function 
of many other parts, in this circumstance. — It is performed with a noise; and so, 
likewise, is the function of the heart. The functions of the brain and the liver go 
on without any indications appreciable by our senses ; but it is peculiar to the. 
function of the lungs and of the heart, that a certain sound should take place. If 
this noise take place in health, — in sound physiology, it must be expected that when 
the function of these parts is disturbed, ihe physiological sound will become pafho- 
logical;— ilvAt the sound will be altered; and such is actually the fact. If this be 
the case, it is our duty to attend to it; if it be not the case, let those who say so 
prove that they are correct. We declare it is so ; and we ask those who entertain 
a contrary opinion to listen for themselves. 

Indicatioyis furnished by Percussion. — x\s to the lungs, it will sometimes be 
found that the healthy sound of respiration ceases altogether. A lung becomes 
impervious at a certain part; — the air will not go through it ; and this may arise 
from an obstruction to the course of the blood into the lung. But it may also arise 
from the lung itself becoming consolidated; or from external pressure of the lung; 
— the dropsical pleura preventing the lung from expanding. We may thus ascer- 
tain, however, that respiration is not going on in that spot. Besides an absolute 
want of sound, in certain diseases of the chest, there is in others an unnatural 
sound; — the sound of respiration does not cease, but becomes strangely altered. 
Information is afforded, not by listening only, but by striking. If tbe chest be 
struck, the lungs in health give out a hollow sound. The lungs being filled with 
air, a hollow sound is necessarily produced. If something takes the place of air; — 
if the lungs become consolidated, or filled with fluid, or sui rounded by it, — it stands 
to reason tiiat, if we then strike that part of the lung, the air being absent, a dull 
sound will lesult. This is actually the case. These things are physical necessities; 
— they occur simply from the common law of physics.*^ They must occur; and 
if tliey do, we ought to apply them to practical purposes. 

Nothing, however, would be more absurd than to attend to these auricular symp- 
toms solely. Tlie faulfof those who merely employ the ear, in diseases of the 
chest, is just as great as the fault of those who do not employ it all. There may 

a The chest may be enlarged from collections within of air, water, or pus. It may be 
contracted (generally on one side) from pleuritic adhesions, and after paracentesis. Adhe- 
sions of the pleura cause difficulty of breathing in the lung to wiiich they correspond; so 
thai the muscles on the affected side are not used so much ason the other. This causes, on 
that side, a diminution of bulk. — Dr. Fletcher. 

^ From anv'xjvo), to dilate. 

« From anj, air ; and Tugjw, to keep ; — the vessel in question being supposed, by the ancients, 
to contain air alone. 

«" From <^vjiq, nature. 



GENERAL PATHOLOGY. 63 

often be a sufficient number of other symptoms to point out the nature of the afTec- 
lion, witliout employing the ear; but whether that be the case or not, it is as much 
our duty to attend to other symptoms, as to those that we learn from the ear, 
Frequendy, by h)oking at a patient while he is breathing, we find what is the slate 
of respiration. We find that, like the pulse, it is more frequent than natural, or not 
so frequent as natural ; — we may have the " respiratio freque.ns''' and "respiratio 
rara,'''' corresponding with the '■'•pulsus frequens" and ^'pulsus rarus." Now and 
then we find respiration performed suddenly; — the inspiraiion and the expiration 
are sudden; and that is called " respiratio ce/er;" and the opposite state, where the 
chest expands slowly, is called "respiratio tarda ;^^ — corresponding with the 
*^ pulsus celer" and ^^ pulsus tardus." These things may be learned simply by 
the sight. The respiration undergoes alterations similar to those of the pulse; — it 
may be regular or irregular, slow or quick, sudden or gradual. It may be deep, 
or exceedingly shallow, — litde air being taken in at a time; and, on the other hand, 
we may have 2. fall respiration. It may h^full and deep; — corresponding with a 
full and strong /9?/?se. I do not mean to say, that the pulse and the function of the 
lungs take place synchronously; but, as we have in the pulse quickness and slow- 
ness, fulness and smallness, jerking and sluggishness, — so in respiration we have 
frequency and slowness, shallowness and depth, suddenness and sluggishness, 
irregularity, and so on. 

Dyspnoia and Orthopnoea. — When respiration takes place with difficulty, it is 
called, in medical language, " dyspnoea;" and if it be so difHcult that the patient 
cannot breathe unless he sit upright, it is called "orthopnoea."* Orthopnoea is 
merely an intense dyspnoea. 

Respiratory Sounds. — Independently, however, o^ the frequency of respiration 
or its slowness, we may hear particular sounds. We may hear Tuivheezing sound, 
which is called " sibilous;" or we may sometimes hear it performed with a snorting 
sound, which is called " sonorous." Even without putting the ear to the chest, or 
employing a piece of wood as an intervening substance, it may sometimes be heard 
when, standing at a little distance. 

Alterations in the Voice. — The voice, also, affords much information. The 
voice is frequently suppressed, faint, harsh, and shrill; and these various changes 
will indicate great debility; or they will indicate particular diseases of the lungs 
themselves, or of the larynx, or of the air-passages. From listening to the voice, 
— with the ear in contact with the chest, or with the intervention of a piece of 
wood, or any similar substance, — frequently the voice does not afford the ordinary 
sound; so that some disease maybe predicted to exist within the lungs. 

Cough. — From a cough, too, we learn much with the naked ear; and the 
varieties generally enumerated are "slight," "severe," "harsh," "crowing," 
"hooping," "shrieking," "tearing," " hacking," "loose," and "dry." There 
is an infinite variety with respect to coughs. "Slight," "severe," "crowing," 
and " hooping" varieties, about which I need not say any thing. We occasionally 
hear a cough " tearing the patient to pieces;" and it frequently indicates more dis- 
position to spasm, than to actual inflammation. Now and then I have heard a 
cough, which has been regularly followed by a shriek, and absolutely alarming. 
At the end of every set of expirations, I lately heard one deep inspiration, not at- 
. tended by a hoop (as in the hooping-cough), but by a shriek; — as though llie indi- 
vidual were about to have a dagger j)lunged into her. 

Alterations in the Heart. — With regard to the heart, we obtain great informa- 
tion by examining tlie chest. For only by the touch can the force of the heart 
be ascertained; but by listening, the various alterations in its sound may be heard. 
Here, again, it is very necessary not to attend to any one system, or to the occur- 
rence of any one sound; but to attend to tlie whole set of symptoms. Instead of 
- the usual double sound which is heard in a healthy person, when the heart is 
affected in a certain way, we hear a sound as though a pair of bellows were blow- 

* From ojfloj, erect; and <n:cn, breathing. 



64 GENERAL PA'THOLOGT. 

ing; sometimes as if a file were in action; and sometimes as if a substance were 
being rasped. If we attend to these alone, we may be led into error; bur fre- 
quently, at the same time, great difficulty of breathing is observed on the slightest 
motion; also a swelling of the legs, and a deficiency of urine; and we are led to 
believe that organic disease is present. In other cases we hear only the sound; 
and then we should not be justified in saying there was organic disease, unless 
it is observed lime after time. In observing these sounds of the heart, the greatest 
care is necessary not to form a hasty judgment at first. We may also observe a 
sufficient proof of organic disease, by attending to the general symptoms; but fre- 
quently there are no other circumstances present. These sounds may arise from 
temporary causes, and not be heard on two successive days,— showing that these 
symptoms, — -like those of the pulse, and almost all other symptoms, — are never 
to be taken alone, but only in conjunction with others; and, then, only when they 
have been examined carefully and repeatedly. 

Abdominal Signs. — With respect to the abdomen, — to descend still farther, 
— the chief symptoms in that region are to be observed by the sight and touch. 
The hearing affoids no great information respecting the abdomen, except some- 
times on striking it, if it be enlarged. If we strike it, — especially with the inter- 
vention of some little substance (either the finger or a piece of ivory), — we learn 
whether the tumour arises from liquids or solids, by its emitting a dead sound, as 
if we struck the thigh; whereas, if it arise from mere air, there is a hollow sound, 
like that of a drum. By going over the abdomen carefully, we may ascertain 
whether there is enlargement of any organ, and we ascertain the shape of an en- 
larged liver with the greatest accuracy; — the dulness occurring where we strike, 
over the enlarged organ, and the hollow sound, where the abdomen is in its natu- 
ral state. This is the only point in which the ear is of much assistance. The 
ear is of the greatest use in diseases of the chest; but in the abdomen we must 
more particularly have recourse to sight and touch. 

If w^e expose a patient, in the case of abdominal disease, we may discover an 
alteration of figure which the hand cannot at once detect. Nothing can be more 
absurd than for a practitioner to prescribe, at once, for a patient who comes to his 
house for disease of the chest or of the abdomen. It is very well to prescribe in 
that way for diseases of the skin, the head, and other affections; but with respect 
to diseases of the chest and the abdomen, if we do not listen, or have the patients 
more or less undressed, it is impossible, in many cases, to form a correct opinion. 
We may form a guess, and we may be right; but shall not be able td form such an 
opinion as a philosophic mind would always wish. 

With regard to the abdomen, by the sight we may discover enlargement, either 
local or general; but it is certainly by the touch that we acquire the greatest in- 
formation. We may feel an enlargement of various parts; we may feel the indu- 
ration of different viscera; and if there be fluid, we may ascertain its existence by 
the occurrence of fluctuation. But one great use of applying the hand to the 
abdomen, is to ascertain the e^tistence of inflammation. Inflammations of the 
abdomen are, in general, easily detected by the hand pressing upon it; — owing 
to the circumstance of the abdomen having no bony coats; and it is always neces- 
sary, in acute diseases, carefully to examine the abdomen by means of the hand. 
In fever, and particularly in various affections of the alimentary canal, if we do 
'not examine the abdomen carefully with the hand, we may overlook inflammation; 
which, if neglected, may prove dangerous. In fever, at any rate, it is right (every 
day or two) to feel the abdomen carefully; — beginning at the epigastrium (which 
is the part most frequently affected), and going more or less all over it. But in 
every case where the abdomen is affected, it is of the greatest importance to make 
these minute observations. It is nonsense to say that a physician is to use his 
pen, and a surgeon his hand. Every physician must be more or less a surgeon, 
and every surgeon must be more or less a physician. It is as impossible for a 
physician to do without the use of his hand, in the case of the abdomen, as it is 
for a suro-eon in the case of fractures; and it is not creditable to any physician to 



GENERAL PATHOLOGY. 65 

pride himself upon not making these " wiecAanica/ examinations,"' — as (I believe) 
they are contemptuously called. 

Characters of Excretions. — With respect to the excretions of the body, the 
sight and the smell give us the chief information. It is only by the sight that we 
judge, chiefly, of the character both of the faeces and the urine; the smell, how- 
ever, gives certain information in these particulars; as it also does with regard to 
the excretion of sweat. The sweat, in many diseases, is exceedingly sour; and 
in others it has peculiar odours, of which I shall speak, hereafter. However, we 
sometimes are more minute in our observations respecting the urine. At any rate, 
it is necessary not to depend upon the sight and the smell merely; but to employ 
chemical means for ascertaining its quality. It is frequently requisite to ascertain 
whether the urine is acid, or neutral, or alkaline; it is right, frequently, to see 
whether it contains albumen or not; and, in other cases, it is necessary to ascertain 
whether it contains sugar. The most minute observations are sometimes neces- 
sary; and, of course, it is only with respect to the excretions that chemical minute- 
ness is at all of service. 

As to one sense, — that of taste, — I believe it can only be employed with regard 
to excretions; and, I presume, with but one of them, — the urine. Some go so far, 
in professional enthusiasm, as to wish us to taste every thing; but it is not usual 
except in case of the urine; and then, for the most part, it is better to get the pa- 
tient to taste for himself. However, this is not absolutely necessary with regard 
to the urine; because, by evaporation, and by weighing the urine, we can easily 
ascertain whether it contains sugar or not. I never yet in my life tasted it; but 
I have no objection, in diabetes, to taste the saccharine extract; for that is not 
urine. 

Alterations in the Surface of the Body. — Having gone through the chief organs 
of the body, I may say that the tvhole surface together gives the same information 
as the head; but in a very inferior degree. We gain certain information; but it is, 
undoubtedly, far less than we gain from inspecting the face. From examining 
the whole body, we learn whether there is a degree of fulness or emaciation. By 
observing its plumpness, we can tell whether the patient is in condition or not. We 
observe, likewise, the dryness or moisture of the skin, and the firmness of the 
flesh. We observe whether or not it is swollen by dropsy. It is to the surface of 
the body that we employ the sense of smell, with regard to the excretion of sweat. 
On the surface of the body we can ascertain the increased temperature of the pa- 
tient; and, for more minute observation, a thermometer is employed. It is generally 
put into the hand, — one of the two principal parts; or put under the tongue, — a 
portion of the head. Every part of the surface of the body has its own affections; 
and it is there that not only the chief symptoms of cutaneous diseases, — the symp- 
toms of all its own affections, are to be found; but there we often observe affections 
of parts beneath. In inflammation, for example, of the dura mater, from an injury, 
the surface immediately above frequently becomes (Edematous. We learn the 
state, not only of the skin itself locally, but of parts beneath it, by looking at the 
skin immediately superjacent.* 

Therapeutics. — These are the chief observations which I have thought it neces- 
sary to make, in a general way, on the third branch of general pathology, called 
" semeiology," or " symptomatology." The fourth division of general pathology 
is " therapeia;" or the general treatment and prevention of diseases. 

* The skin is pale, rough, and dry, (forming the " cutis anserina,") in the cold stage of fe- 
ver.. It is pale, but not rough, in s)''ncope. In the hot stage of fever it is red; and its tem- 
perature is likewise much raised, especially in scarlatina. The skin is green in chlorosis, 
yellow in jaundice and yellow fever, and sometimes blackened from the internal adminis- 
tration of nitrate of silver. It is dry in diabetes and dropsy, has an acid odour in miliary 
fever, and in ramoUissement of the brain its odour resembles that of a mouse. — Dr. Fletcher. 



VOL. I.- 



66 GENERAL PATHOLOGY. 



SECTION v.— GENERAL TREATMENT OF DISEASES. 

Vis Medicatrix. — With regard to most diseases, nature has a constant tendency 
to rid herself of them. It is ordained by Providence, to a great extent, that the 
injurious causes to which we are exposed should have but a temporary effect. 
Either the body has the power of resistance, or the causes exist temporarily; either 
from being applied but temporarily to the body, or from being able to exert no more 
than a temporary influence. In this way it is that, generally speaking, — although 
there are many exceptions,— there is a tendency to shake off disease. This power 
of the body to shake off its morbid state, is called by writers the ^* vis medicatrix 
naturx,''^^ or autocrateia.^^^ For example: if any thing too acrid be taken into 
the mouth, a great flow of mucus and saliva is the consequence; which has a tend- 
ency to dilute the acrid matter, and wash it away. So with respect to acrid matters 
taken into the stomach; — the stomach has a tendency to reject them; or if they be 
passed through the stomach into the intestines, the intestines are excited to action, 
and they are got rid of. This is the general tendency of the frame. 

Temporary Diseases. — Again; many causes of disease are only temporary. A 
person is exposed to a great cause of disease; — the cause ceases; and of course, in 
many instances, the effect ceases likewise. It is not a necessary consequence, 
however, that the effect should cease because the cause is removed; but it very fre- 
quently happens thus. Again: there are other causes which cannot produce an 
influence upon the body, however long they are applied, for more than a certain 
period. If we take the poison of small-pox, it produces a disease of only a certain 
duration. The patient may die; but if not, the disease can only last for a certain 
time; and when it has once occurred, the body, in the greater number of cases, be- 
comes insusceptible of it again. These are the various means which nature has 
provided for getting rid of disease;-— for getting rid of noxious causes before they 
produce actual disease; and for getting rid of diseases themselves. 

Some have so great a confidence in nature, that they leave every disease to itself; 
and that sort of treatment is called "the medicine of expectation" (" medicine ex- 
pectante"). Such treatment often does well; — it is the best in many cases, both 
medical and surgical; but it is totally inapplicable to a large number. No one, 
with a violent inflammation of the lungs, would consent to sit down quietly, in the 
hope that he would grow better day by day; when he knows that, by the lancet, 
he may obtain immediate ease, and get rid of the complaint. When a person has 
taken poison into his stomach, of course he would be mad to wait for nature to 
effect a cure. He would send for the physician's medicine, or for the surgeon's 
stomach-pump. 

Prophylactic, Curative, and Palliative Treatment.-— The treatment of the dis- 
eases of the human body is either " preventive" or "curative." We either attempt 
to prevent disease from occurring, or we attempt to remove it; and when we can- 
not remove it, we attempt to palliate it. The treatment of the human body, in the 
way of preventing its becoming the subject of disease, is called "prophylactic;'"' 
that which attempts to cure disease, is called " curative;" and when we cannot at- 
tempt to cure a disease, still we may do a great deal in the way of palliation; — so 
that medicine is "prophylactic," "curative," and "palliative.'" It is very often a 
great point to enable a person to live (while hemiist live) in comfort and happiness; 
and if he must die, it is a great point to enable him to die easily. In many cases 
we have to adopt both curative and palliative treatment together; — -that is to say, 
we aim at curing the disease; but we adopt palliative measures, all the time, for the 
•purpose of lessening any one symptom, or particular symptoms, which it is a desir- 
able object to get rid of, or lessen, before the cure of the disease enables us to do so. 
For example: in the case of inflammation of the lungs, although we may attempt 



The curative povirer of nature." 
^ From auTof, itself; and x^arsw, to govern. 
c From TTgo, be/ores and ^uXaa-a-iuj to 



GENERAL PATHOLOGY. 67 

to cure the disease by bleeding, it is sometimes of the greatest importance to put 
an early stop to a violent cough, by a narcotic. 

Rational and Empirical Treatment. — We can hardly be said to treat disease, 
when no disease exists; but we must allow an extended use of terms. Whether 
our means, then, are io prevent diseases ("prophylactic"), or whether they are to 
cure them ("curative"), or whether they are io palliate them ("palliative"), — the 
means in question maybe of two kinds, "rational" and "empirical." In the 
treatment of many diseases, as well as in their prevention, we act rationally; — we 
proceed upon general principles; and the whole treatment is in the highest degree 
philosophical. We make an accurate diagnosis, in the first instance; we then see 
what is the wrong state of the system, and employ such means as are evidently 
calculated to remove that state. But in certain diseases, and in certain varieties of 
disease, we are obliged to act empirically ; — to act in a certain way, without know- 
ing why we are likely to be successful. 

This empirical mode of practice is of two kinds. Sometimes we have a specific 
remedy for a disease, without knowing why; and, in other cases, it is impossible 
to know the exact variety and character of the disease; and we fire at random a 
shot that can do no harm, but which may do good. The treatment of inflam- 
mation is in the highest degree "rational;" the treatment of various spasms is the 
same; and the treatment of continued fever, too, I must think altogether " rational." 
The treatment, however, of ague, of itch, and of syphilis, is "empirical;" for it is 
impossible to know why a few grains of sulphate of quinine cure ague; why a few 
grains of sulphur will cure the itch; and why syphilis will cease sooner if we exhi- 
bit mercury, than if we do not. No one would a priori imagine, that any of these 
remedies could have such a peculiar property. There is nothing in the nature of 
the disease, or in the nature of the remedy, that would lead us to any such conclu- 
sions. We are also frequently obliged to be " empirical," where we cannot 
ascertain the proximate cause of a disease. For instance: epilepsy arises, in innu- 
merable cases, from an unknown cause situated in the head, or in distant parts. If 
We can ascertain that it arises from irritation, our treatment is " rational;" — we 
remove the cause. If we can ascertain that it arises from an inflammatory state of 
the system, our treatment is " rational;" — we remove the cause. But sometimes 
we cannot conceive that it arises from either of these sources; and then we use 
certain remedies that are known occasionally to do good; — not that they are a 
specific against epilepsy, — as bark is against ague, or sulphur against itch; but 
because they continually do good in the disease. They are not specifics; for often 
they will not cure one case out of many; and in many cases they are totally inap- 
plicable; but still they frequently do cure the affection. I allude to copper, zinc, 
nitrate of silver, &;c. 

Indications and Centra-indications.— The mode of treatment which is pointed 
out, from the circumstances of the case, is called the " indication;" and things 
which the nature of the case forbid us to do, are called " contra-indications." To 
discover the indications which are necessary in the treatment of a disease, we 
must make a careful diagnosis of the nature of the case; then we must make an 
equally careful diagnosis as to the variety of the particular disease; and then ascer- 
tain the stage of the affection, the exact strength of the patient, and the incidental 
circumstances. For example: we ascertain whether the place in which he lives, 
at all accounts for his disease, or whether the season of the year is such as is 
likely to have aflfected him. We must likewise observe whether there is any pecu- 
liar "constitution" of the period. Sydenham used to mention the character of 
epidemics as " the constitution of the year." Continued fever has sometimes been 
attended by so much tendency to debility, that evacuations were in the hi<ihest 
degree improper; and the patients did much better when they were merely allowed 
to take simple food, with scarcely any other treatment. This was the case during 
several months of the year 1831. If the patient w^as left alone, or treated with 
what (in truth) was no treatment at all, he has in most cases done well. If the 
least evacuation was attempted, the disposition of the disease was to great prostra- 



68 GENERAL PATHOLOGY. 

tion of strength and rapid sinking. It is necessary, therefore, to know the consti- 
tution of the period; and, but for this, I certainly should have destroyed many 
patients, by treating ihem as I had been accustomed to do. However, I was 
warned by the experience of others, and by careful observation of what was going 
on. 

Individual Peculiarities. — It is necessary, also, to know what are the contra- 
indications; — whether there is any peculiarity in the patient.^ Some patients will 
not bear a remedy which is very appropriate to a disease. The disease may 
appear evidently to point out the necessity of a certain mode of treatment; but a 
peculiarity in the individual may render it exceedingly improper. This peculiarity 
sometimes relates not only to particular medicines, but to particular articles of food; 
and sometimes there may be some other disease present, which forbids the employ- 
ment of a particular remedy. For example: if a person have a hernia which cannot 
well be kept up, we should try to do without an emetic, lest we should force the 
intestines down too violently. We are not, therefore, to be satisfied when we 
have given a name to a disease. It is a great point to make a good general diagnosis; 
but that will not do alone. We must make a more accurate diagnosis still; we 
must ascertain its minute variety, individual peculiarities, and all the other circum- 
stances that I have just now mentioned. 

Regimen and Drugs. — The indications of treatment are generally divided into 
two classes, — "regimen" and " pharmaceutical means;" — the former consisting of 
injunctions with regard to the temperature of the place, — to food, exercise, rest, 
and every thing of that description; and the latter respecting drugs.* In prescribing 
medicines, it is necessary to recollect that, however excellent they may be, they 
are frequently rendered abortive by our want of attention to something else. There 
can be no doubt of the use of a large number of remedies, — both drugs of the 
Pharmacopoeia^, and other remedial means; but I have seen them fail, not through 
any fault in themselves, but through something else that was not attended to when 
they were employed. For example: if mercury be given to arrest a violent acute 
inflammation, we cannot expect it to have that effect if we neglect to bleed the 
patient; and even though, in addition to giving mercury, we do bleed, we cannot 
expect to succeed unless we are particular with regard to diet. So, in diseases of 
the skin, there are many remedies which have a particular operation which we 
cannot explain. They are not exactly specifics; but they do great good. Yet the 
skin, in the midst of these diseases, may be in an inflammatory state; and if we 
do not bleed and enjoin low diet, we cannot remove the affection. As no one 
symptom can be depended upon, so it is with remedies; and when we prescribe a 
remedy for a patient, we must take into consideratioH all the other points on which 
it is necessary to give directions. 

But notwithstanding the most scrupulous attention to all the circumstances I have 
just enumerated, we shall often be disappointed in the cure of a disease; but we 
are not to be dismayed on that account. Our profession is capable of effecting the 
greatest good in the prevention of disease. By improvements with respect to 
cleanliness, with respect to air, with respect to food, and every thing else of that 
description, diseases which formerly prevailed to a great extent are now scarcely 
known; and we can do absolute good, to a large amount, in curing disease when it 
has occurred. A great many diseases are inflammatory, and over inflammation, by 
means of bleeding and other remedies, we have the greatest power. When we 
cannot eradicate a disease, still it is of great importance, and it is also a great bless- 
ing, to be able to mitigate pain; and it is to be remembered, that although we fail 
in the cure of many affections, yet, if we make the attempt, more knowledge will 
be attained by degrees; and those who follow us will be able to do what we cannot. 

a The indications of cure are of four kinds:— 1. Prophylactic. 2. Curative. 3. Palliative. 
4. Conservative. Those comprised under the last head are designed to guard againsta relapse. 
We fulfil these indications by three classes of remedies: — 1. Dietetic. 2. Pharmaceutic. 3. 
Surgical.— Z>r. Fletcher. 

" From <j>apjuaxov, a medicine; and ttojiw, to make. 



GENERAL PATHOLOGY. 69 

I have now made the chief preparatory remarks which I deemed necessary, 
before entering upon the consideration of particular diseases, — upon ''special patho- 
logy." I have confined myself to an exceedingly superficial view of the subject 
of ''general pathology;" and to the explanation of a few of those terms which I 
shall most frequently have occasion to employ. More minute remarks 1 shall re- 
serve till a subsequent period. For example: when I come to speak of the causes 
of inflammation, I shall particularly dwell upon the modus operandi of various 
changes and degrees of temperature in producing disease; and when 1 come to speak 
of diseases supposed to be contagious, I shall enter upon the subject of contagion. 
I think it much better to treat these matters in this way, than to treat them in the 
abstract before entering upon particular diseases; for by this means they will not 
only be better understood, but we shall be relieved from the tediousness of dwelling 
long at a time upon general subjects. 



SECTION VI.— METHODICAL NOSOLOGY. 

Methodical Nosology. — I mentioned that one part of general nosology, or one 
part of general pathology, — one branch of that part of pathology which is called 
" nosology," is the arrangement of diseases.^ One branch (if I may so speak) of 
"general nosology" is "methodical nosology." We frequently hear the arrange- 
ment of diseases spoken of simply as "nosology;" but that is incorrect. The ar- 
langeraent of diseases is not simply "nosology," but " methodical \\oso\ogy\''' — 
" nosologia methodica." 

It was long before an attempt was made to arrange diseases. I believe Felix 
Platerus was the first who struck out the idea of arranging diseases methodically; 
he was followed by Baglivi, an Italian physician, and Sydenham. However, it was 
a French physician who first actually arranged them systematically; — Sauvages, 
who published his work in 1762. It was in that year that the first methodical 
nosology was presented to the world. After him came the celebrated Linnaeus, 
who arranged every object in nature. He published his " Nosology" in Sweden, 
in 1763. Another physician, Vogel, published one in 1764. No sooner was the 
thought put in practice, than every body went to work. The arrangement of Cullen 
was published in 1769;^ another was published by Dr. Macbride, and one by Sogar, 
at Vienna, in 1771 ; then one by an author named Vitenus; one by Dr. Thomas 
Young, the celebrated English philosopher; and one, still more recendy, by Dr. 
Good. There have been others, but these are the chief. 

Now, however useful it may be slighUy to arrange diseases, — for the purpose of 
memory, and for the purpose of general views, — I think it must be confessed, that 
all these various " methodical nosologies" only perplex and encumber the mind. 
I formerly studied the arrangement of Dr. Cullen very minutely, and had great 
part of it at my fingers' ends; but I confess that my knowledge of it now is but of 
a very superficial kind, and that it was never of any use to me. The arrangements 
of Drs. Young and Good appear to me just as useless; and I would not advise 
others to plague themselves about nosological arrangements. My own experience 
tells me, that it is a much greater plague to recollect the arrangement, and all the 
hard words, than to recollect the things for which the arrangement is made. I 
never found it of the slightest use; — any more than the barbarous jargon of the 
"Propria qiise maribus,'''' and "Quse genus,'''' of the Latin grammar. 

Inconsistencies of Nosological Arrangements. — On the inconsistencies and de- 
fects of these various arrangements, I will not dwell; for if we turn to any methodical 
nosology, we shall find them in sufficient abundance. We find exceptions made 
to the plan which the author has laid down in his arrangement; and we find the 
most gross absurdities. If we turn, for example, to Cullen's arrangement, (which 
is one of the best,) we shall find that a large number of diseases, which are daily 

« See Page 38. » See Note to Page 37. 



70 GENERAL PATHOLOGY. 

occurring, have no place in it. Such was his arrangement, that not only was there 
no place for uiany most important diseases, but he arranges itch and fracture together. 
But although I think little of Dr. Cullen's arrangement, there can be no doubt that 
it was far better than that of any of his predecessors; and I must be allowed to pay 
a tribute of respect to his memory, as one of the most sagacious and best of men, 
that ever joined themselves to our profession. I should be very sorry to endeavour 
to captivate the minds of any, by attempting to lower any one in their estimation. 
Nothing can be more contemptible; and, as regards Dr. CuUen, nothing could be 
more unjust. We find in his work the utmost candour, and the soundest informa- 
tion; and although he indulged in hypotheses to which some Scotch physicians 
have been prone, yet, independently of that, his descriptions are elegant and simple, 
and his definitions admirable. It is to be remembered that his work on the Practice 
of Medicine, was not considered by him a perfect work; and he modestly called it 
"First Lines," — a mere outline; but such as they are, we shall find them, accord- 
ing to the information of that day, exceedingly useful; and it is on account of tha 
excellency of the original work, that I should perhaps prefer recommending an 
edition of Cullen, with notes, before the work of any other individual. 

Dr. Elliotson's Jirrangement. — An arrangement is certainly useful; although I 
am not an advocate for a methodical one (so called); and in my opinion, the most 
natural mode in which we can attempt to arrange diseases in our mind, — that which 
serves best for the purposes of recollection, is a twofold arrangement; first, as to 
the nature of affections in general, — whether they are inflammatory, structural, 
functional, piechanical, or parasitical; and then, secondly, as to the part in which 
the affection occurs. This is the arrangement which I shall follow. I shall first 
consider general diseases, — such as affect every or most parts of the body ; — 
inflammation, scrofula, and various other organic diseases; — and afterwards, having 
considered all the affections which may attack any part of the body, I shall pro- 
ceed to consider those affections and all others, whether functional, mechanical, or 
parasitical, as they attack the body from the head downwards, a capite ad calcem.^ 
I think we all make two inquiries, in considering any case; — the one is the nature 
of the disease, and the other is ihe situation of it. This is the utmost assistance, I 
think, that the memory can have from arrangement; and this is the plan which is 
continually followed by practical writers. They write on particular diseases, what- 
ever they may be (inflammation, cancer, &c.); and of the whole diseases of parti- 
cular organs, and sometimes of particular regions. One writer publishes a work 
especially on diseases of the urinary organs; another, entirely on diseases of the 
nervous system; another, entirely on diseases of the head; another, on diseases of 
the chest; and this course vv'e naturally fall into. But, independently of that, we 
must make observations upon the general affections to which all parts of the body 
are liable. I am quite satisfied that an arrangement of this sort, — by which we 
first consider general affections, which may attack any one part of ihe body; and 
then consider the affection as seated in this or that part,— will afford us all the 
assistance that arrangement can give; and I hope we shall never plague ourselves 
farther with methodical nosology. 

» «' From head to heel'* 



71 



PART I. 

GENERAL DISEASES 



CHAPTER I. • 
INFLAMMATION. 

Inflammation,^ — the first disease of which I shall speak, — is the most general 
of all afTections. 

General History. — It will attack any part of the body that is vascular. It is 
also one of the most frequent affections. It is a disease which scarcely any per- 
son escapes, and which is seen every day. It sometimes occurs simply by itself; 
and sometimes it is the concomitant of a variety of other diseases. Many diseases 
are always inflammatory, though they are not simple inflammation; — though there 
is something more than inflammation, yet inflammation is united with them. Many 
other diseases are frequently inflammatory, but not always. Inflammation con- 
tinually occurs as a means of benefit to the body. It is not only a morbid process; 
but a process frequently set up by nature for the purpose of restoration, relief, and 
prevention. It is a disease, too, which proceeds from a vast number of causes; — 
causes to the action of which we are continually exposed, whether we will or not. 

Its Protective Power. — Inflammation is tlie process frequently employed by na- 
ture, to prevent the escape of matters into parts where violent inflammation would be 
produced; and it is established to prevent its own occurrence in another spot. For 
instance: when an ulcer takes place in the stomach or in the intestines, if it proceed 
unchecked, the contents of the stomach or the intestines are poured forth into the 
cavity of the peritonaeum, and a violent inflammation is set up; — an inflammation, in 
the general number of cases, fatal. Nature, however, very frequently excites in- 
flammation outside the organ, exactly at the part corresponding to the ulceration 
within; by which means it is glued to the surrounding parts. The blood becomes 
retarded in its course througli the neighbouring capillaries, and the surrounding 
textures become loaded wiih a glutinous, serous fluid; in which, subsequently, 
progressive changes occur, and end with its more or less perfect organization. By 
slow gradations, there take place in it transitions which indicate that the other con- 
stituents of the blood have exuded through the vessels; and. a part of tlie fluid 
efl'used assumes a gelatinous consistence; — forming layers, orfl.akes, which gradually 
acquire complete solidity and organization. This is the interesting process by which 
the surrounding parts are agglutinated; and the extension of the disease of the stomach 
or intestines, by ulceration, into the peritonseal cavity, is effectually prevented. 
Thus, a slight inflammation is set up in one spot, to prevent another, which would 
be fatal to the patient. The adhesion of the stomach, sometimes to the periionanmi, 
and sometimes to the liver, is thus explained. 

Nature, further, frequenUy employs inflammation to give exit to something which 
is injurious to the body. When a biliary calculus is impacted in the ducts, and is 

» From " inflammo," to iyijlame, or burii. 



72 INFLAMMATION. 

too large to escape, it sometimes happens that these ducts become attached, by in- 
flammation, to the duodenum or other intestines. The inflammation, after it has 
excited adhesion, proceeds, perhaps, to ulceration; and when the latter occurrence 
has taken place, the calculus escapes through the opening into the intestines. The 
inflammation, in the first place, is setup to prevent the communication which would 
afterwards take place in the peritonaeum; — so that the bile and the calculus shall 
not escape into it; and when all these parts are firmly glued together, and the 
danger prevented, then, at the particular spot, inflammation goes on to ulceration. 
Ulceration takes place into the intestines; and in that way an exit is given to the 
foreign body. 

Its Sanative Power. — When a part of the body mortifies, whether through 
inflammation or not, — when a part has become dead, and useless to the body, and 
even injurious to it from its presence, — inflammation is employed for the purpose 
of separating it. At the boundary of the living part, inflammation occurs; a red 
line appears at the extremity of the healthy part, where the dead part begins; which 
indicates the circular course of the inflammation, and which afterwards proceeds to 
ulceration. A furrow of ulceration takes place; until the part is ulcerated through, 
and the dead portion falls off*; — having been separated by the ulceration of the 
livinsf disease. 

[There is nothing in the whole domain of medical science, which brings under 
our view phenomena of greater wonder and perfection, than those processes by 
which, through the agency of inflammation, nature oftentimes averts impending 
death. By elaborate and numerous dissections, Abercrombie has shown that a 
portion of coagulum of blood, extravasated into the substance of the brain, passes 
through a curious series of changes, both in consistency and colour, before the work 
of recovery is completely accomplished. 

Physiology teaches, that whenever blood passes beyond the limits of the living 
vessel, its vitality becomes extinct; and that it undergoes certain changes; — sepa- 
rating into its elementary parts, in obedience to common physical laws. The 
aggregate result of these changes in healthy blood, is called "coagulation;" which, 
in a subsequent page, will have a full explanation. When, therefore, an extrava- 
sation of blood takes .place into the hemispheres of the brain, or into the expanding 
track of the crura cerebri, or corpus striatum, — its most frequent situations, — the 
process of spontaneous coagulation indicates the death of the blood. In consequence 
of the pressure of the circumjacent mass, there is not a perfect separation between the- 
serum and crassamentum; — the latter containing within its substance a large propor- 
tion of serosity, which renders the clot loose and flabby. It is evident that the pre- 
sence of this extraneous coagulum in a living structure, must determine that action by 
which the work of reparation is commenced, and in less severe cases wonderfully 
completed; — circumscribed inflammation immediately occurs in the brain surround- 
ing the deposit of blood. 

The continuance of it in a subdued degree, for some time, enables the surround- 
ing parts to effectually protect themselves against the influence of the foreign matter; 
— by forming a circular wall of membrane; called, in surgerv, the '' pyogenic;^^ — 
from its reputed property of secreting pus. When this is being formed, it is 
obvious that the pressure of the coagulum against the brain in immediate contact 
with it, and the surrounding inflammation, must conspire to cause a breaking down 
of the medullary matter; — it is accordingly found, that a cavity is formed for the 
reception of the clot; which is limited by the membrane of which we have spoken. 
Provided the clot be small enough to be compatible with the continuance of life, 
the paries of the cavity begins its function; — that, namely, of carrying away, by 
absorption, the contained blood. The serum first disappears, — leaving three por- 
tions of difl'erent colour; — the thicker yellow part of the serum, — the fibrin, — and 
the red particles. A ready explanation is here found of the various shades of colour, 
which the eftused blood presents in the progress of absorption. The combinations 
of these three portions, would produce a compound colour, approaching black or 
dark yellow; and a variation in the proportion of any one or two, would necessarily 



INFLAMMATION. 73 

cause a corresponding variation of hue. Thus, then, these interesting appearances 
are accounted for. The clot subsequently disappears altogether, and the cavity 
becomes occupied by a serous fluid, — the produce of its membrane; since it does 
not resemble the serum of the blood. Afterwards, this serum itself disappears, 
and leaves the cavity empty. By the pressure of the superincumbent mass, the 
walls become approximated; adhesion occurs; and thus obliteration and recovery 
result. There is no instance, in pathological science, which presents us with a 
more beautiful example of the curative effects of inflammation. 

Surgery supplies us, in great numbers, with other cases, scarcely less admirable. 
It is under the guiding agency of these processes of inflammation, that collections 
of matter in the interior of the body, are brought safely to the surface, or some 
organ communicating with the external air. Abscess of the liver, bursting into the 
bronchi, colon, or surface; — the formation of an artificial anus, by the agglutination 
of the opposing layers of peritonaeum, and their subsequent ulceration; — the adhesion 
of serous coverings of cavities, limiting the extension and quantity of effusion; — the 
spontaneous and artificial obliteration of the cyst of the tunica vaginalis in hydro- 
cele, and of the cyst in ovarian dropsy; — may be enumerated as examples of the 
salutary efi'ects of inflammation. The genius of Dupuytren recognised this principle, 
when he proposed his operation for artificial anus: — the suggestions of Dr. Marshall 
Hall, with respect to the surgical cure of prolapsus uteri (by causing adhesion of 
the sides of the vagina) and the obliteration of the vascular plexus, in naevus, by 
the frequent introduction of a needle, had immediate reference to the restorative 
power enjoyed by inflammation: — a knowledge of this principle likewise led Sir 
A. Cooper to the cure of varicocele, by removing a portion of the integument from 
the upper part of the cord — and thus by the formation of a binding citratrix, pre- 
vent the enlargement of the spermatic vein. — T. Williams.'] 



SECTION I.— GENERAL DEFINITION. 

The general definition of inflammation is, — " redness, swelling, heat, and pain;" 
that is to say, morbid heat, — morbid redness. Swelling and pain require no defi- 
nition, but redness is healthy in some parts; and therefore we must understand 
" morbid redness;" and with respect to temperature, morbid heat. These are the 
four chief symptoms of inflammation, — those which make the definition in general. 
The words of Celsus are, — "rubor et tumor, cum calore et dolore."'* 

These are the general constituents of inflammation; and if they do not all exist 
in all cases, still the greater number are usually present. Sometimes one is ab- 
sent, sometimes another; but the redness is never absent. The redness is certainly 
indispensable to our idea of inflammation; and it will sometimes exist wnthout 
swelling, without heat, or without pain; or with the absence of any two of them; 
and now and then the redness will exist alone. Whether the state should then be 
called " inflammation" or not, may give rise to a difference of opinion. Frequently, 
however, inflammation exists, without any perceptible swelling. We must con- 
ceive the part to be a little increased in size, because there is more blood than natu- 
ral; but without a sufiicient enlargement to justify us in using the word ^'■swelling;''' 
there may not be much increase of heat, and pain may be wanting; and it is to be 
remembered, that both the increase of temperature and the redness (by which we 
understand a morbid degree of them) may arise from other circumstances than in- 
flammation; as may also the swelling and pain. 

Redness. — Still, although redness is indispensable to inflammation, it is not every 
redness that we have a right to call "inflammation." A certain degree of it is 
necessary to the idea of inflammation. How much, cannot be specified; but, like 
sensations in general, it must be experienced to be learned. The requisite intensity 
will vary in difierent parts, according to their natural colour. A blush, or moment- 

» " Celsus de Medicina," Lib. 3, Cap. 10. 



74 INFLAMMATION. 

ary rosiiiess, is not considererl an inflammation; and every part is liable to this 
momentarily in health. As regards the cheeks, a degree of redness there would 
not be considered inflammation, which we should be fully justified in calling so, 
if it affected other parts of the body. The most intense redness, if it last only for 
a moment, we should not call "inflammation." In the cheeks it must be, — sup- 
posing the person has a natural colour, — a very deep red indeed, and more or less 
permanent, — at least not a transient redness, though intense, — to enable us to say 
that the cheeks are inflamed. 

Again: the same degree of redness, — the same intensity of it, would not be con- 
sidered inflammation if alone, which would be considered so if there were also pain 
and morbid sensibility. If we saw in the cheeks a great redness, we should not 
hesitate to call it " inflammation," if we found the part were morbidly sensible; or 
if the patient complained of its smarting, and being painful independently of pres- 
sure. Although the redness might be less intense, and might not continue so long 
as alone to justify us in calling it "inflammation," yet provided it were in a part 
which is not naturally red, like the cheeks, — not liable (like them) to occasional 
flushing and rosiness, — a mu^ch less degree of it, and much shorter continuance, 
might give us the idea of inflammation. Thus we see how many things are to be 
taken into account. A knowledge of these things cannot be gained at once; and 
many circumstances must be called in to aid us in our judgment. When persons 
are speaking of redness in connection with inflammation, instead of the mere ex- 
pression " redness,^'' we ought to say " morbid,''^ or (perhaps) ^'preternatural red- 
ness;" because what is morbid redness in one part, is not morbid redness in another; 
— redness preternatural to the part aflected. 

[In the experiments of Hunter upon the ear of the rabbit, and the observations 
of Kaltenbrunner, redness appeared as one of the earliest consequences of an in- 
jurious impression upon the part. In the web of the frog's foot, it has been often- 
times observed, in an unequivocal manner, that an augmentation of colour is co-equal 
with the initial lesions, in the capillaries of the part undergoing inflammation. Nor 
is this, a priori, improbable; — as will afterwards be rendered obvious, when 
describing the microscopic changes in the aff'ected capillaries. It will then be ex- 
plained, that i\\e first appreciable deviation from the ordinary condition of the part, 
consists in a diminution of the calibre of the minuter arteries, and capillaries. In 
obedience, therefore, to the recognised hydraulic law, the rapidity of the contained 
current will increase in a ratio directly as the contraction. But it will be readily 
conceived, that the augmented velocity of the current will not adequately compen- 
sate the straitened capacity of the channel. It is therefore concurrently remarked 
by different microscopists, that the detained blood, by its mechanical distension, 
and, according to Miiiler, its vital stimulation, excites the capillaries in the imme- 
diate vicinity of the primarily irritated vessels; and thus, quickly difl'using the 
original cause, induces a vigorous activity in the capillary circulation of the inflamed 
spot. This exalted action^ then, unattended by any visible organic change, — dis- 
tinguished only by a circumscribed acceleration of the circulating fluid, and a dif- 
fused blush of arterial redness, — specifically constitutes irritation. Without antici- 
pating what, more appropriately, will come under another chapter, it may be 
observed, that this redness, for its character or shade, is dependent upon several cir- 
cumstances. The nature of the affected part has considerable influence alike upon its 
intensity, and tint or shade. The quality and nature of the causative ajrent, however, 
exercises still greater influence over the character of the resultant inflammation. 

With a view to determine, with greater exactitude, the extent to which difl*erent 
agents — externally applied, or ejected into the trunk of the vessel distributing its 
branches over ihe inflamed part — modified the colour and character of the conse- 
quent inflammation, linstituted a series of experiments, originally sug-gested by the 
researches of Majendie; in which he artificially induces fevers, of difl'erent types, 
by the introduction of septic poisons into the system. Decomposed matters of a 
vegetable kind, generate fevers of an intermittent character; while those of an ani- 
mal nature, induced the continued-iy^ihoi^ specie?. 



INFLAMMATION. 75 

In these investigations, I found that diluted muriatic acid, injected into the carotid 
artery of a rabbit, considerably exalted the circulation of the ear, and produced a 
scarlet colour. The red particles appeared contracted in size; and, therefore, a 
greater number pass through the capillary, than under the agency of ordinary 
stimuli. Common water produced an evident enlargement of the calibre of the 
vessels, a subdued and confused redness, with a visible alteration in the figure of 
the particles flowing through the part; — an appearance which finds a plausible 
explanation in the action of water upon the red particles only of the body; — carry- 
ing away, by rapid solution, the envelope of colouring material. Liquor potass-^ 
produced a similar appearance under the microscope. Various fluids, in different 
stages of decomposition, were likewise introduced by means of a fine syringe; but 
in none of the cases were there distinguishable effects of a distinctive character. 
In all, the blush induced presented a dark colour, or one approaching brown. 
While they are acknowledged to be imperfect, these inquiries reflect important 
light upon the varieties of colour presented by inflammation, under varying condi- 
tions of the general system, and the quality of the blood, irrespective of the structure 
or organ in which it exists. Nor is the discrimination of shade presented by an 
inflamed part unimportant; since, in the treatment of disease, success will often 
paramountly rest upon ascertaining whether an inflammation be simple or raalij^- 
nant, ordinary or specific. In surgery, it is quite orthodox to regard an inflamr/ia- 
tion discovering a blue, or purplish tint, as associated with the operation of some 
poison in the system. It is universally known, likewise, that these cutaneous and 
other inflammations, which depend upon the circulation of a syphilitic virus through 
the body, are marked, characteristically, by a coppery shade. These practical 
facts, then, interestingly teach the consequences which result from attention to the 
character of the redness, in diff'erent species of inflammations. It may here be 
noticed, as a physiological circumstance of interest, that Haes, and Wedemeyer, in 
experimenting upon the relative power of the arteries, and capillaries, observed, that 
when stimulating fluids were injected into the torrent of the circulation, they ex- 
erted their chief effects upon the capillaries; but themselves passed through the 
capillary vessels at a much slower rate than the blood; — demonstrating that some 
adapting vital affinity subsists between the blood and the living membranes of the 
vessels; thus rendering its onward movement rapid and free. — T, Williams.'] 

Heat. — We will now proceed to the consideration of the other symptoms; and 
first of heat. For the same reason which makes one adopt the epithet ^^preterna- 
turaV^ or ^^morbid,^^ with regard to redness, we should likewise affix the same 
epithet to heat; because the body, — in this country (at least), and in most others, 
—is- hotter than the surrounding temperature; and therefore it is always hot. 
A preternatural heat, if not very great, is not of necessity inflammatory. A 
certain intensity, and a certain duration, are necessary to constitute inflammation 
in the case of heat, as well as in the case of redness. The greatest intensity of 
heat, if transient, would not be considered inflammation. The burning heat upon 
the cheeks, the palms of the hands, and the soles of the feet, in hectic, is never 
considered inflammation, even though it be combined with preternatural redness. 
The most intense heat, and also the most continued, is not of necessity inflamma- 
tion, unless it be united with a permanent preternatural redness. The example of 
hectic shows, that even a combination of heat with intense redness is not sufficient 
to give the idea of inflammation; for in these intense spots in hectic there is no 
pain, nor are the parts most affected tender on pressure. In addition to the tem- 
porary duration of the morbid heat, there is no swelling in that affection; and 
therefore we have still greater reason for saying, that it is not inflammatory. 

With regard to heat, the temperature of the affected part appears much higher to 
the patient, than it really is; — a circumstance which arises from the morbid sensi- 
bility of the parts. In palay it is not very uncommon, when there is no increase 
of temperature, — no inflammation, for the patient to feel every thing hot; so that if 
he sit on any thing without his clothes, it causes a sensation of heat; or if ho put 



76 INFLAMMATION. 

his hand on any substance, whatever it may be, it appears as if it were heated. 
This is a pecuUar state of the system, which is not inflammation. There is in 
inflammation a general morbid sensibihty of the part; and therefore the degree of 
heat which actually occurs, produces greater effects than it would in any other part 
of the body. But although, from the morbid sensibility of the part, the increase 
of heat appears greater than it really is, there can be no doubt that in inflammation 
the temperature is raised. When the nostrils are inflamed, or the bronchial* mem- 
brane, or the throat, the air that we expire is so heated in passing over the parts, 
that (as it comes out at the nostrils and lips) it is felt to be burning. If the hand 
be applied (in a state of perfect health) to the inflamed part it feels hotter than 
usual; and if the thermometer be used, the point is ascertained to a nicety. The 
parts inflamed appear hotter, by many degrees, than other parts of the body. It is 
not uncommon to find them at 107°. John Hunter made experiments, to show 
that the temperature of inflamed parts was but little augmented; — at least not 
higher, nor even so high, as that of the blood at the heart and in the chest; — that 
if the parts had naturally a lower temperature than the centre of circulation, — as 
for instance, the hands and the feet, — when they became inflamed, their tempera- 
ture never rose so high as that of the centre of circulation. The general tempera- 
ture is said to be 98°; but it varies in different parts. The farther removed from 
the heart, the lower it becomes; because there is less circulation there, and the parts 
are more exposed to the temperature of the surrounding atmosphere. 

John Hunter's Experiments. — John Hunter produced inflammation in the tho- 
rax, peritonaeum, rectum,'' and vagina; and he found the heat but one degree and a 
half higher than before the inflammation; and he frequently found it unaltered. He 
states that the temperature of the vagina, at the utmost, increased to 101^°; but he 
found the temperature of the tunica vaginalis only 92° in health; whereas, when 
inflammation was produced in it, it rose to 99|°; — 98° being about the natural 
temperature of the body. It is to be remembered, however, that the scrotum is a part 
very much exposed to the surrounding air, — a depending part; and is therefore as 
much exposed to the atmosphere, as the hands, feet, ears, or nose. He infers, 
further, that the heat is never raised above the natural standard at the centre of 
circulation. If the natural temperature of the tunica vaginalis be 92°, certainly 
the increase to 98|'^ is very considerable. He remarks, that he once found the 
abdominal fluid raised as high as 104°, and that if inflammation attack any part with 
a temperature of 98°, the heat may proceed beyond that of a healthy person. Now, 
however correct these experiments may be, it is only necessary in the case of ery- 
sipelas to take a thermometer, lay it upon the inflamed part, and cover it up. It 
will be seen that the temperature, although it be erysipelas of the leg, is often 
raised to 104, 105, 106, or 107 degrees. 

Everard Homers Experiments. — That the temperature of the body may be in- 
creased very considerably, in various circumstances, is shown by the following 
facts. Sir. Everard Home" observed the oviducts of a frog when about to spawn, 
and when a great local activity of circulation was going on, to be two degrees higher 
than the temperature of the heart. There was no inflammation here; but merely 
a great activity of circulation, approaching to inflammation; — such as occurs in the 
generative process; and the result was as I have stated. If, then, a mere natural 
process, short of inflammation, will raise the heat above that of the centre of circu- 
lation, we may well suppose what inflammation will do. Even in vegetables, when 
a certain process is going on with gr«at activity, a very considerable increase of 
temperature takes place. When the arum cordifolium, and the arum maculatum, 

» From S^'}yx°i^ ihe throat. 

^ From " rectus," straight^ owinp: to an incorrect notion of its course. 

* It is only an act of literary justice to John Hunter, to caution the reader against receiving 
any thing which Sir E. Home has published, as his own; — since the exposure that recently 
took place before a parliamentary committee, has associated the memory of Home with eter- 
nal infamy,~as the foulest literary robber that ever disgraced the annals of science in this, 
©r any other, country. — T. Williams. 



INFLAMMATION. 77 

are about to burst, the increase of temperature is such, that by placing a consider- 
able number around a thermometer, the latter has been raised very considerably. 
Twelve were placed around a thermometer; when so high a degree of heat was 
developed, in the physiological process of bursting, that the instrument was raised 
from the temperature of 70° to that of 143°. Even in fever, by placing the ther- 
mometer under the tongue, we find the temperature raised many degrees; and the 
same occurrence takes place in acute rheumatism. In one case of phlegmasia dolens, 
on placing the thermometer on the thigh, and covering it with the hand or bed- 
clothes, I found it rise to the same degree of heat that is frequently observed in 
fever, and in acute rheumatism; — namely, to 107°. Indeed, one gentleman says 
that, having introduced a thermometer into the vagina, during labour, he has ob- 
served the temperature of the uterus to be 120°. During the violence of the spasm 
in tetanus, the temperature is frequently as high as 107°. There can be no doubt, 
therefore, that inflammation is frequently attended by a great increase of temperature. 

But as increased heat may exist without inflammation, so inflammation — that is 
to say, redness and swelling, of an undoubted inflammatory character — may exist 
without any preternatural heat. Inflammation — that is to say, preternatural red- 
ness and swelling, going on to suppuration — may exist without any increase of heat; 
— a state which has been called ^^passive inflammation." Some regard this condi- 
tion as only one of congestion. But it will go on to suppuration; and therefore 
may be called "inflammation," although there is no increase of heat. Discrepant 
notions have prevailed with regard to the limits within which the term ^^ inflamma- 
tion''^ should be restricted; — some supposing the presence of pain, others of heat 
and redness, necessary to constitute this state. Andral calls any state in which 
there is a morbid collection of blood, "hyperemy,"^ — excessive quantity of blood 
in a part; when it is actively inflamed, 'Uictive hyperemy;" and when a passive 
state occurs, he terms it ''passive hyperemy." Thus he gets rid of the difficulty 
altogether, by no longer using the word ''inflammation;^^ but by using a word 
signifying " congestion of blood," and applying one epithet (" active") or another 
(" passive") to it. 

Swelling. — If we consider the third of the symptoms (swelling), we shall find 
that it also may exist without any inflammation. Swelling, although frequently a 
symptom of inflammation, — more frequently than not, — may (just like an increase 
of temperature, or an increase of redness) exist without inflammation. Any injury 
produces a swelling. The mere displacement of a part (the dislocation of a bone, 
or hernia), the effusion of haemorrhage, a collection of water, any morbid growth 
(whatever its character), or the presence of air within the body, — will produce 
swelling. For a swelling to be considered inflammatory, it must be united with 
pain or a preternatural redness; and even then it may be chiefly dependent on other 
causes. In dislocation, for instance, inflammation of the ligaments and integuments 
may occur, — producing pain; but the swelling arises chiefly from the displaced 
bone. Again: it is to be remembered that inflammation may sometimes exist with- 
out swelling; as is occasionally noticed in ophthalmia;^ in which the turgescence 
often gives rise to no perceptible swelling. Frequently, however, this affection, 
and many superficial inflammations of the skin, are not attended by any swelling. 
A part will appear inflamed, sometimes without the presence of pain or increase of 
temperature; but marked by excessive redness and excessive swelling. The con- 
gestion is extreme; and gangrene, in such a case, is very likely to take place. 

It is therefore evident, not only that the symptoms will arise from various other 
causes than inflammation, but that, when they do occur, they are frequently out of 
proportion to each other. Sometimes a little inflammation is attended by very 
violent pain; and sometimes a little inflammation, — a little increase of heat, is at- 
tended by a most violent swelling. There is no necessary proportion between au}' 
of these symptoms. 

Pain. — The last of the marks of inflammation (pain), may arise from many 

* From vm^i in excess; and aifxayblood. * From o<^«X/uo?, the eye. 



78 INFLAMMATION. 

Other causes than inflammation. Pain will arise from a mere spasm.* Nothing is 
more painful, for example, than cramp in the legs. Pain frequently arises from 
scirrhus, or cancer; which some call "chronic inflammation;" but certainly there is 
something superadded. Pain, too, is frequently neuralgic; being dependent on a 
violent affection of the nerves, in which no inflammation can be detected during 
life, and no eflectof inflammation discovered after death. Pain continually arises 
from inflammation; but it continually arises, also, from the othersources just pointed 
out; and sometimes it is absent in inflammation. A part is violenfly red, and vio- 
lently swollen, without any pain at all; and sometimes nothing is worse than this 
state; for the part may fall into gangrene. 

Characters of Pain. — The character of the attendant pain varies with differences 
in the structure of the part in which it occurs. If the part be unyielding, then the 
pain is of a tense character and great in severity; hence inflammation of the theca 
of a tendon, is generally attended with great agony. From a similar cause, also, 
when matter is formed and cannot escape, the pain is most agonizing; whereas, on 
making an incision, so as to allow the escape of even the smallest quantity of mat- 
ter, and so relieving the tension, the pain instanfly disappears; and thus the great 
irritation of the system, which, perhaps, amounted to a violent delirium, also van- 
ishes. Hence, too, the great use of incisions in certain inflammations of the skin 
and the cellular membrane; where the latter becomes excessively gorged with fluids, 
and the skin is distended over it, — producing the greatest agony; but a few incisions 
afford immediate relief. If it be inflammation inclining to suppuration, the pain is 
of a throbbing character. If the skin be affected, the pain frequently assumes a 
smarting or tingling character. If a mucous me'mbrane be inflamed, there is fre- 
quenfly a burning and pricking pain; while inflammation of a serous membrane is 
characterized by a stabbing sensation, — as though a knife were being plunged into 
the part. The difference in the character of the pain in inflammation of serous 
and mucous membranes, is owing, I presume, to the fact, that serous membranes, 
in general, are tense, and therefore give rise to the most violent pain when inflamed; 
whereas mucous membranes are all of a more yielding character; and, consequently, 
inflammation of them is never attended by this violent stabbing pain. 

Sometimes there is merely a soreness; — no pain is felt unless the part be irritated 
mechanically, or some particular stimuli are applied. Again: parts which have 
litfle or no sensibility in health, acquire a degree of sensibility, under inflammation, 
which is frequenfly very intense. Many parts that may be cut in health, without 
the individual experiencing any sensation, cannot, when inflamed, bear the slightest 
motion or pressure. If, therefore, parts which show no sensibihty in health, be- 
come very sensible in inflammation, we may fairly suppose that parts which are 
naturally sensible in health, may become very painful when in a state of inflam- 
mation. 

Pain affected by Pressure. — The pain of inflammation is generally increased by 
pressure, — at least by stulden pressure; while pain arising from spasm is generally 
relieved by pressure. This is very strikingly shown in colic and enteritis. In the 
latter, the pain proceeds from inflammation, and is aggravated by the slightest pres- 
sure; while, in the former, which is spasmodic only, pressure rather diminishes 
than augments the pain. It is necessary to remark, however, that although the 
pain of inflammation is increased by pressure, it is rather due to its sudden or 
partial application. For, if pressure be applied suddenly to an inflamed part, or if 
it be only applied to a part of the inflamed surface, then the capillaries cannot be 
emptied with sufficient rapidity, and pain results from the degree of tension which 
is produced. If, however, the pressure be applied slowly, or over the whole sur- 
face, — so as gradually to empty the capillaries, or diminish their contents, -^then 
little or no tension is produced; and, consequently, pain is either absent or very 
trifling. 

Pressure, a Curative Agent, — Pressure, therefore, has been recommended as a 

" From o-Trao), to draio. 



INFLAMMATION. 79 

means of cure, by certain writers, in some inflammatory diseases. It was advocated, 
for the cure of gout and rheumatism, by Dr. Balfour, of Edinburgh; and by Velpeau, 
in erysipelas. But it frequently happens that, although relief may be given in some 
cases, considerable aggravation is excited in others. It is necessary that the part 
should be equally compressed; for any deviation in this respect, by which a part 
of the vessels might become more distended, would only increase the mischief. 
Very frequently, too, inflammation does not depend altogether upon local causes. 
There is a tendency to it in the constitution. The circulation of the part, although 
impeded, sufl'ers little diminution in its impetus; the large arteries around are found 
to throb violently against the part compressed; and pressure frequently cannot be 
borne at all. On all these accounts, it is exceedingly diflicult to cure inflammation 
by pressure. As a general rule, however, we may say that the pain of spasm is 
diminished by pressure, and the pain of inflammation increased by it; and this 
criterion is continually resorted to, as a means of diagnosis; — as a means of dis- 
tinguishing whether pain be inflammatory or spasmodic. 

Inflammation is generally known by pain, increased on pressure; by feverishness; 
and by a disturbance of the function of the part. "When a person is observed 
labouring under disordered function, under feverishness (pyrexia), and under pain 
increased by pressure, a strong presumption is afforded, that the proximate cause 
of these symptoms is inflammation. Sometimes there is no pain experienced, but 
simply disturbance of function and feverishness; and when such is the case, the 
presence of internal inflammation may be questioned. When a part can be seen, 
the symptoms which I have already mentioned (pain, heat, redness and swelling,) 
-^-few or more of them, — will be sufficient to characterize the complaint; but we 
are certain also of the existence of inflammation, even when the part is invisible, — 
when we cannot ascertain whether it is red, hot, or swollen, or not; but where there 
is pain increased on pressure, the function of the part is disturbed, and the patient 
labours under whaf is called " feverishness," or " pyrexia." 



SECTION II.— APPEAEANCES AFTER DEATH. 

The foregoing are the symptoms of inflammation during life; but they may have 
existed at that period, and yet none of them remain after death. The pain and the 
heat, of course, must disappear; but the redness and swelling might be expected to 
remain. When, however, the part inflamed during life is seen, or such symptoms 
have been present as to leave no doubt of the existence of inflammation, in both 
cases it may be found, on examination after death, that no marks of inflammation 
are discoverable. Yet the absence of these marks does not, in any way, inva- 
lidate the opinion formed during life; for it will sometimes happen that, after death, 
every mark of inflammation will disappear. In inflammation of the surface of the 
body, or the eyes, visible enough during life, we And both parts pale after death. 
The skin, perhaps, will be slightly swelled; but the swelling will be greatly dimi- 
nished, and the redness entirely gone. After apoplexy, frequently nothing is 
observed; although, during life, the head appears to be bursting from an accumu- 
lation of blood, and the patient dies of the complaint, yet, after death, no morbid 
appearances can be discovered. 

[There are many observations made by Dr. Carswell, in his " Elements of 
Morbid Anatomy," which render it probable that all variations of appearances pre- 
sented post-mortem, by parts which were, ante-mortem, unequivocally inflamed, 
are referable to two circumstances; — that of position, and that relating to the extent 
or grade of inflammation before death. Althoug^h Dr. Carswell does not carry the 
explanation further, I think it may^with probability be suggested, that if any disor- 
ganization has occurred, even to the extent of caitsing a stagnation and coagulation 
of the blood in the inflamed part, and therefore the adhesion of its red panicles and 
fibrin to the sides of the vessel, no disappearance after death can occur. It is 
evident, however, that at any limit short of this extent, — as in congestion and irri- 



80 INFLAMMATION. 

tation only, — a more or less complete disappearance of the blush may take place, 
when the operation of the exciting causes ceases, by the occurrence of death. This 
explanation is further supported by the valuable practical views of Dr. Carswell. 
He states it as a circumstance, the truth of which is established by his extensive 
pathological researches, that the 'permanence of the redness, and vascularity of in- 
flammation after death, is the only character, under doubtful circumstances, by 
■which its existence can be determined, and its distinction from other local con- 
gestions with which it may be confounded, conclusively made out. — T. Williams.'] 

Redness. — On the other hand, it is not every preternatural redness, discovered 
after death, that is inflammatory. It is not unusual to find an intense redness of 
the internal parts in the bodies of patients, who did not, during life, present any 
symptoms of inflammation; and such an appearance is not enough to justify belief 
in its previous existence; for, just as the redness of inflammation will frequently 
disappear after death, so, after death without any antecedent inflammation, morbid 
redness of the parts may occur. If the patient have died with great difficulty of 
breathing, a large accumulation of blood has taken place in the lungs; and the liver 
may be found gorged with blood, and the mucous membrane of the stomach and 
intestines exceedingly red; — not from inflammation; but simply because the blood 
was obstructed in the lungs, or in the heart; and from the consequent occurrence of 
congestion. In a case of great debility, a continuance of the patient in one posture 
during the latter period of his existence, will cause such an accumulationrof blood 
as, after death, to give rise to great redness; and these appearances are always 
greater, in proportion to the number of capillary vessels in the part to which the 
blood inclines iDy its gravitation. The blood will not merely accumulate in the 
vessels, but will transude from them, and dye the surrounding parts perfectly red, 
and prevent the distinct.'on of the appearance from inflammation. This is par- 
ticularly the case in hot climates and in hot weather. Dr. Davy, the brother of 
Sir Humphry, says (in a paper published in the tenth volume of the " Medico- 
Chirurgical Transactions"), that in hot countries he has often found it impossible 
to distinguish the redness of inflammation, from the redness of transudation, or 
from the redness acquired by a piece of membrane merely steeped in blood; and 
from all his observations and experiments he draws the conclusion, that if, in a 
hot climate, a body be not opened within twenty-four hours after death, the surfaces 
become red; that the serum of the cavities likewise becomes bloody, and that the 
viscera become livid; so that no opinion can be formed as to what was the state of 
the parts during life. The reason is this; — the hotter the temperature (within 
certain limits), the sooner does decomposition take place; and the more a part is 
decomposed, of course the more easily does transudation occur. The solids be- 
come more soft, — more spongy; and blood which comes in contact with them, 
easily pervades them, oozes through them, and dyes them, and any of the liquids 
which the parts may happen to contain. 

Redness simulated hy Transudation. — In dead bodies which have lain any 
time upon their back, especially in hot weather, the posterior parts all become 
livid, and filled with blood; while the anterior parts become pale. The body 
being usually placed on the back, the lungs, towards the posterior part, are heavy, 
—■filled with blood, — livid; and, in fact, exhibit the same appearance as the ante- 
rior part does in violent bronchitis; and every one accustomed to make post-mor- 
tem examinations, aUows for this occurrence. He never thinks of considering it 
a morbid appearance; it is simply the effect of the blood gravitating to the lowest 
parts. It is observed, also, when bodies are at all decomposed, that red streaks 
appear along the surface, in the direction of the various veins. As, after death, the 
blood accumulates in all the veins, and as the substance of their coats becomes 
more and more decomposed, the blood contained within the veins transudes; and 
thus the coats themselves become thoroughly dyed with blood, and the cellular 
membrane likewise around the vessels. The superficial veins may be traced in 
the dead body from this appearance. This is nothing more than a transudation of 
decomposed blood. 



INFLAMMATION. SI 

The observations made by Dr. Davy, many years ago, — respecting the import- 
ance of examining bodies early in hot weather, and showing the importance of 
knowing that such appearances as are induced by inflammation may take place 
merely from decomposition, — have been all lately confirmed by Andral; who, to 
make his observations the more striking, has examined the same part of the body 
at different periods. Early after death, he has found an organ pale; but if it were 
afterwards so placed as to favour the gravitation of the blood to a certain portion of 
it, that part of the organ, when examined in a few days, — ^decomposition having 
proceeded, — had become intensely red. 

The blood will not only accumulate in the solids in this manner, and not only 
exude in sufficient quantity to dye any liquids that may be within the cavities, but 
it will itself exude to such an extent, that a canal may be found containing a large 
amount of pure blood. By causing a considerable portion of intestine to be de- 
pendent, the blood has gravitated to such an extent, as to pass through the vessel 
into the cavity, and lie there in the form of a hgemorrhage. Two French writers 
(Rigot and Trousseau) have made numerous experiments upon this subject; and 
they say that they have frequently made the blood ooze from the inner surface of 
the intestines, by merely giving a portion of them this dependent position. 

Effects of Time, Gravitation, and Obstruction. — The mere appearance of red- 
ness, therefore, is not sufficient to justify us in saying that a part has been inflamed. 
A part may be red because it was inflamed during life; but we must always take 
into consideration whether the body has lain long; — so as to be partly decomposed, 
and to allow the diffusion of blood into the substance of the parts. Indeed, not 
merely does a degree of putrefaction allow this infiltration of blood into the parts, 
but the parts themselves become dissolved into a liquid substance; — they liquefy. 
As the body putrefies, it becomes soft; and a large quantity of liquid is produced, 
in addition to the pure blood; and assists materially in dyeing the different parts. 
We have therefore to take into consideration what is the period at which to ex- 
amine the body, and also the position of the part; — whether it be such as to have 
favoured the gravitation of its own blood, and that of other parts, in any quantity. 
We have also to take into consideration another circumstance, independent of time 
and of position; — that is, whether any mechanical obstruction existed during life. 
If there have been a mechanical obstruction to the return of the blood through the 
lungs and heart, the redness of the stomach will be explained, without the necessity 
of referring it to inflammation. There are, therefore, three circumstances to be 
taken into account; — the period at which the body is examined, the situation of 
the part as to gravitation, and the previous existence or non-existence of mechanical 
obstruction. A simple inspection of the parts which are red (provided there is 
nothing but redness), will give no information whatever; unless the symptoms 
during life have been ascertained, and the three circumstances to which I have just 
alluded observed. 

Effusion. — There is, however, another circumstance, which will frequently 
enable us to say that inflammation actually existed; — I mean the presence of the 
products of inflammation. If the part be intensely red, and a layer of lymph 
effused, or a large quantity of serum, — perhaps turbid serum, — with flakes, — the 
redness may be regarded as inflammatory. The redness, it is true, may be in- 
creased by decomposition or by mechanical circumstances; but if the products of 
inflammation are observed, it may be concluded that the redness, in great part, is 
inflammatory. These observations are useful with respect to inflammation in the 
inner surface of the heart. The lining membrane of the cavity of the heart, espe- 
cially at the valves, is sometimes very red, without any inflammation. Some per- 
sons will say there was inflammation during life; others will say there was not. 
Of course the point may generally be cleared up by minute observation; — by feel- 
ing whether or not the heart is soft, so as to allow the membrane to be stained by 
transuded blood; but if an effusion of lymph upon tlie membrane is seen, it is cer- 
tain that the redness is of an inflammatory character; — that it is the result of in- 
flammation, either in part or altogether. 
VOL. I. — 6 



82 INFLAMMATION. 

These are the observations which I have thonalit it necessary to make respecting 
the marks of inflammation during hfe and after death. 

[Besides the re(hiess of the part, and the presence of the products above men- 
tioned, its texture sliould also be noted as an element vv'hich may assist us in de- 
termining whether a lissure or organ has or has not been the seat of inflammation. 
Acute inflammation almost always gives rise to softening. Thus the lung in the 
second stage of Pneumonia, aUhough more dense and thus apparently firmer than 
natural, is in reality less coherent, so that the finger will penetrate it with the 
slightest force. Mucous membranes are generally both thickened and softened, 
under the influence of acute inflammation. Softening, however, may result from 
other causes, as perverted nutrition and cadaveric changes; hence it is not alone 
proof of inflammation. Like the other evidences mentioned, it is only valuable 
when viewed in connection with these, or with other circumstances. Induration is 
rarely met with except where inflammation is chronic, and is most commonly a 
termination of it. T. S.] 



SECTION III.— PATHOLOGY OF INFLAiVIMATION. 

Having described the various signs by which the presence of inflammation is 
indicated during life, and after death, let us, in the next place, examine what are 
the pathological conditions necessary to the production of these effects. 

General Remarks. — That blood-vessels have a contractile power in the large 
vessels is well established; the capillaries likewise have been proved by Schwann 
to possess the same power. The action of the capillaries, and arteries, contribute 
to the circulation in health; and in disease they alter the circulation, according as 
they are constricted or dilated; — thus supplying more or less blood to the part 
itself, and those parts to which these vessels lead. But although it is quite cer- 
tain that the arteries and capillaries have this power of contraction, and although I 
doubt whether it can assist \x\ furthering the circulation, (though it certainly may, 
and certainly does alter it every day,) I cannot conceive that this increased action 
is compatible with increased redness and fulness. I cannot conceive that, in inflam- 
mation, when a part is redder and fuller than it should be, there can be increased 
action; — by which I mean, that the vessels can be at once more constricted and 
more dilated, than before; for if they were redder at the one moment, they would be 
paler at the other; — the one state would counterbalance the other. But whether 
there be increased action or not, it appears certain, that there is a diminished motion 
of the blood, in inflamed vessels; this retardation is commensurate with the inflam- 
mation. This has been s-hown by Vacca, Lubbock, Bichat, Allen, Dr. Wilson 
Philip, and recently, under the microscope, by Dr. Hastings. Still more recently, 
Gendrin has confirmed the observations which were made by Drs. Philip, Hastings, 
and others. They applied mechanical violence, heat, cold, and ammonia; and they 
perceived, by the microscope, that at first the blood moved more rapidly. There 
was an increased velocity; and a contraction of the vessels was seen, inducing pale- 
ness. After the increased action, — after the contraction of the vessels, the motion 
became slower; the course of the blood was retarded; the vessels became dilated; 
and inflammation appeared. In this they all agreed. If the part was already 
inflamed, the application of a stimulus had ihe immediate eflfect of quickening the 
blood's motion, and constricting the vessels; and then the inflammation ceased. If 
the stimulus were applied very violently, so as to produce most violent action, and 
extreme rapidity, of course this lasted a shorter time; and the second stage, — that 
of slow motion, dilatation of the vessels, and inflammation, — came on sooner. By 
applying the stimulus very violently, the second stage might be made to come on 
immediately. It would appear from these experimenters, — who are very numerous, 
reside in difl'erent countries, have succeeded each other, and have each repeated 
the experiments with a view to ascertain whether his predecessors were correct or 
not, — that, in an inflamed part, the blood moves more slowly; that the vessels 



INFLAMMATION. 83 

are dilated; and that, by applying stimuli, you cause tfie vessels to contract, and the 
blood to move more rapidly; and that then the inflammation ceases for a time, till 
the blood is retarded aofain. and the vessels dilate. One would not expect that 
cold would have exactly the same effect as stimuli; but such was found to be the 
case. We all know that, if parts are cold, they become reddish; as is seen in the 
nose and cheeks in winter. They grow dark, — more and more red; till at last 
they become of a mulberry-colour; and congestion sometimes takes place to such an 
extent, that gangrene occurs. 

The large vessels going to an inflamed part, are frequently felt to throb. If there 
be a whitlow upon the finger, the digital artery behind it throbs violendy; and, in 
inflammation of the face, the angular artery may be felt doing the same. In the 
case of headache, the temporal artery is in a similar condition. This, however, is 
no proof of increased action in these vessels; for the same occurs in an aneurism, 
or a dilated artery. When an artery is dilated (though weakened), softened, and 
nnable to act as it did before, it will be found to throb violently. In that kind of 
inflammation which is called passive, and which some say is not real inflammation, 
but mere congestion, this enlargement of the surrounding vessels is wanung; so 
that there is no throbbing of the large vessels. When a raucous membrane is in- 
flamed, its secretion will stop. The secretions of a part, at the height of inflamma- 
tion, cease, or at least are greatly diminished; so that a spasmodic and constricted, 
state must be supposed to exist; though, perhaps, the word '^spasmodic'''' may be 
objectionable. Far more changes than these, however, take place. The blood is 
buffed and cupped; it contains more fibrin; and this fibrin is thinner than it ought 
to be. The blood, in the small vessels, becomes homogeneous, — broken down; 
the red particles are indistinct; and sometimes flocculi are seen in it, which are not 
visible in the immediate surrounding capillaries. When a part is mortified, the 
blood around it is yellow; its various constituents separate; and it is evidently in a 
state of disease. 

With respect to the symptoms of inflammation, the redness is very easily 
explained, from the existence of blood in vessels that ought not to contain it, and 
the existence of too much in those which should contain it. The swelling will 
arise from the same circumstance; and also from the increased secretion that is 
going on around. The pain will arise from fulness, and from the tension of all 
the parts. This is produced by the accumulation of blood; and by the excessive 
secretion around. But the pain will also arise, probably, from an increased degree 
of sensibility. There is, in every case, pain from fulness and tension; but the pain 
is felt far more severely, on account of the morbid sensibility. With respect to 
the heat, I presume it arises from the increased momentum of blood in the part; — 
the increased quantity which is circulating there. If the same quantity of blood 
were in the part, and motionless, of course the part would grow cold; but as the 
blood which is in it is far greater than usual, and still moves on so as to come 
round to the lungs, a greater number of changes giving rise to heat must take place. 
There is far more blood in the part than there should be; and as heat appears to be 
connected with the existence of blood which is circulating, — coming round to the 
lungs and undergoing chemical changes, — in proportion to the quantity of blood 
circulating, there must be increased temperature. If the blood ceases to circulate, 
or the circulation becomes languid, — so that it does not undergo a regular chemical 
change, then of course the part becomes cold. Momentum is composed of rapidity, 
and quantity. The rapidity is lessened, but the quantity is greatly increased; so 
that, on the whole, the momentum is greatly augmented. 

a. Microscopic Condition of the Capillaries. 

Wilson Philip^s Researches. — [It is to Wilson Philip that we are indebted for 
the introduction of the novel method of investigating the ultimate lesions induced 
by inflammation, through the assistance of the microscope. The mean conclusion 
which he deduced from his numerous observations, instituted so far back as the 



84 INFLAMMATION. 

year 1801, is — that the primary step consists in an enlargement and debility of the 
capillaries of l!ie inflamed part, while the larijer vessels leading to the spot are op- 
positely affected; having- their currents appreciably accelerated, and their pulsations 
increased in power; — observing-, further, that the blood in the enfeebled capillaries 
became retarded, and eventually arrested in its course; and that, subsequently, the 
skme condition extended to the neighbouring vessels. 

At a later period (1809) similar researches were prosecuted by Thomson; and 
afforded results analogous to those of Philip: — differing from them only in the point 
which related to the arrest of the blood; — the latter arguing that the blood suffers 
only a retardation in its flow through the aflected vessels. It will be readily re- 
marked, that these experimental observations, while we concede to their authors 
great ingenuity, place us iitUe in advance of the knowledge brought down to us 
by the theory of obstructed vessels propounded by Boerhaave; or the hypothesis 
which supposed the existence of a spasm of the extreme vessels, promulgated by 
Cullen; or the profounder surmises of Hunter, in reference to the influence of vital 
endowments on the parts undergoing inflammation. More recent observers, how- 
ever, have made important additions to our knowledge, in reference to the state of 
the capillaries under the operation of different substances, and the intimate changes 
in which inflammation consists. 'I'he experiment of Hastings, Kaltenbrunner, 
Wedemeyer, Koch, Oesterreicher, and others, have led to conclusions which ena- 
ble us to entertain some definite views, in respect to the pathology and therapeutics 
of inflammation. 

Contraction and Dilatation of the Capillaries. — According to the inferences au- 
thorized by their experiments, the changes which follow the application of chemical 
and mechanical agents to the small capillary arteries and vems, may be classed 
under two orders; dilatation, namely, and contraction. It is right to remark, how- 
ever, that in different hands the same agents produced different effects; — -common 
salt, ammonia, alcohol, hot water, ice, opiuin, acids, and mechanical injuries, (on 
different occasions, but apparently under similar circumstances,) causing opposite 
results with respect to the state of the capillaries. 

Contraction. — From the constancy of its occurrence, the fact has at length been 
generalized into a law; — that the contraction o^ the capillaries is attended by an 
acceleration of the contained current, while their dilatation is accompanied by a 
retardation. Although the blood, ceteris paribus, must, according to the recognised 
mechanical law, flow more rapidly in a contracted vessel, it is obvious, that if its 
fluidity has been diminished, or incipient coagulation induced by the agency of the 
substance applied, its velocity will be considerably retarded. On the other hand, 
in a dilated vessel, the circulation, casteris paribus, must be slower : increased 
rapidity of the current, in such a state of the capillaries, can be accounted for only 
on the supposition, that dilatation from an external cause may diminish the friction 
between the parietes of the vessels and the molecules of the blood [Miiller). — 
Whether these two states, of diminished and increased diameter of the vessels, be 
explicable on mere chemical principles, or wliether they are more properly refer- 
able to the subtle influence of vitality, would be rendering the subject too abstract 
to inquire. But we may, with Hastings, conclude, that the alcohol employed in 
these experiments, in virtue of its affinity for it, abstracts the water from the cells 
of the tissue in immediate contact with the cylinder of the vessel: and thus, by re- 
moving the distending agent, allows the collapse of each cell by its elasticity, and 
consequent pressure upon the capillaries; — hence their contraction. 

Tur^escence with Dilatation. — The opposite state of turgescence with dilatation, 
has offered a more difficult problem for the acumen of microscopists to explain. It 
is conjectured, by Miiller, that, under the excitement created by a stimulus, — the 
innervation of the part becoming more energetic, the organic affinity between the 
blood and the coats of the vessel and the circumjacent tissue, acquires additional 
force; so that the blood is detained in the part, and thus gives rise to accumulation. 
Another and not less plausible explanation is given by M. Poiseuille.* He regards 

' * Ancell's Lectures on the Blood.—" Lancet" for 1839 and 1840. 



INFLAMMATION. S5 

the passage inwards into the vessel, of the fluid contents of the neighbouring cells, 
— caused by. some peculiarit}'- in the action of the aorent, — as the manner in which 
dilatation takes place. It is not improbable that dilatation, when caused by the 
application of salt, is dependent upon endosmose alone [Midler). The salt, when 
applied to the part, penetrates the tissue, until it reaches the capillary vessels; an 
attraction is then exerted between the salt and the blood, which has a tendency to 
dissolve the salt, as the salt itself has a tendency to be dissolved in the blood; in 
consequence of this affinity, the blood will be arrested and accumulated in the 
capillaries; which subsequendy become distended, and the circulation within them 
retarded. Majendie has carried further the attempt to make out a rationale for the 
action of these causes of inflammation; premisinor the discovery of a subtle fluid 
interposed between the innermost and middle tunic of the capillary, he labours to 
account for the phenomena resulting from the agency of these causes, by supposing 
that this attenuated stratum, like his sub-arachnoidean serosity, is absorbed and re- 
moved by the cause or substance applied. And, since the presence of this fluid is 
essential (by lubricating the internal tunic, — thus diminishing the friction between 
the revolving molecule and itself) to the integrity of the circulation, it may be sup- 
posed that its removal will be followed by the adhesion of the particles to the sides 
of the vessels; and a dilatation of their capacity will necessarily result. 

It will perhaps be a speculation of too theoretical a character, to inquire into the 
relative merits of these several hypotheses. It has, notwithstanding, been thought 
desirable to supply the reader with a summary sketch of them; — as calculated to 
facilitate the study of the microscopic changes in inflammation. It may have been 
gathered, from the observations formerly advanced, that, according to tiie most re- 
cent and approved views respecting the ultimate character of these changes, what- 
ever may be the nature of the agent employed to produce them, they pass with 
rapidity, varying with the circumstances, through three staores, — in theory intelli- 
gible, and in practice of the greatest conceivable importance. These stages are 
irritation, congestion, and inflammation. 

b. Pathological Changes in the state of the Capillaries. 

Irritation. — To pursue our investigation, in the order in which these stages 
occur in the living body, it will be required to understand, first, what is pathologi- 
eally signified by the term ^^ irritation.''^ lam the rather inclined to admit the 
probability of the explanations ofl'ered by MilUer, Majendie, and Poiseuille, in re- 
ference to the modem which contraction of the vessels (by the substances formerly 
enumerated) is occasioned; since the experiments of Treviranus, Wilson Philip, 
Baumgaertner, and Miiller, have done nothing towards establishing the influence 
of the nerves over minute vessels and capillaries. It is most likely then that salt, 
alcohol, galvanism, mechanical injury, acids, and so on, when they do produce 
a state of contraction in the capillaries, operate chemically, — by abstracting the 
water from the adjacent tissues, or vitally, — by increasing the contractility of the 
investing tissue. Whatever be the rationale, it is now generally allowed, by 
minute observers, that the state which is distinguished by contraction of the capil- 
laries, and an accelerated circulation, constitutes irritation, — properly so called. 
In irritation, then, there is no slackening or arrest of the current of blood: but an 
opposite state of augmented velocity; — in obedience to a common law in hydraulics, 
of which the expression is — that the rapidity is inversely as the area of the tube. 
Upon reasoning still more closely into the consequences flowing from this condi- 
tion of the capillaries, it will appear plain that the increase in the momentum of the 
current will not adequately make up for the contraction. It is accordingly observed, 
that the detained blood finds its way into the neiorhbouring vessels, and induces a 
similar state of circulation in them; until, at length, the whole circulation of the 
part acquires such vigour and activity, as to give to the spot an erythematous blush; 
this state, generally, is one of temporary duration only; but the period over which 
it persists, will depend upon the nature of the cause, the quality of the blood, and 



S6 INFLAMMATION. 

Other circumstances; and likewise tlie quickness with which the second stage 
(congestion) supervenes. As this is not the place to continue the subject of irri- 
tation to its practical bearings, we shall proceed to the consideration of the suc- 
ceeding change. 

Congestion. — It has before been intimated, that the microscope discovers two 
things to be present in congestion; — namely, dilatation of the vessel, and an obvi- 
ously retarded circulation, without any detectable stagnation; although, frequently, 
something very nearly approaching to it is observed; — the amount of motion in 
the blood being so small, that it resembles more a semi-revolvmg or oscillatory 
movement of the globules, than an actually advancing stream. During this stage, 
the characteristic marks of inflammation are not perceived. It is unnecessary to 
re-argue the mode in which the causes and agents capable of producing this inter- 
mediate state operates. It may suffice to state that, whether it be by the endos- 
motic entrance of the salt, alcohol, and other materials, into the interior of the 
vessel, — causing a*>disturbance of the affinities, which may be supposed to exist 
between the several constituents of the blood, or whether it be simply by mechani- 
cally distending the vessel, which is the least probable, the ultimate effect is dilata- 
tion. 

Inflammation, — Provided the same causes continue to operate, and other circum- 
stances be f^ivourable, this state of turgescence will be replaced by that of inflam- 
mation. The initial step towards the production of this, consists in the coalescing 
of a few of the globules of the blood, and the adherence of them to the side of the 
capillary. A change also appears to occur in the quality of the blood; for the 
particles thus aggregated, no longer present their ordinary figure. The circulation, 
at the central point of irritation, is now completely suspended; and, for some dis- 
tance round, the retardation of the blood, and dilatation of the capillaries, become 
Tery evident, — producing congestion. A little further from the focal point of 
action, the circulation is more active; the still dilated vessels, and the globules of 
blood, become less distinct; at least, at the extreme limits of the areola, the circu- 
lation is accelerated, the capillaries are contracted, and the blood abounds in arterial 
molecules, — constituting a state o{ irritation. All these transitions may take place 
in a few minutes. There are other phenomena, superinduced upon this state, which 
are of the greatest physiological interest. From the change occurring under these 
conditions in the constitution of the blood, and the new affinities between the 
blood and the tissues which are brought into play, the colouring matter falls away 
from the red particles;** and the liquor sanguinis exudes from the capillaries, — the 
blood containing it in much larger quantity than under circumstances of health (as 
ascertained by Miiller). The tendency to coagulation in this fluid, appears to be 
great in proportion to the quantity of fibrin contained in it; under intense action it 
solidifies quickly; it is a gelatinous fluid, — the invariable product of inflammation, 
modified, of course, in its quality by constitutional and other circumstances; it may 
eitlier undergo organization, or rapid conversion into pus. When the former 
occurs, the red particles are divested of their coloured envelope; transude through 
the coats of the capillaries, by some mysterious vital process; re-acquire their red 
coals; and shoot, in various directions, through the effused fluid. Kaltenbrunner 
declares, that he has observed the red particles escai)ing from the interior of the 
vessel, and making arborescent tracts for themselves in the surrounding textures. 
This theory has always appeared to me improbable, on physiological principles; 
since the particles, thus extra-vascular, must immediately have their vitality ex- 
tinguished. Nor are we to disregard the high authority of Miiller upon this 
question. And without violatinjj the rigorous laws of induction, we may argue in 
reference to the escape of the red particles, as he does with respect to pus globules; 
— that as hitherto all physiological investigations are opposed to the theory which 
admits the existence of pores in the walls of the capillaries, and, further, as the size 
of the red globule equals — that of pus exceeding — the diameter of the minute ves- 

» Gendrin. 



INFLAMMATION. 87 

sels, there is no warrant for the inference, that the ret! particles escape as such from 
the inflamed capillary. That hypothesis is less objectionable, according to which 
the globules are considerably reduced in size before their escape from the vessel; 
and afterwards, by an action going on in the effused fluid, are restored to their 
former figure. Whichever theory we adopt, however, to account for the formation 
of new vessels in the inflammatory product, it is very certain that they take place. 
Gruithnisen, who was the first to make any decisive observations upon this subject, 
inclined to the opinion of Gendrin; — that' globules appear as red points, throughout 
the mass; — gradually enlarging, and soon presenting a stellated appearance. Has- 
tings, likewise, seems to regard this as the mode in which the liquor sanguinis be- 
comes organized. And, lastly, it may observed, that Sir A. Carlisle^ attempted 
recently to prove that vascular organization, at its commencement at least, is de- 
pendent more upon physical, than vital laws; — that the red blood, generated on the 
surface of the plastic matter extravasated in inflammation, radiates irregularly in 
the direction in which it finds least resistance — by mere mechanical force; — pre- 
senting, as the vessels become completed, a dendritic form. This hypothesis, 
however, is wholly untenable on physiological principle; since these changes must 
appear to all, to fall within the influence of the " creative power," or " organic 
force," so beautifully shown, by the masterly arguments of Miiller, to regulate the 
building-up of all living matter. Although, in inflammation of a limb, the capilla- 
ries are extensively obstructed, it is known that the absolute quantity of blood pass- 
ing through the arterial trunk and returning by the viens, is augmented in a ratio 
corresponding with the intensity of inflammation in the limb. Notwithstanding the 
plausibility with which these microscopic observations appear to explain the 
pathology of inflammation, there are inany data presented in its progress which 
oblige the inference on our part, that an explanation on mechanical principles alone, 
is insufficient to embrace all. The act of resolution alone, by which the coalesced 
particles become disunited, and made again to circulate onwards, the capillaries 
resuming their former size and function, teaches that some creative organic force 
— wholly apart from mechanical laws — must, here, be in full operation. — T. Wil- 
liams.'] 



SECTION lY.— COURSE OF COMMON INFLAMMATION. 

Inflammation is usually divided into two kinds; — the one "common," the other 
"specific." " Common" inflammation is that which we see every day, where a 
local injury takes place, or when a part has been exposed to the vicissitudes of tem- 
perature; but the epithet "5/)ecz/?c" is given to inflammation, when it runs a pecu- 
liar course; or when it arises from a peculiar cause, neither mechanical nor simply 
irritative. When inflammation runs a peculiar course, it is then by many called 
"specific;" but more frequently it receives that appellation only when it arises 
from a peculiar cause. For example: inflammation of the urethra, from the forcible 
introduiUion of a bougie, or of a catheter, would be ""common inflammation;" but 
the inflammation of gonorrhoea, arising from a peculiar cause, is termed "■specific 
inflammation. In specific inflammation, all the symptoms which occur in common 
inflammation are present; but some peculiarity is superadded. 

Common Inflammation. — I will first describe the course of common inflamma- 
tion. It may he^\v\ with pain, with a blush, and with a feeling of unusual warmth; 
but the redness is sometimes not in the form of a blush, but occurs in one particu- 
lar point; from which it spreads.- If the part be a secreting organ, its secretion 
will become changed in its appearance, and perhaps likewise in its odour, at the 
same time increasing in quantity. The pain and the redness increase in degree, 
and also in extent; and are succeeded bv swelling, or tension, or both. 'I'he purls 
swell to a certain point; and if they cannot swell farther without difliculty, they 

* Guy's Hospital Reports; April, 1S40. 



SS INFLAMMATION. 

become tense. As the inflammation proceeds, the secretion of the part generally 
diminishes again; though perhaps it does not come down to, or does not descend 
below, its natural amount; but the secretions still remain unliealthy in appearance, 
and perhaps also in smell; the constitution subsequently suffers; — the pulse becomes 
quickened, and it likewise becomes variously altered in its volume, firmness, 
strength, and regularity. The affection of the pulse is not always according to 
the danger; for in mere inflammation of the tonsils, or in mere rheumatism of the 
joints, — both of which are unattended by danger, — the pulse may be rapid and 
violent. The same remark may be made with regard to the temperature. The 
temperature of the whole body will sometimes be greatly elevated, although the 
inflammation may be one of no danger. In a case of mere acute lumbago, I found 
the pulse at 160, and the heat of the whole body 107°. I find, in a note which I 
made, that the patient required no blood-letting at all; — that he merely took " vinum 
colchici" for three or four days, and yet his pulse was 160; and — by the thermo- 
meter placed in various parts of the body, uncler the tongue, and in the axilla — the 
temperature was found to be not less than 107°. The heat frequently varies, too, 
in difl^erent parts of the body. 

Besides the alteration of the pulse and the temperature, the patient becomes 
restless, — uneasy in any position; and complains of general soreness. The whole 
surface of the body frequently becomes tender; the head and loins frequendy 
become painful; and sometimes the pain in these two parts is among the 
severest constitutional symptoms. The derangement of the system extends to 
the secretions, so that most of them become diminished and altered; and from this 
circumstance thirst originally happens. The tongue becomes dry or white; and 
sometimes, if there be much gastric disturbance, assumes a yellow character; and 
if there be litde strength, dark. The skin becomes dry; though, in one particular 
inflammation, — active rheumatism, — it generally falls into profuse sweating. The 
urine becomes scanty; and though it remains clear, it is high coloured, and has a 
strong animal smell, — resembling gravy-soup. The bowels become torpid, and 
the faeces unhealthy, both in colour and smell. These are all instances of dimi- 
nished or altered secretion. 

Fever. — These constitutional symptoms altogether, are called by Cullen and his 
followers " pyrexia." We have no English word for this term, '•'' pyrexia,'''' un- 
less we use ^'feverishness;^^ but " isA" implies only a slight degree of any thing, 
whereas the pyrexia may be very great; and therefore the term '•'' pyrexia''' is 
always better. The word is used by Cullen to distinguish this constitutional 
excitement, in all circumstances, from those specific diseases, which (whether 
remittent, intermittent, or continued) he calls " fever;" — to distinguish it from 
fever properly so called. Some persons denominate these symptoms "fever" in 
all circumstances. Others, however, — aware of the confusion which might arise 
from calling these symptoms " fever," and other specific fevers (such as typhns) 
*' fever" also, — denominate these symptoms, when they are dependent upon in- 
flammation, or some other local cause, — " symptomatic;^'* and they call the others, 
— fevers properly so termed, — "•idiopathic fevers."* These symptoms, which 
are, by some writers, called " constitutionnl excitement," or " constitutional de- 
rangement," are, by others, called "symptomatic fever;" — to distinguish them 
fioin real specific fever, which they call "idiopathic." Cullen, however, does 
not employ the word '•'fever,''^ given to this state; but the word ''''pyrexia.'" For 
the purposes of clearness, it can make no difference whether, in the case of inflam- 
mation, we say " pyrexia" or " symptomatic fever;" for the object of language 
is to render our meaning intelligible. 

It very frequently happens, that when the local disease first begins, — before it 
has increased to such an amount as to quicken the pidse, and induce the other 
symptoms which I have mentioned, — the person complains of chilliness, a general 
soreness, and even rigors; so that he shivers with cold; — the pulse at this time 

a From ihoqy peculiar; and TraSoc, ctn affection. 



INFLAMMATION. 89 

being small, the face pale, and the skin rough. From its deprivation of blood, and 
its low temperature, it is rough, and is called " goose's skin" ("cutis anserinn"); 
and this state altogether is called " horripilatio." After the existence of these 
symptoms, — this cold stage, for a certain time, the inflammation appears, and the 
excitement of the whole constitution gradually comes on. Sometimes, therefore, 
inflammation begins; and, after a certain period, is attended with conslituiional 
excitement; but sometimes, when inflammation begins, the system immediately 
falls into a cold stage, like fever; — exactly as happens in the cold stage of an inter- 
mittent; so that the local inflammation appears simultaneously with the constilu- 
tional symptoms. 

Relation behveen the General and Local Signs. — The general symptoms are 
usually proportionate to the intensity and the extent of the local inflammation; and 
likewise to the importance and sympathies of the organ affected. Sometimes, as 
I have already mentioned,* the general symptoms are disproportionate in their 
violence, and likely to mislead us in forming a prognosis of the case. If an indivi- 
dual have a temperature of 107°, and a pulse of 160, he may be inferred to be in 
eminent peril, provided the inflammation were not known to be inconsiderable, or 
seated in a part not at all necessary to life, — not at all of importance to the system; 
whereas, the same derangement attending inflammation of an important organ, or 
attending a very extensive inflammation of another organ, even not so important to 
life, would point out the greatest danger. It is obvious, therefore, that we are not 
to depend upon one symptom, — one circumstance, in a case; but must always take 
into view as many particulars as we can ascertain, in considering the question of 
inflammation. 

Disturbance of Function. — Besides these local and these general symptoms, 
the functions of the part inflamed are disturbed. If the brain is inflamed, there is 
delirium; if the lungs are affected, dyspnoea is present; if the stomach be inflamed, 
vomiting is an urgent sign; if it be the intestines, constipation or diarrhoea usually 
attends it; if it be the bladder, there is a frequent and painful desire to make water. 

Changes in the Blood. — It is not, however, merely these disturbances,- — these 
changes, that take place. The blood itself becomes changed in inflammation. The 
red particles separate so fully from the fibrin, that this fibrin generally remains 
colourless and transparent at the top; and when this occurs, it is said to have a 
*' buffy coat." There must some change take place in the blood, for this pheno- 
menon to occur; and as soon as a portion of blood is removed from the body, we 
find that some alteration has taken place; for such are the effects. Occasionally 
the fibrin — white above and clear from the red particles which are below — is drawn 
into such an excavated form, — its centre so depressed, that it resembles a cup; and 
such blood is called " cupped." Blood may be huffy ivithout being cupped. The 
red particles may separate entirely from the fibrin, and leave a buflTy coat; but 
sometimes, in addition to this, the fibrin is drawn into an excavated form; so that 
it is buffed as well as cupped. 

Coagulation of the Blood. — Blood coagulates, when it has escaped from the body, 
whetlier it be warm or cold, in the air or in vacuo; diluted within certain limits, or un- 
diluted, at rest or in motion. WhUe within the vessels, rest, which causes a cessation 
of intercourse between the motionless portion and the general mass, always disposes 
it to coagulate. Coagulation is supposed to depend upon the escape of carbonic acid; 
it is said to be proportioned to the quantity of gas evolved; — the latter bemg given 
off during the coagulation, and ceasing to escape when the coagulation is complete. 
Galvanism and oxygen gas raise the temperature of blood; but do not affect its 
coagulation, — any more than mechanical agitation. The coagulation of the blood 
is ascribed, by John Hunter, to its life; by Mr. Thackrah, on the contrary, to its 
death; because the separation of a portion of the blood from the whole mass, by its 
escaping from a vessel, is likely to kill it if alive; because every change likely to 
impair life, such as debility and fainting, promotes coagulation; and because blood 

» See Page 88. 



90 INFLAMMATION. 

frozen (which process is likely to kill it if alive), and again thawed, instantly 
coagulates. According to the experiments of Dr. Scudamore, — though others 
have not found the same results, — coagulation appears, in most cases, to be attri- 
butable merely to the escape of carbonic acid. This hypothesis, however, is 
known to be erroneous; since the quantity which escapes, exercises no influence 
upon the phenomenon of coagulation; and as coagulated blood, or fibrin, becomes 
vascular, we can hardly, if the fluid be alive, regard a coagulum as necessarily 
(lead. Large quantities of blood are found fluid in every dead body: — showing 
that the simple loss of vitality is not sufficient to cause coagulation. Iiideed, the 
blood of the heart and vessels is found, most frequently, in opposite states; — fluid 
m one part, and coagulated in another; yet it is all equally dead. From all these 
contradictory circumstances, I regard the coagulation of the blood as quite uncon- 
nected with its vitality or its lifelessness, and as entirely a chemical result. That 
it is influenced, however, by the vital properties of the containing vessels, is pos- 
sible; but these properties may operate upon the blood, in this respect, as a mere 
chemical compound; and even if it be alive, and they influence its life, still the 
influence, as far as respects coagulation, may in effect be chemical. 

The blood generally coagulates in the living body, on escaping from its vessels, and 
even in its vessels, if its motion be prevented by ligatures. When itdoes not,its subse- 
quent escape from the body almost always produces instant coagulation. John Hunter 
mentions the coagulation of blood let out from the tunica vaginalis; in which it had 
lain fluid for sixly-flve days after a wound. It almost always coagulates, likewise, in 
the vessels which run through healthy parts to others in a state of mortification; 
and in large vessels adjoining a pulmonary abscess; — in which cases, the ^?2«/ 
cause is prevention of haemorrhage. The efficient cause, however, in all these 
examples, is unknown. In all of them, the blood is stfll in contact with living 
parts; and in the two last, it is not at rest till it coagulates. John Hunter mentions 
that, after mortification of the foot and leg, he found the crural and iliac arteries 
completely filled with strongly coagulated blood; and adds, that this could not have 
arisen from rest; because, if that were the case, the same thing ought to happen in 
amputation, or in any case where the larger vessels are tied up. Besides, coagula- 
tion after extravasation, or when a portion of blood in a vessel is included between 
two ligatures, is not an invariable occurrence. These facts, in addition to those 
before stated, show that fluidity or coagulation is not dependent on the simple j)re- 
sence or absence of vitality. 

When blood is drawn, the serum easily separates on the coagulation of the 
fibrin; but the latter coagulates before the colouring particles have time to fall to 
'the bottom; and, from entangling them, acquires a red colour; — thus forming the 
crassamentum. If, however, the fibrin coagulates slowly, as in the case of a 
phlogistic diathesis, and pregnancy, the greater specific gravity of the cruor de- 
taches it very considerably from the fibrin, which remains colourless above; — con- 
stituting what is called " the inflammatory coat, crust, or buff*." In the phlogistic 
diathesis, both the fibrin and the serum are more abundant, and the blood lighter. 
The receiving of it into a shallow vessel, and the rapidity of the stream, greatly 
affect the rate of coagulation; so that one portion of the same blood coagulates 
sloivly when drawn quickly, and another quickly when drawn sloivly. 

The appearance of the buff'y coat does not arise from slow coagulation, though 
increased by it; for, of two portions of the same blood, one has afforded no huffy- 
coat, although it remained fluid at least ten minutes after the buff'y coat began to 
be formed on the other. If, as appears from Mr. Hewson's experiments, the huffy 
coat arise from the thinness of the fibrin, while the red particles continue of I heir 
usual weight, — the above circumstance proves, that slow coagulation is not alto- 
gether dependent on mere thinness of the blood, though generally connected with 
it, and proportional to it. Yet, when the blood is thin, rapid coagulation, by means 
of a slow stream, may prevent the formation of abufl^y coat; — by not allowing lime 
for the difl^erence between the weight of the fibrin, and that of the red particles, to 



INFLAMMATION. 91 

effect a separation; — the slower the coagulation of thin blood, (occasioned, for 
instance, by rapid bleeding,) the greater will be the buffy coat. 

The different cups of blood drawn in an inflammatory disease, may vary as to 
the buffy coat, according to accidental variations in the stream; but generally it is 
the^rs^ cup that abounds in buff, and frequently the last has none. This occurs 
when there is no difference in the stream. Sir Charles Scudamore finds much 
more fibrin in buffy blood; and consequently concludes that, not merely the thin- 
ness of the blood, (as Hewson found,) but likewise its quantity may vary during 
the flow of blood. Dr. Scudamore did not find a buffy coat in blood drawn im- 
mediatly after violent exercise. 

The blood of different brutes coagulates in different periods of time. Mr. 
Thackrah imagines the rapidity of coagulation to be inversely as the strength and 
size of the animal. Thus, while healthy human blood coagulates in from three to 
four minutes, the blood of the horse and ox coagulates in from two to fifteen; that 
of dogs, sheep, rabbits, and fowls, in from half a minute to three minutes; and in 
mice and fish in a moment. 

The Blood in Pregnancy. — Occasionally, this buffy appearance of the blood 
takes place (it is said) without inflammation. It is usual in pregnancy; but a preg- 
nant woman may be considered to be in an inflammatory state; — not a state of 
actual inflammation; but the condition of the womb is really inflammatory. In 
pregnancy the whole body frequently wastes. The eyes become hollow; and the 
whole health, for the most part, suffers a little. The pulse becomes very quick, — 
quicker than in health; and all the blood-vessels of the womb become greatly en- 
larged. The womb itself, if it be not in a state which justifies us in calling it 
inflammatory, is, nevertheless, in a state of activity so great, that it comes as near 
to inflammation as possible. When, to look at other periods of generation, animals 
are " in heat," and copulation takes place, the genital organs become violently red, 
— violently hot, — perhaps blackened with blood, — as if they would burst; and all 
the blood-vessels throb. If that state ought not to be called " inflammation," still 
it is very clear that it nearly approaches to that state; and whatever word be em- 
ployed, we must look at it as physiologists and pathologists. We cannot wonder, 
therefore, that in pregnancy the blood should frequently be buffy. 

Absence of the Buffy Coat. — But this state of the blood is sometimes absent in 
inflammation. We may find a patient undoubtedly labouring under a most violent 
inflammation; and, on using the remedies for that affection, the most decided effects, 
and even cure, may result; and yet no buff may be present in the blood. This is 
by no means uncommon in bronchitis; where a patient has a rapid pulse, and great 
heat of body; cannot turn in bed without coughing; suffers under a difliculty of 
breathing, — so that he is obliged to breathe in a shallow manner; cannot expand 
the lungs without extreme soreness, tightness, and violent cough. The tongue is 
white, and violent pyrexia is present; ami if bleeding be resorted to, instant relief 
is afforded; so that both the symptoms and the treatment prove the existence of 
inflammation. In many cases of bronchitis, the blood will not show the slightest 
morbid appearance; whereas if, instead of the lining membrane of the air-tubes, it 
were another membrane that was inflamed, (as, for instance, the pleura,) the 
smallest quantity of blood that could be taken away, would most likely show an 
intensity of buff, and be cupped in addition. The absence of this buflliness of the 
blood, is by no means a proof that there is not inflammation; but, if it be present, 
it is generally in proportion to the violence of the inflammation. If doubt existed 
as to whether the patient was labouring under inflammation or not, the appearance 
of this buffmess might justify the conclusion, that the symptoms which were sus- 
pected to be inflammatory really were so. The absence of it is no proof that in- 
flammation does not exist; but the presence of it will, in doubtful cases, very much 
confirm your conclusions, that the symptoms treated were inflammatory. The 
bufiiness, however, is not necessarily in proportion to the danger of the inflam- 
mation; for, in acute rheumatism, where there is no immediate danger, unless com- 
plicated with internal inflammation, the blood will generally be intensely bufled, 



92 ' INFLAMMATION. 

and not unfreqnently intensely cupped at the same time. We are usually, there- 
fore, to consider this as a mark of inflammation, or of an inflammatory state; but 
its absence will not warrant us in saying that there is no inflammation; and the 
intensity of the bufl'y or cupped state, is not to be considered as a proof that the 
inflammation is of an exceedingly dangerous character. 

Many particular circumstances are necessary to be observed with regard to this 
phenomenon. The first cup will often be buffy; while the second, taken within 
a minute or two, is much less so, or perhaps not at all. When this circumstance 
occurs, I believe the difl'erence generally arises from the amendment of the patient; 
for the beneficial effect of bleeding is sometimes very striking; — it sometimes checks 
the inflammation immediately. One may conceive that a certain portion of benefit, 
in such cases, takes place before half the blood we intend to withdraw is removed; 
and when the second cup exhibits less bufl^iness than the first, we may ascribe it to 
the actual amendment of the patient. 

Relation between the Time of Coagulation, and the Buffy Coat. — The bufli- 
ness of the blood is certainly affected by the slowness of the coagulation; so that 
if the blood do not flow freely at first, but does afterwards, the quick coagulation of 
the first cup may not give the red particles time to subside; and this may prevent 
its being bufl'y. Hence we see that the quick or slow coagulation of blood must 
effect its bufliness. As blood coagulates the sooner the more it is exposed, and 
therefore the more slowly it trickles down the arm, increased quickness of coagu- 
lation may prevent bufliness in blood which would otherwise present it; and when 
it Qomes out more freely into the second cup, it may coagulate more slowly; and 
then, if there be a disposition to bufT, the buff will form; so that it is not at all un- 
common to have no bufliness in the first cup, but to find it in the second. There- 
fore, although a patient may have improved from bleeding, and have a disposition 
to form less bufl" in the second cup than in the first, yet the accidental circumstance 
of its trickling down the arm into the first cup, may give rise to an opposite occur- 
rence, and may counterbalance the operation of the benefit. Bufliness may be 
shown in the first cup, and none in the second, from the improvement of the 
patient; or we may have no buffiness in the first, and find it in the second, — not- 
withstanding that the patient has improved, — from the accidental circumstance of 
the second cup coagulating less speedily than the first. 

Dr. Stoker's Experiments. — But although the quickness and slowness of coag- 
ulation may affect the formation of buff", yet they are not the cause of it; for it has 
been known that, of two portions of the same blood, one has continued fluid ten 
minutes after the other had begun to form buff*, and yet has shown no buff". When 
the stream of blood is exactly the same, causing the blood to flow into cups with 
equal rapidity, we sometimes find the difl^erence of buff to be exceedingly great; 
and sometimes the buffiness is the same when one cup has coagulated very slowly, 
and the other very quickly. Dr. Stoker has given us some experiments upon this 
point, in his " Pathological Observations."* He has furnished twenty-seven ex- 
periments; in fifteen of which buff* was formed, while in the other twelve it was 
not. Among the twelve in which no buflf was formed, no coagulation took place 
in three of them in less than from twenty to forty minutes; and in four there was 
no coagulation for eight minutes. There was abundance of time, through the 
slowness of coagulation, for the red particles to separate from the fibrin, and yet 
the result was as I have stated; whereas, in the fifteen in which buff' was produced, 
not one specimen delayed to coagulate longer than fourteen minutes, and in all but 
three coagulation took place in five minutes, and yet buflf was produced. The 
real cause, therefore, of the buffiness of inflammatory blood, certainly is not the 
slowness of the coagulation; but from what it proceeds I do not know. It may 
be owing to the thinness of the fibrin; for it appears to be a fact, that the fibrin of 
buffy blood is both thinner and more abundant than thai of other blood. If it be 
thinner, one may conceive that the red particles will more easily separate from it, 

a Published in the year 1829. 



INFLAMMATION. 93 

and subside to the bottom. That may be the reason; but I do not say it is. As 
the quantity of fibrin is known to vary during the flow of blood, so probably may 
the thinness, and this may be the reason why blood which showed buffiness in 
the first cup, exhibits none in the second; — the blood being thicker, the red parti- 
cles do not so easily separate. At any rate, the buffiness of the blood is not pro- 
portionate to the slowness of the coagulation. Dr. Stoker's experiments confirmed 
the opinion I had previously formed from observation and reading; yet I believe 
it is true, that buffy blood generally coagulates more slowly than other blood; 
although I do not ascribe the buffiness to this circumstance. The slowness of co- 
agulation may be in a great measure owing to the thinness of the fibrin; for if the 
fibrin be thin, it will probably be less disposed to solidify. It is said, that the mere 
celerity of the circulation does not eff'ect any changes in the quality of the blood; — 
that it is not because the pulse is quick in inflammation, that the quality of the 
blood changes. 

But although inflammatory blood, showing bufl^, generally coagulates more slowly 
than other blood, yet the buflf coagulates if there be strength of body very firmly, 
— more firmly than the crassamenium in health. The firmness and the cup-like 
form, are usually proportionate to the strength of the patient; but it is to be remem- 
bered, that the firmness of the coagulum is sometimes very great, without there 
being any cupped appearance. The firmness and cupped form are said to be greater 
in inflammation of fibrous membranes, — such as aponeuroses, ligaments, and ten- 
dons, — and in inflammation of serous membranes, than of other parts. 

If it so happen that the buflf of the blood be not firm, then the blood is said to 
be "sizy;" and when the coagulum of blood is soft, whether it be bufFy or not, the 
serum will be found too abundant. 

The cupped appearance of the blood, as well as the buffiness, is very much 
affected by the size of the vessel into which we draw it. If we extract the blood of 
a patient into a tea-cup, we have an infinitely greater chance of finding it bufly, 
than if we draw it into a hand-basin. The larger the vessel the less is the dispo- 
sition to form the buff', and likewise to form the cupped appearance. For accurate 
observation, blood should certainly be drawn into small vessels. 

Blackness of the Blood. — It is a general observation, that the blood is very black 
in the inflamed parts; although it is more arterial m ihe surrounding vessels; since 
it passes through the capillaries into the veins without acquiring the venous cha- 
racter. Leeches, at their first application to an inflamed part, abstract black blood; 
but after several applications it becomes bright."" I have observed this frequently, 
and I presume it arises from this circumstance; — that the blood, from moving slowly 
in the inflamed spot, acquires more of a venous character. I have known thd blood, 
times innumerable, to be black, on the first application of leeches; and I once knew 
the blood, in a case of chronic inflammation of tlie liver, highly offensive; so that 
almost as soon as it was removed, it passed into a state of putrefaction; but as 
leeches were applied day after day, it became brighter and brighter, and at last 
regained its natural odour and nature. It would be wrong to consider inflammation 
as merely aff'ecting the solids; it affects likewise the blood itself. 

Duration of Inflammation. — Having spoken of the effects of inflammation, I 
now proceed to consider its duration; and this is very various, — depending much 
on its intensity. If an inflammation be exceedingly violent, it cannot last long; but 
if that be not the case, it may last a great length of time. Inflammation may exist 
for o:dy a very few hours, and may certainly destroy life in the course of a tlay. 
It is sometimes so rapid, that a person shall be well in the afternoon, and die from 
it before the next morning is much advanced. Pericardiiis may occur suddenly in 
the evening, from exposure to cold, and end in death by the next morning. In- 

» It is a curious fact, that blood drawn by leeches never exhibits the biiffy coat. It scUlom 
appears on blood that has been removed by means of cupping-glasses; but I have seen it 
take place.— D?-. Watson's Lectures on Infiammation; '' London Medical Gazette;'' Volume 
27; Pacre 339. 



94 INFLAMMATION. / 

flammation may be so acute as to destroy life in a few hours, .without any mortifi- 
cation, but simply from its own intensity. A child is sometimes seized with a 
violent rush of blood to the head; — its eyes will become red; its face flushed; and 
its head distracted with violent pain. It screams; and death ensues in the space of 
one or two minutes. The same thing- will happen in adults. After death, a great 
quantity of blood will be found within the cranium, and externally to it. If this 
state be inflammatory, which is questionable, it certainly proves that inflammation 
may be almost momentary; and that it will destroy life in this sudden manner. 

But inflammation, if it be not violent, may last for many months, and even years; 
for if it remit, it may often be tolerably violent, and yet continue for a very long 
time; — its severity not renjaining the same during the whole of the period. If it 
once degenerate into the chronic form, it may last indefinitely: and when it does 
so, it generally induces various changes of structure, which I will hereafter mention. 
When a part has been once inflamed, the redness will occasionally remain some 
years, without any pain or any heat. We frequently see this after burns, and after 
cutaneous diseases. A portion of a scar will remain exceedingly red; — the vessels 
would appear to be in a state of passive dilatation. There is no pain, no heat, no 
tenderness, but extreme redness; and this — after it has existed a year or two, or 
perhaps longer — will sometimes decline; and the vessels will at last gradually re- 
cover their natural tone. After ulceration, the skin will frequently remain of a red 
colour, perhaps of a very dingy red, and almost of a brown colour. In the case of 
a person who has had a sore leg, the portions corresponding with the spots of 
ulceration are frequently very red, brown, variously discoloured, or perhaps nearly 
black. 



SECTION v.— RESULTS OF INFLAMMATION. 

Inflammation may terminate in complete health of the part. The part may, in a 
direct manner, regain its former state; and when this is the case, it is said to termi- 
nate in "resolution." Generally, however, when there is this resolution,* there is 
some increased secretion, either at a distant part, or (if the part affected be of a 
secreting character) in that part itself. If it be a serous membrane, there is more 
or less effusion; if it be a cellular membrane, there is a more or less oedematous 
condition, which can be observed externally. But if these effects be very slight, — 
only temporary, — perhaps no inconvenience is produced; and the termination of 
inflammation is then said to be in " resolution." If, however, it be a serous mem- 
brane that is attacked, and there be a copious secretion, it is said to terminate in 
"effusion." If it be a cellular membrane that has been inflamed, and it does not 
terminate in resolution, a new fluid is formed, called " pus;" and the formation of 
this new fluid is denominated "suppuration." If it be a mucous membrane which 
has been affected, a great discharge either of mucus or pus supervenes; so that sup- 
puration either from a cellular or mucous membrane may occur. It is actually pus 
that is formed, in inflammation of a mucous membrane; pus likewise may even be 
produced by the interior of a vessel. But it is right to say, that although authors 
call these phenomena "terminations," yet these copious secretions are not neces- 
sarily terminations; and that when they begin, it is not a matter of course that 
inflammation shall end. Although the part may suppurate, or fall into a state 
of effusion, these processes may, nevertheless, be inflammatory. It may still be 
desirable to go on with anti-inflammatory measures; — since heat, pain, tenderness, 
and all the marks of inflammation may continue. We ought, I think, rather to say 
that inflammation, sooner or later, induces these changes; or that these occurrences 
take place in inflamed parts; — whether the inflammation subsides or not. Inflam- 
mation may terminate, however, not in health, either direcfly or after these processes, 
but in death, either general or local. It may destroy life, without the occurrence 

» From "resolvo," to loosen. 



INFLAMMATION. 95 

of any farther change. It is very common to see persons die of enteritis, without 
mortification, or any other chano-e. It sometimes happens, however, that inflam- 
mation does not destroy general life, but the life of the individual part; and then it 
is said to terminate in "mortification." But the inflammation may still continue, — 
not in the dead part, but in the parts around; and may extend farther, till more 
parts die. 

[Before proceeding to the individual effects of inflammation, it is necessary to 
understand that, according to the accepted theory, in every degree of inflammation, 
contradistinguished from congestion and irritation, effusion must necessarily occur: 
the quantity of which obviously varies directly with the intensity of the action. 
This may be regarded as a law established by the numerous observations of Kal- 
tenbrunner. The stages of irritation and congestion may pass away without the 
occurrence of anv extravasation; but he has uniformly observed, that so soon as 
the stasis of the blood in the capillaries, which constitutes true inflammation, takes 
place, so soon does the liquor sanguinis permeate the coats of the vessels, to gain 
and occupy the surrounding cells. It is therefore certain that, although inflamma- 
tion may end in recovery by resolution^ an exudation of the more fluid part of the 
blood has taken place. This, of course, will vary with the character of the struc- 
ture ill which inflammation occurs; — being adhesive albumino-fibrin in serous mem- 
branes, glutinous mucus in mucous membranes, and consisting, in the parenchy- 
matous structure of organs, for the most part of inspissated liquor sanguinis. — 
T. Williams.'] 

Resolution. — I will now speak particularly of these various "terminations," as 
they are called; the first of which (resolution), is really a termination. When an 
inflammation is resolved, all the symptoms decline, and no fresh symptoms arise; 
and this is essential to the character of resolution. While the inflammation is going 
on, the urine is generally high-coloured, and clear; but when it subsides, there is 
usually a copious red sediment. The reason assigned for this by chemists, is the 
following. Urine in a healthy state contains, besides other matters, lithate of am- 
monia, and a yellow colouring matter; which, according to Liebig and others, is 
believed to be isomeric with lithate of ammonia; both of which remain in solution 
under ordinary circumstances. If, however, the urine undergoes any change in its 
constitution, from the existence of diseased actions in the system, these constituents 
become, to a certain extent, insoluble; — forming a precipitate, the colour of which 
pretty accurately indicates the nature of the changes that are taking^lace. If the 
colour of the precipitate he pink, it is owing to the action of nitric acid (which, in 
certain diseased states, is found in excess), or a portion of lithate of ammonia, con 
verting it into purpurate of ammonia, and giving to the rest of the precipitate a pink- 
ish hue. If the precipitate be yellow, then it consists of lithate of ammonia alone, 
slightly tinged by the yellow colouring matter of the urine. If the precipitate be 
reel (laleritious), it is owing to the presence both of purpurates and colouring mat- 
ter; which form a red colour, when they are mixed together. During inflammation, 
the lithatesof soda and ammonia are in excess in the urine, and nitric acid is formed; 
which, acting on the lithic acid, produces the purpurates. These give a pink tinge 
to the lithates, whether tliey are in solution or precipitated; and this pink colour, 
by admixture with the yellow colouring matter of th.e urine, is changed to red. 
The reason why the urine is red without sediment, during the progress of inflam- 
mation, is this, — the same substances are in the urine, but held in solution during 
the activity of the complaint; but when it declines, an excess of lithic acid is formed, 
— producing super-lithates, which are known to be insoluble; and therefore a great 
portion of them falls down in the form of a precipitate. Hence tiie appearance of 
the red sediment. This is the explanation given by one who, perhaps, understands 
these things better than any other man in Europe; — I mean Dr. Prout. Tlie deep- 
red colour, with transparency, during the activity and copious red deposit on the 
termination of the disease, are respectively characteristic of inflammation. 

Effusion. — If, however, the inflammation do not terminate in resolution, but 
produce such an effusion as from its quantity may do harm, the symptoms of the 



96 INFLAMMATION. 

inflammation may subside, and a fresh set of symptoms may come on, from the 
compression of the parts. If the pleura, for example, has been inflamed, and the 
inflammation induces at last copious efl'usion, after the pleuritis has subsided, a 
fresh series of symptoms supervene, dependent upon compression of the lung. 
When there is this excessive effusion, however, in a serous membrane, there is 
generally something more. Liquor sanguinis is usually thrown out; — sometimes 
forming layers, — sometimes difl'used in the serum, and forming flocculi; so that 
the serum becomes turbid. When albumino-fibrin is thus poured out by a serous 
membrane, it is at last often entirely absorbed; while the fibrin remains, and fre- 
quently we find fibrin where there is no appenrance of serum; — the serum having 
been absorbed. Professor Thomson, of Edinburgh, says that he has seen lymph 
lyino^ on a serous membrane, within four hours after he had induced inflammation. 
Sir Everard Home says, that he has known an efl'usion of albumino-fibrin form 
vascular adhesions in the course of twenty-four hours. Sometimes the efl'usion 
which occurs, is purulent. Thus the pleura, the pericardium, or the tunica vaginalis, 
may be filled with pus; and sometimes with a mixture of pus and serum. 

Suppuration. — Tlie third eff'ect of inflammation is " suppuration." When this 
occurs, the pain generally ceases, but the swelling increases; and is marked, for 
the most part, by the sense of fluctuation which it imparts to the finger. This 
fluctuation is not always discoverable at first; but becomes more and more decided, 
as the fluid increases. The pain, however, does not always cease. It may decline 
at first; but, as the fluid increases, considerable pain may come on from tension; — 
the part becoming exceedingly tense, from the quantity of fluid; which is afterwards 
absorbed, or escapes either by art or nature. Besides this, where there is suppu- 
ration of a cellular membrane, or of any organ, fresh symptoms from pressure may 
occur; — just as in efl'usion from a serous membrane. If the suppuration be exten- 
sive, shivering may come on, and what are called "rigors" take place; followed 
by, when matter is being formed, great heat and sweating, — constituting " hectic 
fever." 

Hectic Fever. — This hectic fever is marked by a quick, but weak pulse; by heat 
of the whole surface; but particularly heat, with a red flush, upon the cheeks, the 
palms of the hands, and the soles of the feet. Sometimes the whole of these are 
red; but more frequently the redness is partial, forming patches; so that a portion 
of the cheek, the size of half-a-crown, may be intensely red, while all around is of 
the usual pal# character. In addition to these symptoms, the patient has profuse 
sweating; so that as soon as he falls asleep, he is almost sure to fall into a sweat. 
Free perspiration likewise happens often during the walking state. These symp- 
toms are generally aggravated at night, and frequently also at noon; and, indeed, 
at any time when food is taken. The eflect of sleep upon the sweats is remarkable. 
If a patient fall asleep but for two minutes, although he may not know it, it is very 
common to find these sweats break out. They are frequently very partial; — being 
particularly observed about the head and chest. 

In hectic fever, when suppuration is going on, the urinary deposits are of a pink 
colour. The chemical changes are precisely the same; — the purpurates acting 
upon the lilhates, and producing this pink colour. This pink colour is not changed 
to red; because the yellow colouring matter of the urine is absent, and therefore 
the pink of the purpurates and lithates remains unchanged. The intestines often 
pour forth a fluid as ahundanfly as the skin, and then there is purging; not unfre- 
quently tiie purging alternates with the sweating; so that if there be an increase of 
the sweating, there is a decrease of purging; and vice versa. This sweating and 
purging is called " colliquative," — " melting the patient down;" and hence the 
name.* The alimentary canal often becomes inflamed; and when a patient who 
has laboured under this state is examined after death, the mucous membrane appears 
red and ulcerated. The tongue at length becomes red. We may see it yellowish, 
or of a deep brown colour; but for the most part it is red, either on the surface, or 

■ From " coUiqueo," to melt. 



I 



INFLAMMATION. 97 

at the tip. or at the sides and tip. The mind generally hecornes very quick; the 
patient is excessively alive to every thing; and. at the very last, a dejiree of deli- 
rium takes place. When that occurs, it is usually the precursor of a fatal end. I 
need not say there is usually extreme debility and wasting of the body. It is to 
be remembered, iiovvever, that these symptoms (called "hectic fever") may occur 
without any suppuration. They will occur, I know, from mere depression of 
mind; they will frequently occur in women from excessive suckling; — from suck- 
ling too much, or suckling too long. All these symptoms, without suppuration, 
will sometimes remain for a great length of time; and the patient, at last, by proper 
management, do very well. 

Mscess. — Sometimes the matter is collected together in a cavity; — forming what 
is called an " abscess." [In explaining the formation of an abscess, it is necessary 
to remember that the invariable result of inflammation is — the efTusion of liquor 
sanguinis, differing in its quality, according to the varying condition of the system. 
When inflammation occurs, therefore, in any given part, circumscribed by defined 
limits, the cells of the tissue become infiltrated, at the spot in which the action is 
most intense; — softening of the original structure succeeds; and a more or less 
perfect solution of the proper tissue takes place, in the inflammatory effusion. 
This change constitutes that condition, which, in scientific medicine, is regarded as 
an essential preliminary to the process of absorption under every combination of 
circumstances. The doctrine, first propounded by Hunter, which supposed the 
previous solution of the substance of a part as unnecessary to its absorption, was 
subverted by the researches of Mr. Key, published in the 'J'ransactions of the 
Medico-Chirurgical Society. The views of Mr. Key havebeenlikewise advocated 
by Dr. Prout; who puts it forth as a principle of universal application, that the 
solution of a part is an essential pre-requisite to its absorption. Physiology pre- 
sents us with numerous instances of interest, which might be advanced in con- 
firmation of this view. The yelk, in immediate contact with the beautiful web of 
the area vasculosa, undergoes liquefaction before it passes into the vessels, to fulfil 
the purpose of nutrition. The lymph is taken up by the absorbents in a perfect 
state of liquidity. Thus, then, the first steps in the formation of abscesses are 
rendered intelligible. This disintegration, induced by the softening, soon becomes 
limited by more active inflammation — a separation is worked out between the (lis- 
organized and the surrounding living parts, by the production of a sacular mem- 
brane — which in surgery is called pyogenic* It consists, at the beginning, of the 
cells of the encircling structure infiltrated with a fibrinous deposit — which subse- 
quently acquires the characters of membrane. — It is supposed to exercise the 
function of absorption and secretion; — thus renewing the contents of the abscess. — 
T. Williams.'] 

This pyogenic membrane, together with the adjacent soft parts, become gradually 
absorbed at one particular point of the abscess, nearest to the surface, or some prin- 
cipal ouUet of the body; wherever, in fact, the easiest exit for its contents is to be 
found; — abscess of the liver, for example, may either point outwards towards the 
surface, or upwards towards the lungs; and, after producing absorption of the inter- 
vening diaphragm, discharge its contents. Such, at least, was the opinion of Hun- 
ter; it is however certain, that there are other circumstances to be considered; — 
such as the structure of the affected part, and the greater or less facility with which 
it takes on inflammation and ulceration. When there is danger of pus escaping 
into a cavity, or part of the body where serious consequences would result (as, for 
instance, into the peritoneum), then a great deal of additional lymph is frequently 
thrown out for the purpose of gluing the various parts together; — in order to pre- 
vent, as much as possible, the escape of the pus in an improper direction. Thus 
nature usually thins the walls of an abscess at that point which is most eligible for 
the escape of the pus; and thickens them where it would be dangerous for the pus 

» Pus— ymaw. 
VOL. I. — 7 



98 GENERAL PATHOLOGY. 

to escape. This extraordinary provision of nature, may truly be considered as one 
of the most wonderful phenomena which claim the attention of the pathologist. 

The absorption at the former point, whererer it may be, woes on. If it be near 
the surface, we see the chief swelling- at one particular part; and the collection is 
said to " point." At length a minute opening is formed, and the matter escapes. 
When the latter occurrence takes place, and the cavity is thus opened, minute red 
granules, highly vascular, soft, and covered with pus, are seen within. In fact, they 
secrete the pus. Sometimes the opening at which the matter escapes, although 
small at first, enlarges; absorption takes place to a great extent; ulceration runs on 
to a considerable distance, and perhaps lays bare the cavity very much. 

These red granules grow larofer and larger, till the cavity is filled up. This pro- 
cess is called " granulation." When the cavity is entirely filled up, portions of skin 
form upon its surface, and portions of the surrounding skin are prolonged into them; 
so that there is a double source of new skin. Fresh skin appears in insulated 
points; and the healthy skin around shoots prolongations into it. In this way the 
surface of the granulations becomes covered with skin, and is healed. The smaller 
the granulations are, the better; for if they be large, they are generally spongy; in 
which state they are popularly called " proud-flesh." 

From the loss of cellular substance which takes place in the formation of the 
abscess, (for the cellular membrane is, more or less destroyed,) and from the con- 
traction of the new parts (for these granules, which were very vascular at first, 
become less and less so), after the healing takes place a depression is seen. If it 
be a very minute abscess, — such as is only called a *' pock," as in small-pox,^ 
there is merely a litde depression, — a pit; but if it be a more extensive formation 
of matter that has taken place, " scars" result. They are exactly the same thing, 
only on a difl^erent scale. The contraction of the new parts, and the loss of the 
cellular membrane, are sometimes so great, that the joints cannot be extended; and 
the arm becomes bent to the body, or the fingers bent down to the hand. 

Pus is sometimes collected in an abscess, in this way, without any lining of 
lymph; but when the latter is absent, the pus is almost always diflfused. Pus is 
often formed in the cellular membrane in a diflfused manner, — so as to run to a great 
extent, and do very serious m.ischief; — producing, wherever it spreads, new in- 
flammation, and the most frightful devastation. This is observed in that form of 
erysipelas styled " erysipelas phlegmonoides." Where suppuration takes place 
in the cellular membrane, uncontrolled by a cup of lymph, it often runs on exten- 
sively; and sometimes a whole arm, or a whole thigh, is in this way covered by a 
sheet of matter. 

SuppKrution ivithout an Abscess. — Sometimes, however, there is a formation 
of pus, and an absorption of the skin and cellular membrane, without any collection 
of matter. This is seen every day in the case of the throat, and sometimes upon 
the skin itself; but more frequently upon a mucous membrane. If the latter be 
attacked by a slight inflammation, the epithelium may be absorbed, together with a 
small portion of the mucous membrane; — in fact, there may be an ulcer; and that 
ulcer will secrete pus, without there being a collection of matter underneath. In an 
abscess, the matter is formed in the cellular membrane, or in a solid structure, and 
tends outwards; but frequently, in a mucous membrane, the process goes on in- 
wards. Nothing is more common than to see this in the throat. The surface, 
which is a little inflamed, becomes abraded; matter is formed upon it; and in that 
way an ulcer is formed, without the previous existence of an abscess. If the part 
heal, it is afterwards filled up; — in the same way as if the matter had been collected 
in a cup, in the cellular membrane. 

Characters of Pus and Mucus. — Pus, if healthy, is an opaque fluid, yellow or 
white, homogeneous, short, and creamy; so that if we take a drop between our 
fingers and separate them, it breaks. The drop divides into two, — does not hang 
in strings. If it be perfectly healthy, it is bland to the taste, and without smell. 
Some say it is rather mawkish; but one never thinks of tasting it, except in the 
case of a gum-boil, or other suppuration in one's own mouth. It is said to be 



INFLAMMATION. 99 

neither acid nor alkaline; although, by exposure to the atmosphere, it turns sour. 
It is also insoluble in water. It contains globules; and hence it is distinguished 
from pure mucus, by being placed between two bits of glass, and then looked 
through at the sun. From the existence of the globules, we have an iridescent 
appearance; — resembling the colours of the rainbow. This is not the case with 
mucus; for mucus contains no globules. It is said, however, that when pus is first 
secreted, it is not globular; and that these globules do not appear in it, till it has 
been poured forth from the yessels for fifteen minutes. Mucus, again, is not short, 
like pus. If we take a portion of mucus between the finger and thumb, and sepa- 
rate them, it drags out into threads. 

Persons have endeavoured to discover the difference between pus and mucus by 
chemical tests. John Hunter says, that he found pus easily coagulate by a solu- 
tion of muriate of ammonia; but that mucus would not. Dr. Darwin (Junior) 
says, that a solution of caustic potass does not dissolve pus; but makes it a viscid 
semi-fluid substance; stringy, like mucus; — not dissolvable in water; but resem- 
bling the diseased mucus of the bladder. When the bladder is in a state of chronic 
inflammation, — when the mucous membrane is in a state of cystorrhtea, and there 
is a great discharge of mucus from the surface, its mucus is very ropy, and may 
be dragged out to a great length; and this is the appearance which pus exhibits, if 
it be mixed with a solution of caustic potass. Dr. Darwin also says, that the 
same effect is produced, by adding to the pus sulphuric acid; whereas, if we add 
these acids to healthy mucus, small flakes are produced, and not a stringy semi- 
pellucid substance. On the other hand, two modern French writers (Andral and 
Baumes) deny this distinction. Then, again, another chemist (Grasmyer) says, 
that if pus be triturated with an equal quantity of water, and this combined fluid 
be then mixed with an equal quantity of carbonate of potass, a jelly is produced 
in a few hours; but that is not the case with mucus. Pus in general sinks in 
water, but mucus generally does not; and if pus be diffused in water, the water 
becomes uniformly white. 

As to all these distinctions, however, the fact that pus and mucus are converti- 
ble into each other, is established by modern organic analysis. Mucus may be 
diseased, so as to be something like pus, — puriform; and they will run into each 
other by insensible degrees. In disease of the lungs, the distinction between pus 
and mucus has been thought most important, as tending to show whether ulcera- 
tion exists; but here the two secretions are continually mixed together. When 
there is an abscess of the lungs, or a number of abscesses, and matter is discharged 
from them, a quantity of mucus is at the same time secreted from the bronchial 
tubes; so that the pus and the mucus are expectorated together; and in proportion 
as the former surpasses the latter in quantity, or the latter exceeds the quantity of 
the former, the characters of the one or the other are presented. If the quantity 
of mucus be very considerable, the pus may be borne up by it in water, — not 
allowed to sink. Besides this, there may be an abscess in the lungs; and there 
may also be an excavation secreting, not pus, but mucus. The lining membrane 
of the cavity in the lungs — at least, if fresh ulceration have not taken place — may 
secrete mere mucus. Again: every mucous membrane which is inflamed, may 
produce absolute pus; so that pus may be discharged from the lungs, when there 
is no ulceration at all; while, on the other hand, there may be ulceration of the 
lungs; but the lining membrane of the abscess may have become of such a mucous 
character, as to secrete real mucus. 

Analysis of Pus. — With regard to the constitution of pus, Schwilgue (who is 
one of the last that has analyzed it) says that it consists of albumen, extractive 
matter, fatty matter, soda, muriate of soda, phosphate of lime, and some other salts. 
When pus is scrofulous, it is said to have more soda and muriate of soda, than 
healthy pus. Pus was once imagined to consist of the dissolved solids. Seeing 
that a cavity existed, it was imagined that the solids were melted down, and turned 
into pus. But frequently pus may appear when there is no ulceration at all; nor 
is the formation of pus in proportion to the loss of the solids. From a sujall 



100 INFLAMMATION. 

) 

abscess, there may be an immense secretion of pns, if by chance the abscess do 
not heal; and yet it does not extend. The pus is a new excretion. Whether 
globules are formed in it, — whether it be perfect immediately or not, — is of no 
consideration. The fluid from which pns is produced js a secretion. It appears 
to possess solvent properties; for John Hunter found dead flesh dissolve very 
readily in pus. He put an equal quantity of dead flesh into pus, into jelly, and 
into water; and he found the portion put into pus dissolve very readily, while the 
portions put into jelly and water did not. Hence it would appear, that pus is use- 
ful in dissolviug the solids when they die. 

Healthy pus is called by the old writers " laudable." I recollect, when a 
student, hearing good pus, instead of being termed *^ healthy pus," commonly 
called ^^ laudable pus," — '^praiseworthy pus."* Healthy pus should abound 
with globules. 

If the globules be deficient, and the pus be watery, then we have what is called 
" ichorous^ pus." But there may be other differences in pus, besides a deficiency 
of globules. If it be thin and bloody, it is called " sanious;" and it is called 
*'scrofulous" if there be in it little curds; which curds, very possibly, are shreds 
of lymph. Pus sometimes very much resembles mucus. It does not abound 
sufficiently in globules, is glairy or muciform, and will hang out in little strings. 
"When mucus, however, becomes something like pus, we call it "puriform." Pus 
frequently becomes fetid. This particularly occurs if a bone be diseased; but in 
suppuration of the tonsils, likewise, it is not uncommon for the pus which escapes, 
or is let out by a lancet, to be most horridly fetid. Generally, however, it is when 
pus comes from the bone, or the immediate neighbourhood of a bone, that it 
assumes this fetid character. 

We have already mentioned in how short a time albumino-fibrin has been seen 
effused on a serous membrane;" and pus also has been seen to form in a few hours. 
It has been seen produced by a mucous membrane, in a few hours after inflamma- 
tion has been set up; and when an abscess has been produced, matter has been 
formed in so short a time as from twelve to eighteen hours from the commence- 
ment of the inflammation. 

Mortification. — The ne-.t termination of which I shall speak, is *' mortifica- 
tion."* This is shown by the part becoming of a darker red than before. When 
a part is about to mortify, it grows of a dingy red; from red it becomes purple, 
and then black; and when it is once dead, it changes from the decomposition of 
the matter to a green colour, and various other hues. The pain ceases, — the part 
becomes cold, — and, if it be the surface, we often see vesicles; which, although 
they are frequently filled with a pale fluid, yet are more frequently filled with a 
bloody serum. If it be the skin which is mortified, it becomes variegated; and 
perhaps the part crackles under the finger. From the extravasation of air, the 
swelling increases; the part has often a doughy feel. These are the local symp- 
toms; but general symptoms take place. There is extreme prostration of strength, 
with extreme restlessness. The face becomes ghastly; the pulse becomes rapid 
and exceedingly weak, — perhaps intermitting and irregular. There is a general fall 
of the temperature of the body; and a cold clammy sweat takes place. The tongue 
becomes brown or black; — the patient's manner becomes exceedingly quick; and, 
frequently, a little delirium takes place. The cessation of the local, and of all the 
violent general symptoms, ^will take place just before death from inflammation, 
when that inflammation does not cause mortification, or any other local change; — 

• This has been considerecl an sb^urd epithet; but it serves as well as any other to express 
what was meant; namely, that kind of pus which accompanies benign forms of inflamma- 
tion, and which indicates that all is going on regularly, and promises a fortunate ending; — 
pus, in short, the appearance of which was to be commended. It is certainly not more absurd 
than the term ''■heaUkii pus."— Z?r. Watson, in the '■^Medical Gazette ' 'for November 27, 
1840; A^<?. 678; Vulu7ne9.1; Page M^. 

*> From ix^'i, atfiin^ acrid finid. ^ See Page 96. 

^ From "mors," death; and " fio," to become. 



HTFLAMMATION. 101 

although, when mortification occurs to any extent, the very same thing is observed. 
That is to say, the cessation of pain, the ghastly countenance, the rapid, feeble 
pulse, the extreme sense of debility, restlessness, and at last death, without any 
mortification, may happen, — without any other local cliange whatever. Frequently, 
from the symptoms of enteritis, we should imagine that mortification of the intes- 
tines had taken place; but, on opening the body, we may find no mortification, — 
nothing but intense inflammation. 

When the parts inflamed become of a purple colour, and cold, and fall into in- 
cipient mortification, restoration is not impossible. Parts will recover that have 
become purple, and lost a portion of their temperature. Even parts which have 
been congealed, will recover by good management; but this, I believe, takes place 
in man and the other warm-blooded, more than in cold-blooded animals; and Pro- 
fessor Thomson, of Edinburgh, says that if a whole limb be frozen, it is never 
restored. 

Gana:rene and Sphacelus. — A still higher degree of mortification is called "gan- 
grene;"* and the complete death of a part, — when it is gone irrecoverably, — is 
termed " sphacelus.""' In the latter case, the part is cold, senseless, black; and 
putrefaction follows. There are three degrees, therefore, of mortification; — the 
one where the parts are merely purple and cold; a second where things are more 
advanced, but the part is not absolutely dead; and the third, in which the part 
is really dead, — "mortification" being the generic term for all the three stages. 
When a part is dead, and putrefaction is be^un, the progress of the latter depends 
very much upon external circumstances. The warmer the weather, of course the 
more readily will putrefaction take place. 

Separation of Dead Parts. — If the part which is in a state of sphacelus be not 
important to life, it may be separated by nature from the body. The process of 
nature, here, is exceedingly wonderful. The large vessels, which go to the part, 
become plugged up; — a coagulum of blood forms in them, or adhesive fibrin is 
poured out from the inner surface; so that in one way or other the progress of the 
blood is arrested; the consequence of which is, that it coagulates to some extent 
above the plug, and the plug thereby becomes increased. Dr. Thomson (of Edin- 
burgh) says, that a coagulum never extends higher than the first communicating 
branch;' and that is what we should suppose. The blood coagulates behind the 
plug, nearest the heart; and therefore, we should not expect a plug to extend 
beyond the first communicating branch. Dr. Thomson has seen a vessel com- 
pletely obstructed, without the formation of any plug at all; — the whole obstruction 
being producod by an effusion of lymph, — lymph which has become organized, 
and formed an internal adhesion. He has even seen an artery completely obstructed 
without any lymph, — without any plug; but simply from its becoming closely 
contracted; — so contracted that it would not admit a bristle. The contraction has 
formed as complete an obstruction to the blood as a coagulum, or a quantity of 
fibrin, would have done. He says that he has noticed the same circumstance in 
an amputation, where no ligature had been employed. The vessels have become 
so contracted, as not to admit of the introduction of a bristle; and have thus pre- 
vented all haemorrhage. In whatever way it is done, — whether by a coagulum 
of blood, or by a plug of lymph forming an adhesion, or by the mere contraction 
of the vessels, or by any two of these, — such is the fact, that nature generally 
succeeds in preventing hfemorrhage from a mortified part, by obstructing the 
course of the blood in the larger vessels leading to it. 

The process of separation is accomplished in this manner: — A red line appears 
at the boundary of the healthy part, which is nearest to that which is dead. This 
red line is a line of inflammation; and in it ulceration takes place, and gradually 
penetrates the healthy part, till a complete separation takes place; and in this way 
a whole limb is sometimes separated from the body. 

Necrosis. — Of course I have been speaking of soft parts; but if a long bone die, 

* From yga«, to feed upon. ^ From (r^aKoo, to destroy. 



102 INFLAMMATION. 

without any death, or any especial disease, of the surrounding parts, a new bone 
is formed around it. The process of nature, therefore, is quite different here, 
from that which is employed to separate a dead soft part. In this case, a new 
bone is formed under the periosteum, around the dead portion; and in this way 
the parts exterior to the new bone — the periosteum, the ligaments, and the carti- 
lages — all become attached to it. When the old bone within the new one is com- 
pletely loosened, an opening is formed in the new bone; ulceration takes place in 
it at one spot; granulations occur on the inner surface; and these granulations push 
the old bone through the ulcerated opening in the new one; — at least they lend to 
do so. The aid of a surgeon is frequendy of use in assisting to draw out the old 
bone, and enlarge the openings in the new; but this is the process adopted by 
nature when a bone dies. It is called " necrosis;"* and the old bone within will 
frequently rattle, — like the kernel of a dry nut. The old bone is called *' seques- 
trum." 

Exfoliation. — If it be not a long bone which is dead, but merely a plate, or a 
flat bone, this is separated by ulceration. Granulations form under the old bone, 
and push it off. This process is designated *' exfoliation;" because the bone comes 
off like a leaf (yb/iMm). 

These are the " terminations," as they are called, of inflammation; but I should 
rather say they are the effects of inflammation, than terminations; because inflam- 
mation does not necessarily terminate when they occur. Inflammation frequently 
goes on after these effects take place; and therefore we ought to say, strictly speak- 
ing, that these are the effects of inflammation, or circumstances that occur from 
inflammation. 

Induration and Softening. — Some authors mention " scirrhus" among the 
terminations of inflammation; but if they mean the scirrhus which afterwards 
becomes cancer, they are certainly wrong; because scirrhus will occur without 
marks of inflammation. A part, without these marks, will gradually become can- 
cerous. It seems to be a specific disease. If, however, by "5aVr/m5," these 
writers mean true scirrhus, — mere induration, then they may be right; because 
one of the effects of inflammation is to harden. When a part has been inflamed 
for a length of time, it frequently becomes indurated; so that scirrhus, in that 
sense, may be said to be the effect of inflammation, but not a termination of it; 
because the inflammation will go on, and the part become more and more indurated. 
Induration, however, is only one of such effects of inflammation as they ought to 
enumerate; for it has as great a tendency to cause parts to become softened, as 
hardened. Induration is rather the effect of chronic inflammation; while acute 
inflammation rather produces softening. 

Hypertrophy and Atrophy. — Inflammation, when it continues, will sometimes 
cause an enlargement of parts. It will cause them to increase, — to be over-nou- 
rished; and then the occurrence is termed " hypertrophy," — excessive nourish- 
ment. On the other hand, it will sometimes cause them to waste, — to be under- 
nourished, if I may so speak; and then it is called "atrophy." It will occasion 
them to be indurated, or to be softened; and it will give rise to various transforma- 
tions; so that a part shall become pretty firm cartilage, or even actual bone. These 
results of inflammation are sometimes combined in the same part; so that a part 
may be both hypertrophied and atrophied. If a part be compounded of different 
structures, one structure may increase, — become harder, and thicker than before; 
while another constituent of the same organ wastes away; and one part may become 
indurated, while another shall become softened. Hypertrophy and atrophy, or 
induration and softening, in different structures of the same compound organ, may 
therefore co-exist. A thickening of the investing membrane of an organ, for 
example, and a wasting of the substance of the organ itself, are met with. The 
retina is sometimes found in a state of atrophy, while other portions of the eye are 
excessively thick, or indurated to the consistence of cartilage. Acute inflammation 

* From v6x^o«, to destroy. 



INFLAMMATION. 103 

more frequently, as I have already said, causes softening than hardeiiins:; and 
wasting" rather follows acute inflammation than chronic; except when the chronic 
form induces such over-nourishment of one constituent part of an organ, that 
another structure wastes. Generally, however, acute inflammation is disposed to 
produce softening; and if any other change occur, it is rather that of atrophy. 
Chronic inflammation, on the other hand, chiefly causes parts to become hard, and 
hypertrophied, — over-nourished, — thickened; and it is this which causes trans- 
formations, — causes parts to become cartilage or bone. I do not mean to say that 
these changes will not arise without inflammation; but when they are produced by 
inflammation, it is usually the chronic, and not the acute form, which gives rise to 
them. 

Changes unthont Inflammation. — It is to be remembered, that these various 
changes of size (hypertrophy and atrophy), and of consistency (induration and 
softening); as also these transformations; the occurrence of haemorrhage; the 
occurrence of dropsical eff*usion; the occurrence of a discharge from a mucous 
membrane (a gleet); and perhaps adhesion, ulceration, and mortification; — may all 
take place without any inflammation. They are continually the efl'ect of inflam- 
mation; but certainly most of them do sometimes occur, without our being able to 
discover that any inflammation existed. In the case of haemorrhage, though it is 
frequendy the result of an active inflammation, and generally, too, in a mucous 
membrane, yet it is often passive; and is poured forth without either pain, heat, 
swelling-, or general irritation; — -nay, it is frequendy poured forth without any ful- 
ness discoverable in the vessels of the part. I have opened persons who have 
died from haemorrhage, in whom there was no collection of blood to be found in 
the parts which afforded the haemorrhage. While every part of the body, from 
head to foot, was perfectly pale, there was haemorrhage from time to time, until 
death ensued; and it must have come from small vessels, because no large vessels 
could be discovered to be ruptured. Chronic hydrothorax and ascites certainly 
do sometimes occur without any inflammation of the serous membranes; — 
no pleuritis, — no peritonitis. With respect to mucous membranes, a gleet fre- 
quendy exists, without the occurrence of any one symptom of inflammation. It 
is even thought by some, that suppuration of the lungs will take place without 
inflammation;— that where a single vomica of mere tubercular matter has been 
generated, and suppuration has taken place, there has often been no previous 
inflammation. It is certain that large adhesions continually occur in the pleura, in 
persons who have no recollection of having been the subjects of inflammation 
within the chest. Occasionally portions of fibrin are spit up from the bronchial 
tubes, without a person having, beforehand, suspected the slightest inflammatory 
state of those parts. Ulceration is thought, by some surgeons, occasionally to 
occur, without inflammation, in the cartilages of joints, and ulceration will cer- 
tainly now and then take place in the skin and throat, with litde or no inflammation. 
Such ulceration is continually seen in scurvy. Ulcerated, like softened, mucous 
membranes, are sometimes quite pale. Mortification frequendy occurs without 
inflammation. Instances of this are seen in the lungs; and more rarely in other 
viscera. 

Ligature. — When the chief vessel of a part is obstructed by a ligature, this will 
frequently produce mortification of those parts below, to which the ramifications of 
the obstructed blood-vessel are distributed. 

Diseased Grain. — Spurred rye, or "ergot of rye," causes mortification, I 
believe, in all animals; though the quantity requisite for that purpose varies in 
difi"erent species. If an animal live upon it, there is sometimes a reddish fluid 
observed to ooze from the nostrds; sometimes there is violent pain of the extremi- 
ties; and sometimes there is also heat and redness, — actual inflammation; and then 
gangrene takes place. Frequendy, however, it does not cause heat and redness, 
but a withering of the part; which will dry, and look like the extremities of a 
mummy. The extremities become cold, dry, and shrivelled; and, at the same 
time, diarrhoea, vertigo, convulsions, and delirium, very frequendy take place. 



104 INFLAMMATION. 

Internal inflammation is frequently induced in the alimentary canal; but the extre- 
mities generally mortify, and present the appearance which I have described. It 
is common in France, and formerly prevailed in England; the cause of which 
appeared to be the consumption of diseased wheat. Sometimes the legs will 
mortify from bad food; and the most common kind which produces this effect, is 
diseased grain. 

I believe that other grain, diseased in a similar manner, has a similar effect. 
The ergot of maize in Colombia, is said to act in the same way. At least, it will 
cause the hair to fall off, — sometimes the teeth to drop out; and it frequently 
induces sudden death. It so happens that brutes are exceedingly fond of it. They 
will therefore frequently gorge themselves with it, and then die suddenly. It was 
observed that the hens which ate of it, in Colombia, discharged their eggs prema- 
turely,— before the shell was formed; and it is thought that the fact of its occa- 
sioning the abortion of eggs in hens, led persons to employ it in the case of , the 
human subject, for the purpose of emptying the uterus feT:)eedily. Its peculiar 
properties appear to be destroyed by cold; for it is found, that if this diseased 
maize be carried over cold mountains, — over the Paramos, it may afterwards be 
eaten with impunity. 

Gangrene from Ossification of the Blood- Vessels. — Mortification will some- 
times occur, not from inflammation, but more probably from ossification of the 
minute arteries. Some say that mortification will arise from the ossification of the 
larger and more distant arteries; but certainly it is generally believed to be some- 
times occasioned by the ossification of the minute arteries. Cruveilhier, by artifi- 
cially inducing a similarly obstructed state, produced the same effect. He injected 
mercury into the arteries, so as to fill the capillary vessels with it; and when an 
obstruction was thus produced, mortification was the consequence. 

Dry Gangrene. — The mortification which arises from obstruction in the vessels, 
induced by ossification of the minute arteries, most frequently takes place in males; 
and especially in the old and voluptuous. Generally the gangrene is dry, — the 
part shrivels up; and this state is preceded by very great pain. There are two 
varieties of dry grangrene; — the pale and the black. Mortification may occur 
without inflammation. Many things, however, are asserted, in medicine, without 
sufficient proof; and occasion a great deal of trouble to those who follow the as- 
serters, by making it necessary for them to prove that the assertions are not true. 
This circumstance, in medical writings, is too common an occurrence. I do not 
know that it is proved, that mortification is always preceded or accompanied by 
inflammation; but if it be, the mortification is often not proportionate to the inflam- 
mation. The severest mortification may be seen with the slightest inflammation, 
or with its entire absence; and, on the contrary, the most intense inflammation, 
without inducing mortification. Some inflammations have a peculiar tendency to 
end in mortification. The inflammation of glanders, in the human subject, though 
not more intense than many other inflammations of the face, has nevertheless a 
great tendency to induce mortification. 

Changes from Inflammation. — With respect, then, to all the effects of inflam- 
mation, and those changes which, though they frequently are its effects, yet some- 
times appear not to be exactly so, — I may mention that induration is generally the 
result of slow inflammation; but that softening is continually seen without any 
signs of inflammation at all. Hypertrophy (over-nourishment), like induration, is, 
I believe, generally the result of slow inflammation; but atrophy, the wasting of a 
part, is frequently seen without inflammation. In phthisis, the heart is usually 
small, flabby and perhaps shrivelled; though not previously inflamed. The trans- 
formations of one structure into another structure, natural to the body, though not 
to the individual part, and therefore called " analogous" formations, are certainly 
more frequently the result of inflammation than otherwise; but the new formations 
— those which are not analogous to any thing already existing in the body — are far 
more frequendy not the result of inflammation. It continually happens that there 
is not a vestige of inflammation to be found during their production. They appear 



INFLAMMATION. 105 

to be alterations of action, rather than the result of an actual inflammation. The 
part is entirely altered, and a new product is formed. When inflammation does 
accompany those new formations which are called " non-analogous,'''' such as en- 
cephaloid disease, or cancer, it is often only an accompaniment, and not their cause. 
Sometimes it is only the predisposing cause. Inflammation throws a part into a 
predisposition to disease; and then a fresh disease is set up. That these tilings are 
not the result, at any rate, of mere inflammation, is shown by the fact, that more 
inflammation continually occurs, without such eflfects being induced. In these 
aflfections, although we may employ the most vigorous antiphlogistic measures, in 
the most persevering manner, the disease may resist; we scarcely control it, or not 
at all. The tendency to the morbid process is continued; and the disposition to it 
would often appear to excite the inflammation: — that is, the inflammation appears 
to be the consequence of the disposition to the disease; and not the disposition to 
be the result of the inflammation. Indeed, inflammation, in many cases, is only 
the ultimate effect. The new formations irritate the part so much, that inflamma- 
tion is excited, and an attempt is made by nature to discharge the formation. In 
this way scirrhus has sometimes been completely separated, by nature, from the 
body. 

Tubercles. — The existence, in the lungs, of tubercles, (which are new formations, 
not analogous to any thing in the body,) cannot be the result of mere inflammation; 
because inflammation occurs every day without them; and they, too, are often pro- 
duced without signs of inflammation.* Occasionally, people who are disposed to 
this disease will, by having the lungs thrown into an unhealthy state by inflamma- 
tion, become the subjects of tubercles from that time; because any thing which 
throws the body out of health, gives a predisposition to disease of some kind or 
other; or if there be a predisposition, it is increased, and the new disease is excited. 
If a rabbit be badly fed, and kept in a damp place, and in the dark, — so that it has 
a deficient quantit}^ of light and heat, together with unwholesome food, — it may- 
become the subject of tubercles. A new, depraved secretion takes place; which, 
however, is not the result of inflammation. If we gave stimulants to an animal, we 
might produce an inflammatory state of the whole body, or of any organ; but should 
not induce tubercles. The attempt to explain every thing by inflammation, ap- 
pears to me an absurdity; and I am happy to find that my opinions on this subject 
coincide with those of Andral and Louis; who argue successfully, that inflamma- 
tion is not always the cause of tubercles; that they occur continually without in- 
flammation; and that when they do occur as the consequence of inflammation, it is 
not so much the result of the inflammation itself, as of the part being thrown out 
of health, and thus easily becoming the victim of the predisposition to tubercles. 
These are all the observations that I have thought it necessary to make, respecting 
the symptoms and effects of inflammation. I shall hereafter speak of changes of 
structure in general. 

Such are the usual phenomena of inflammation. Such are the chief symptoms; 
such are the general eff*ects or terminations; and such is its course. The next point 
which I shall consider, is the variety in all these respects, occasioned by the nature 
of the structure which it attacks. The varieties induced in inflammation by the 
structure affected were first considered by Dr. Carmichael Smith; who published 
(in the second volume of the " Medical Communications," printed in 1788) a very- 
admirable and classical paper on this subject. His attention, however, was con- 
fined to inflammation. Nearly ten years after this, Pinel, a celebrated French phy- 
sician, adopted this same arrangement; and he, I believe, generally has the credit 
upon the continent; while our countryman is overlooked. Bichat, in his "General 
Anatomy," afterwards pointed out that all diseases might be considered according 
to the structure which they aflfect. 

» This view is confirmed by the recent important pathological researches of M. Louis, 



106 INFLAMMATION. 



SECTION VI.— VARIETIES OF INFLAMMATION. 

There are five chief structures, which Dr. Carmichael Smith considered as giving 
rise to the most decided varieties in the symptoms of inflammation. These are the 
skin, the mucous membranes, the serous membranes, the celkilar membrane (in- 
cluding the substance of the organs), and (according to him) the muscles; but we 
ought rather, perhaps, to say the fibrous membranes; such as ligaments and apo- 
neuroses, tendons, and the periosteum. 

Inflammation of the JSki7i.— When the part inflamed is the skin, it exhibits an 
intense shining redness, which is instantly removed by the pressure of the finger; 
nnd as instantly returns, or nearly so, when the finger is removed; — so that the skin 
is made white by pressure; but almost as soon as the finger is removed, a blush 
pervades the part, which becomes as red as before. If this inflammation of the skin 
b ; of a simple character, and in a patch, — if there be nothing more than the inflam- 
Kiation of the part, the term given to it is "erythema." It is not every inflamma- 
tion which is erythema;* but the simplest patch of inflammation on the skin is so 
designated. 

The character of the pain, when the skin is inflamed, is burning and smarting; 
and when the inflammation subsides, it is frequently followed by the separation of 
the cuticle in branny particles, or scales, or even large shreds. This process is 
called "desquamation."" 

Very frequently, when the skin is inflamed, vesicles of various sizes appear; and, 
not unfrequently, there is a very great effusion of serum into the subjacent cellular 
membrane; so that where the skin is inflamed, the whole part becomes swollen, 
puflfy, and oedematous. As the skin is a continuous surface, every inflammation of 
it which is entirely superficial, has a great tendency to spread; and sometimes, 
when that takes place, the part first affected recovers itself; so that the disease ap- 
pears to wander along the body, like a cloud; — forsaking one part, and going to 
another. But, on the other hand, we sometimes have the part originally inflamed 
still aflfected; — the disease having merely extended itself still farther. Sometimes 
the inflammation does not spread in this way, but dips down; so that the cellular 
membrane below is not merely filled with serum, but becomes the subject of actual 
inflammation. If this occur in mere points, matter may be formed; and what are 
called "pustules," — which consist of a number of little minute collections of pus. 
Sometimes they may be formed, indeed, withotit the cellular membrane being 
affected; ihe surface of the skin alone being attacked; but frequently the pustules 
extend through the skin, deeply into the cellular membrane. Sometimes, moreover, 
a frightfully extensive inflammation of the cellular membrane takes place; — suppu- 
ration being very likely to occur; and then the disease is designated " erysipelas 
phlegmonoides," by some called " diffused inflammation of the cellular membrane." 
The skin, therefore, may be inflamed superficially, and remain so; or the inflam- 
mation may dip down into the cellular membrane below; and then all the characters 
of inflammation of the cellular membrane, in addition to those of inflamTnation of 
the skin, appear. This may be considered a complicated disease; — an inflamma- 
tion of two parts. 

Inflammation of Mucous Membrane. — The second structure which gives 
variety to inflammation, is mucous membrane. Mucous membranes are very nearly 
allied in structure, as well as in all other qualities, to the skin. In Bichat's beauti- 
ful " Treatise on Membranes," the analogy is pointed out between mucous mem- 
branes and the skin. It is a work well deserving of study. Heule, however, has 
recently published some important researches on the intimate organization of mem- 
branes. He has shown that the epithelium, which is the proper cuticle of mucous 
membranes, consists of vesicles flattened and disposed in a tesselated manner. When 
a raucous membrane is inflamed, it becomes thicker than usual; its temperature in- 

» From ggu^gof, red. ' ^ From " desquamo," to scale off. 



INFLAMMATION. 107 

creases; and it becomes tender to the touch. The pain which is experienced is dull 
and diffuse, though sometimes it is of a pricking character; but if not pricking, it 
is obtuse and diffused. When the inflammation first begins, the secretion of the 
part is increased. It is, however, watery, or thin; and perhaps acrid. This any- 
one may observe in a common catarrh. When a cold begins in the Schneiderian 
membrane of a nostril, the nose " runs," as it is called. The secretion is increased, 
but is not at first very excessive; nor is it thick, but thin; frequently, however, 
it is more or less acrid. As the disease advances, the discharge becomes, perhaps, 
entirely suppressed; but, as the disease declines, the secretion increases again, — 
becomes excessively copious and viscid, — perhaps offensive; and then, again, it 
gradually lessens. If the inflammation be not intense, the secretion remains mu- 
cous; although it may be altered in its quality, — may be diseased, still it is mucous. 
If, however, the inflammation be more intense, the secretion becomes puriform; and 
a still higher degree of intensity will give rise to absolute pus, — purulent discharge. 
All this is observed in inflammation of the urethra; where inflammation is far more 
violent than that which occurs in the nose. The inflammation of catarrh generally 
produces nothing more than mucus; but the inflammation of severe gonorrhoea is 
so violent, as to cause the formation of pus. If, however, the inflammation be still 
more violent than that which occurs in purulent gonorrhcea, you may not simply 
have pus produced, albumino-fibrin will be poured out. One of the most violent 
inflammations of a mucous membrane, is the croup of children; in which disease, 
the mucous membrane pours forth a plastic fluid; by which the parts become ob- 
structed, and a tube of new secretion is produced. I have seen the same occur in 
the urethra; where an individual, in consequence of a violent gonorrhoea, has used 
strong injections, the result of v/hich was the excitement of a dreadful inflammation. 
Pus had been secreted before, but now adhesive matter; a portion of which, exactly 
resembling an earth-worm in appearance, except in colour, was discharged from 
the urethra. 

Occasionally, when mucous membranes are inflamed, hasmorrhage takes place 
from them. They become so overloaded with blood, that the vessels allow its 
escape, and haemorrhage ensues. This is more particularly the case with inflam- 
mation of the mucous membrane of the intestines, and of the urethra. Now and 
then ulceration and mortification occur; this circumstance generally happens, how- 
ever, in the throat and intestines. It often takes place from the very beginning; and 
is not at all in proportion to the degree of inflammation. There often appears to be a 
strong disposition to ulceration. Inflammation of a mucous membrane frequently 
degenerates into a state of chronic discharge; so that when the inflammation is over, 
the part continues to pour forth a quantity of fluid, without pain and without heat. 
This particularly occurs when a mucous membrane has been inflamed several times; 
and we especially notice this gleet, as it is termed, from the bronchi and the urethra. 
The latter is every day seen in young men; and the former in those who are old. 
Hence we have " catarrhus senilis," — a gleet, — a constant discharge from the 
mucous membrane of the air-passages, without any inflammation. 

If we examine these membranes after death, when they have been inflamed, we 
find them thicker and softer than natural. If the inflammation should have con- 
tinued very long, they will frequently become very soft and thin; but, on the other 
hand, just the reverse is frequently observed. If inflammation have induced soft- 
ening, they may be rubbed off by the finger, from the cellular membrane beneath. 
Sometimes, however, these mucous membranes become indurated. If we find a 
mucous membrane soft, — as we frequently do in the case of the stomach, — it is no 
proof that it has been inflamed. I believe that a part will occasionally become soft- 
ened, without any inflammation; — at any rate, I know that the softening is fre- 
quently out of proportion to any inflammation that has existed. Generally, when 
a mucous membrane has suffered acute inflammation, it is found to be thicker and 
softer than natural. It is much more rare to find it hardened. The usual effect of 
acute inflammation, is to soften parts; but if it should occasion a considerable depo- 
sition of albumino-fibrin, and that be retained in the cells long enough to coagulate, 



108 INFLAMMATION. 

it will cause an appearance of induration. Baron Dupuytren, the eminent French 
surgeon, and Dr. Thomson, of Edinburgh, found inflamed arteries softened; and 
the stomach, bronchia, and heart, when inflamed, are continually found soft. This 
is the more general eflfect, therefore, of acute inflammation of mucous membranes. 

[The softening which follows inflammation, may be appropriately considered of 
two kinds — that which immediately succeeds an attack of acute inflammation, and 
depends upon the effusion of liquor sanguinis in the cells of the structure in which 
the action occurs — and that intimate change in the organization of a part, which su- 
pervenes at a more remote period after the accession of disease. This latter state, un- 
like the former (which is mechanical), is caused by perverted nutrition, and is vital; 
for the softening is an organic process, and does not depend upon the solvent power 
of the fluid effused into the cells. If the more serous portions of the contents of 
the tissue were taken up by absorption, and the remaining fibrinous parts to undergo 
coagulation, it is evident that the opposite state o^ induration would result. It is 
necessary, however, to distinguish this from another species of Aarrfenm^, which is 
due to hypertrophy, or excessive nutrition. — T. Williams.'] 

Sometimes, when a mucous membrane has been severely inflamed, it is almost 
black. Through the mere congestion of blood, it will look dark, as if it w^ere 
mortified; but, on handling it, it is not found lacerable, like a mortified part; but 
still rather firm and solid, and devoid of fcetor. Great mistakes have been continu- 
ally made in the inspection of bodies. After inflammation of the intestines, we 
often find portions of them nearly black, without any particle of mortification; and 
frequently such cases have been pronounced, at once, to be mortification of the in- 
testines. Mere congestion of blood will make a mucous membrane almost black; 
as is seen in the case of the genital organs of rabbits during heat. The error to 
which I have alluded, is pointed out by Dr. Baillie, in his "Morbid Anatomy."* 

It is a general remark that the feverishness, — the pyrexia attending the inflam- 
mation of a raucous mer^ibrane, is comparatively mild, and the tolerance of the loss 
of blood is low. The pulse is generally soft, although quickened; and the more 
frequent the attacks of inflammation, in any individual mucous membrane, the 
more mild they are, and the more early and profuse is the discharge. 

Serous Membranes. — If the part inflamed be a serous membrane, — such as the 
arachnoid, the pleura, the pericardium, the peritoneum, or the tunica vaginalis, — 
the pain is for the most part acute, — darting, — lancinating. The pulse is not soft, 
as in the case of inflammation of a mucous membrane, but is generally hard, though 
by no means always. It is a general, but not a universal remark, that the pulse 
is hard. The inflammation causes here a copious effusion of serum, with fibrin in 
solution. This fluid is sometimes limpid, clear, and of a lemon-colour; but is gene- 
rally turbid; except, perhaps, in inflammation of the head. The serous collection 
is generally of a yellowish colour, like whey; and sometimes it is puriform; — the 
fluid, in many portions, resembling pus; although other portions of it may be more 
like serum. Sometimes, however, absolute pus is produced; so that the pericar- 
dium has been filled with this fluid. Sometimes it forms a jelly-like yellowish 
mass; sometimes minute shreds or flakes are seen swimming about the fluid; and 
sometimes it forms regular layers, resembling skin. These deposits of fibrin will 
at length grow vascular; and, when vascular, they will adiiere to the surrounding 
serous membrane; and at last become thin again, and in all respects resemble cellu- 
lar membrane. Hence they have been frequently called " false membranes." A 
false membrane is, originally, nothing more than an effusion of liquor sanguinis; 
which has become organized, and adherent to the surrounding serous membrane 
from which it has been poured forth; and has then become, in all respects, like 
cellular membrane. 

» There is no difficulty, however, in distinguishing between this congested condition of a 
part, and the state of positive rnoriification. When congestion only exists, the proper 
organization of the part continues, and its strength is such as to resist the pressure of the 
finger; bat in mortiftcatioa the natural structure is lost, and the slightest force breaks down 
tkepart.— 7^. Williams. 



INFLAMMATION. 109 

This deposit is distinguishable into two portions; — one solid, and the other fluid. 
The solid is fibrin itself; but within the various portions of the solid mass, be- 
tween the layers and cells, is found a fluid which is albuminous. When these 
depositions have become adherent, they may be injected from the surrounding 
parts; but, — as a coagulum of blood has been seen to have vessels of its own, 
although such vessels are formed from the influence of, and connected with, those 
which surround them, — so will these depositions of fibrin, before they are visibly 
adherent to the surrounding serous membrane, become vascular. Within these 
products, there has even been found a puriform fluid, while they were still uncon- 
nected with the surrounding parts. Andral says, that he has distinctly found a 
fibrinous concretion, unconnected with the surrounding parts, swimming in liquid 
in a serous cavity; and frequently, even in this concretion, he has found pus. It 
is said that the circulation within these parts is of three kinds. When they are 
first formed, currents take place in the interstices, through irregular areolae; in the 
next place, insulated vessels are found; and thirdly, these vessels at last become 
continuous with those of the neighbouring parts. Andral says, that each of these 
stages may exist in different parts of the same fibrin. The opinion entertained by 
recent patliologists is, that although these concretions may form before death, they 
cannot become organized unless attached to the sides of the heart or vessel. 

When a serous membrane which has been inflamed is opened, some points, 
stars, or patches of vascular redness are found. In the first degree of inflammation 
there are merely points; if there be still more inflammation, there are stars; but if 
there be a still higher degree, and very numerous vessels contain blood, then a dif- 
fused redness appears. 

Parenchymatous Structures. — When the part inflamed is either the cellular 
membrane, or the substance of organs, as the liver, the pain is fixed; — not diffused, 
as in the case of a mucous membrane; but fixed and rather acute, though not so 
acute as in an inflamed serous membrane. It is rather dull, but rather acute, not- 
withstanding; and even pulsating, or throbbing. There is an effusion of serum 
into the surrounding parts, and at length suppuration takes place in that spot where 
the inflammation is most intense; and in the midst of the effusion an abscess is 
formed. If any tumour be produced, it is hard; and it becomes soft when suppu- 
ration commences, — the pain remitting at the same time; though, generally, the 
tension, from the collection of matter, keeps up the pain and the other symptoms. 
When the matter escapes, the part heals by granulation and cicatrization; — as I 
mentioned when speaking of abscesses.* 

Inflammation of the substance of the viscera, or of any part of the cellular mem- 
brane, forming an abscess, rarely ends in gangrene; except that particular form 
which is called "carbuncle." The inflammation of the cellular membrane, or 
substance of the viscera, is called "phlegmon." When, however, it is near the 
surface, and has a tendency to produce gangrene, it loses that name, and we call it 
"carbuncle." In the latter, the cellular membrane will die to such an extent, that 
surgical aid is necessary, to make large openings for its escape; — in order that its 
spread may be arrested. 

Inflammation of the cellular membrane, and of the viscera, is sometimes not in- 
sulated, but diffused; and (as was remarked, when speaking of the skin*") this is 
frequently called "erysipelas phlegmonoides," — provided the skin be also inflamed; 
or "diffused inflammation of the cellular membrane," if the skin be not inflamed. 
This inflammation is occasionally chronic. Nothing is more common than for 
inflammation of a mucous membrane to be chronic; but inflammation of a cellular 
membrane is not so frequently chronic, though sometimes it is; and we observe 
this especially in the lungs and liver; so that people labour under chronic pneu- 
monia, and more frequently under chronic hepatitis. 

Fibrous Membranes. — Fibrous membranes include fascia, aponeurosis, tendons 
and their sheaths, ligaments, the sclerotic tunics, and periosteum. If these be 

» See Page 98. '' See Page 106. 



110 INFLAMMATION. 

inflamed, the disease which commonly exists is rheumatism. There may, how- 
ever, be inflammation of any of these parts without rheumatism; but if there be a 
general tendency to inflammation of these throughout the body, it is called " rheu- 
matism." Frequently, however, the inflammation of a single one of these parts is 
the same disease. In rheumatism, although the pain is obtuse, yet there is a feel- 
ing of tension; and gelatinous exudations, analogous to synovia, take place. This 
form of inflammation rarely runs on to suppuration; still more rarely, if ever, to 
mortification. The pyrexia may be out of all proportion to the violence of the 
local inflammation; and, indeed, one character of the disease is the occurrence of 
profuse sweating. In acute rheumatism, profuse sweating is seldom absent, at 
some period of the disease. It generally occurs at the commencement of the aflfec- 
tion. At any rate, if the patient be kept at all w3rm, the tendency to it is sure to 
show itself; and the sweats are frequently of so marked a character, that we can 
be at no loss instantly to discover their nature. They are usually very sour. This 
variety of inflammation generally terminates in resolution, or degenerates into the 
chronic form; — perhaps with a chronic collection of gelatinous matter about the 
joints, and in the thecse of tendons. 

The peculiarity of this inflammation, is its jrreat tendency to wander, — to mi- 
grate; so that it is now in one joint, and in a few hours in another. Occasionally 
it is metastatic; it will cease in these particular parts, and inflammation of an inter- 
nal part will begin; — generally an inflammation of some membrane; either the 
arachnoid, I believe, or the dura mater; — we cannot say exactly which; but, cer- 
tainly, more frequently than not it is the pleura or the pericardium; — the latter, 
however, more frequently than any other. But it is not by metastasis only, that 
this internal inflammation takes place; for inflammation of the pericardium or of 
the pleura, occurring in rheumatism, is continually brought under our notice, while 
the afli'ection is going on in the joints, just as violently as before; and frequently 
this internal inflammation does not take place, till after the rheumatism has ceased 
for some time. When the pericardium, for example, has been inflamed, if the 
person do not die, the pericarditis has a great tendency to become chronic. Dis- 
ease of the heart is then set up; the substance of the heart itself frequently becomes 
thickened, or hardened, or softened; the internal membrane, chiefly about the valves, 
becomes aflfected; and organic disease of the heart is soon established. This is by 
far the most common origin of diseased heart in young persons. It commonly 
begins in pericarditis, which is generally connected with rheumatism. 

Varieties from Sympathy. — Such are the chief varieties of inflammation occa- 
sioned by structure. The sympathies of the particular part effected, likewise 
occasion varieties in the general symptoms. Some of the symptoms arise from 
the sympathies of the ^eMer«/ structure affected. For example: if the structure 
affected be a serous membrane, its sympathies give rise to a peculiar pulse; — in 
general a hard pulse. From another sympathy, when fibrous membranes are 
affected, a particular sweating is excited. But, besides these general sympathetic 
eff*ects, — which are due to a peculiarity of structure, — other sympathetic eflfects, 
depending upon the particular office of the organ, arise. If the stomach or intes- 
tines be inflamed, we generally have a sensation of great weakness, and a wiry 
pulse; but this does not occur as the consequence of an inflammation of the peri- 
toneal coat of the intestines, or any other of their coats; — for then it would take 
place when a similar structure was inflamed in other parts; but it occurs because 
the organ aflfected is the intestines or stomach. When the kidney is inflamed, 
vomiting, a retraction of the testis of the same side, and various other symptoms 
occur; simply because the kidney is inflamed. Hence a certain set of symptoms 
is induced in inflammation, from the peculiar sympathy of other organs with the 
part aflfected. 

There are other varieties also observed. Erysipelas of the head has a great 
tendency to run to the brain. This can hardly be called " metastasis;" because the 
inflammation frequently still continues violent in the fiice itself, even after the 
symptoms of phrenitis come on. Inflammation of tlie parotid glands, of that pecu- 



INFLAMMATION. Hi 

liar kind said to be contagious (called "mumps"), has a great disposition to occa- 
sion sympathetic inflammation of the brain or of the testes. Indeed, when any 
organ is inflamed, and the inflammation continues any length of time, it is not un- 
common for another and a distant organ to become inflamed likewise. This organ 
is generally either the brain, the lungs, or the alimentary canal; — sometimes, how- 
ever, (though less frequently,) the skin, and sometimes the throat. When a part 
has been once inflamed, it has a great tendency to fall into inflammation again, 
from slight causes. We certainly have inflammation of an organ, from sympathy 
with the particular organ affected; and very frequently when this second inflam- 
mation occurs, although it may be very slight, it is attended with very considerable 
ill eflfects. The constitution is so much impaired by the first inflammation, that 
the addition of disease, though slight, in another organ, produces very great danger, 
and frequently death. 

Intermittent Inflammation. — Inflammation is sometimes intermittent, and some- 
times absolutely periodical. Inflammation of the eye has been observed to recur 
at particular periods. It has frequently been observed to be intermittent, — to come 
on violently every evening, or every other evening, at a certain hour. I have also 
seen periodical catarrh. 

General Health. — There are variations of inflammation, according as the consti- 
tution is healthy or unhealthy. If the constitution be healthy, the inflammation is 
more active, — is more rapid; and the terminations, when they occur, are more 
perfect. When the constitution is in an unhealthy state, the parts inflamed are 
feeble. There is less activity in the inflammation, less brightness of colour. The 
terminations which take place are less perfect; and the secretions of the part are 
more unhealthy. 

Specific Inflammation. — There are other varieties in the symptoms of inflam- 
mation, depending on the cause which has produced it; and the inflammation on 
this account is frequently termed "specific." For example: inflammation of the 
skin, as in small-pox, is induced by a specific cause; and therefore it is called " a 
specific inflammation." Independently of the cause, some inflammations run a 
peculiar course^ and are therefore specific. Such is erysipelas. 

Passive Inflammation. — I have hitherto been considering active inflammation; 
but inflammation is sometimes also said to be passive. If, in inflammation, there 
be but little pain; if the redness be dull; if the heat be but slightly increased, 
perhaps not at all; if there be more than the usual swelling, and a very abundant 
secretion; — in this case the inflammation is said to be " passive." I have already 
mentioned,* that some persons object to this term; and say that such a set of 
symptoms as these are not inflammation; and Andral, to avoid the difficulty, calls 
all inflammations and congestions *' hyperemy," — the excessive presence of blood 
in the part. "Active hyperemy''^ is synonymous with "active inflammation;^^ 
whereas, if the symptoms be those I have just described,— -a dingy colour, flac- 
cidity of the parts, and little or no pain, — then, instead of calling it " passive 
inflammation,''^ which he says is absurd, he calls it " passive hyperemy.'''' 

Acute and Chronic. — These terms apply merely to the duration of inflamma- 
tion; and not to the diff'erence whether it is active or passive. An acute inflam- 
mation may be passive from the first. When a person is already weak before the 
attack of inflammation, or the part has been frequently inflamed before, then at the 
very outset the inflammation may be of a passive character, although acute. After 
inflammation has continued for a length of time, it may be still active; — the part 
may still be hot and painful, and this state may yield only to the lemedies of 
active inflammation. Hence " «c/zt^e" and "/?«sszt?e," with respect to inflam- 
mation, as well as all other diseases, are not synonymous terms with " acute'' and 
" chronic.''^ 

Tonic and Atonic. — Inflammation is sometimes distinguished into tonic and 
atonic; and these terms refer, not to the active or passive condition of the part, 

' See Page "7^ * See Page 37. 



112 INFLAMMATION". 

but the powers of the system. If the constitution be strong, the Inflammation is 
called " tonio;" wiiereas, if the system be in a weak state, the inflammation is called 
*' atonic;" — because inflammation is sometimes very violent in the part, and yet 
there is no power in the system. The activity is all of short duration; the powers 
are exhausted; and perhaps mortification takes place. The activity, — the violence 
of inflammation in a part, is more than commensurate with the powers of the 
system. If the part be in a state of activity, the inflammation is called " active;" 
but if not, it is called "passive;" whereas, the words '■'tonic''' and ^''atonic''' refer 
rather to the powers of the system at large. 



SECTION VII.— CAUSES OF INFLAMMATION. 

Predisposing Causes. — I shall now consider the causes of inflammation; com- 
mencing with the remote; and of the remote causes, i\\Q predisposing^ of course, 
come first to be considered. * The circumstance which primarily predisposes to 
inflammation, is the sanguineous temperament; and the next may be considered 
high health. In the sanguineous temperament, there is generally a great quantity 
of blood; — at any rate, there is a large quantity in the minute vessels; so that the 
blood — the pure blood itself — circulates to a great extent throughout. The body 
is readily flushed; vessels, which should not, readily receive blood; and the circu- 
lation is full and rapid. I need not say, that high health must have the same 
eflfect. A person in a high state of health, has a florid colour. There is an in- 
creased quantity of blood circulating throughout the body, and to a greater extent 
than in other temperaments. Besides these two general circumstances of the 
body, the same occurrence may take place locally. There may be a local san- 
guineous fulness, — a local fulness of blood; and that may predispose a part to 
inflammation. The face is certainly more supplied with blood, than any other 
portion of the surface of the body; and consequently when exanthematic aff"ections 
(such as measles and small-pox) take place, most of them afl^ect the face, sooner 
than any other part of the surface; and the inflammation which occurs there is 
severer. The same thing will occur from a particular period of life. In children, 
the circulation appears most vigorous in the head. What is called *' determination 
of blood to the head" takes place; — all that is meant by which term being, that 
more blood (proportionately) is circulating there than in other parts. In youth, 
the greatest determination is towards the chest; and in the middle period of life 
and afterwards, it is in the abdomen. Hence children are particularly disposed to 
hydrocephalus, — to inflammation of the arachnoid membrane of the brain, — to 
other cerebral afl?*ections; and are continually having fits, — continually having 
afl"ections of the head; and, consequently, a large number of children die of acute 
diseases of the head. Hence, too, children are particularly subject to epistaxis. 
Persons in youth — those who have passed the period of childhood — are certainly 
more subject to all aff"ections of the chest, — to all thoracic inflammations, and to 
inflammatory spitting of blood. It is adults, particularly, who have inflammation 
of the stomach and intestines, both acute and chronic; — especially chronic inflam- 
mation of the stomach and of the liver; — indeed, inflammation, and congestion, 
and structural changes of all the abdominal organs. 

Seasons and climates will operate in the same way, by exciting either general 
or local fulness. Pulmonary inflammation is more common in cold climates, and 
likewise in the winter and spring; whereas in hot climates, and in the autumnal 
season of temperate climates, hepatic inflammation is most common. 

Occasionally a part will acquire an increased excitability from a previous 
injury; and this is remarkably shown in the head. If a person have once had a 
severe injury of the head, he may afterwards sufl^er from a slight cause; — a cause 
which scarcely would have disturbed him before. I saw a person who had had a 
fracture of the skull; and, for many years afterwards, he would become com- 
pletely delirious, on taking a glass of spirits. This is an occurrence, indeed, that 



INFLAMMATION. 113 

I have frequently seen. I very well recollect the case of a man, who laboured 
under rheumatism of different parts of the body, and amono- others of the scalp; 
but he had suffered severe fracture of the skull some years before; and the mere 
excitement of the external part of the head, was sufficient to excite it internally; 
so that he had violent delirium from mere trifling rheumatism of the scalp. 

Previous inflammation from any cause, disposes a part to be inflamed again. 
Various causes, of an opposite tendency, will also have the same eflect. Bad air, 
copious evacuations, bad food, depression of mind, fatigue of bv'uly, fatigue of mind, 
the frequent exhibition of mercury, an exhausting climate, and previous disease of 
any kind, will also dispose to inflammation. While all these predisposing causes, 
however, induce inflammation, its character differs totally according to the nature 
of the cause. The inflammation induced by the first kind of causes I mentioned, 
is active and tonic; whereas the inflammation predisposed to by bad food, bad air, 
depression of mind, and so on, is either passive or atonic; — the inflammation itself 
is of a passive character; or there is not sufficient power in the system to carry it 
on, — to get the patient well through it, or to produce a healthy secretion of pus, 
if pus be produced. Hence the character of the inflammation varies, accordino- as 
the predisposing cause is one which gives strength, high health, and excitement; 
or one which destroys health and strength, and gives a tendency only to an un- 
healthy excitement. 

Some of these latter causes, such as the defect of heat and of food, act as pre- 
disposing causes to inflammation, without producing any debility, or any atonic 
character of inflammation. If a part be exposed to cold, it becomes more affected 
afterwards by a given degree of heat. If a person be deprived of food, and then 
a small quantity of food, though of the weakest character, be given him, it will 
produce an excitement which only strong food and a large quantity would have 
produced before; and therefore some of these predisposing causes may act, also, 
by rendering the part more liable to be affected by stimulants; for stimulants act 
according to circumstances that went before them. According to the first, so is 
the second; and all that is requisite is, that there should be a great disproportion 
between the two. It is no matter whether the first is very defective, or the second 
is very great; for the effect is in proportion to their relative intensity; and there- 
fore parts which have been exposed to cold, become violenfly inflamed if exposed 
to a moderate heat; and a person who has been nearly starved previously, has 
been known to become delirious, on taking merely a litUe veal-brolh. Many of 
tlifise causes, however, produce a cachectic* state of the constitution; and then in- 
flammation, if it occur, is of a corresponding character. 

Exciting Causes. — With respect to the exciting causes, we may mention, in 
the first place, a local stimulus; — be that stimulus mechanical, or chemical, or 
what is properly called " a stimulus;" — a stimulus independent of mechanical or 
chemical qualities; such as alcohol. The effect of all stimuli (as I have just now 
said) is not dependent upon their positive degree of force; but upon the difference 
between these stimuli, and the strength of those which preceded them. Every body 
knows the danger of going from cold to intense heat. 

Cold. — Besides local stimuli, whether mechanical, chemical, or true stimulants, 
the depression of stimulation in one part, will cause an inflammation in another. 
From having the excitement in the feet exceedingly depressed, — by getting wet 
through, and sitting with wet shoes, — there will be such increased activity at a dis- 
tant part, that inflammation may occur; so that many persons always have a sore 
throat, or inflammation of the chest or eyes, if they get wet through, or have wet 
feet. This application of cold — depressing the action of one part, and thus pro- 
ducing an excitement in another — de|)ends very much for its eflect upon the pre- 
vious excitement. If the feet, for example, have been already hot; — if they have 
been heated, and are in a state of perspiration, — then the application of cold pro- 
duces so great a depression, that the inflammation of the throat (for example) or 

* From xaxof, had; and i^j?, a habit. 
VOL. I. — 8 



114 INFLAMMATION. 

the lungs, will be so much the greater. The more partially cold is applied, 
the more injurious (within certain limits) is it found to be in producing distant 
inflammation; but cold will itself, I believe, directly induce inflammation; — exactly 
as great heat will do. When we are exposed to cold air, — when exceedingly cold 
air is passing through the nostrils, the nose will " run;" and it has been found, by 
microscopic observation, that cold, like a positive stimulus (such as heat), will 
induce that condition of the capillaries which was formerly defined as essentially 
constituting inflammation;* namely, stagnation of the blood, and eff'usion of the 
liquor sanguinis. Nothing is more common than for rheumatism to be felt in the 
shoulders, or for an inflammatory pain to be felt in the ear, when cold air is blow- 
ing upon these parts; although unquestionably, for the most part, these aflections 
are of a nervous, and not an inflammatory character. 

Thus it appears, that cold may induce inflammation in three ways: — 1. By 
rendering the body liable to be very much excited by the stimuli that come after- 
wards; — by depressing the action so much, that when the stimulus of increased 
temperature is applied, ihe effect of this is tenfold increased. 2. By depressing 
the action in one part, and thus exciting a correspondent excess of action in another. 
3. By exciting inflammation immediately and directly. There are many instances 
to illustrate these three modes of operation. First, when a person passes from 
the cold into a warm room, his face will become very red and hot; and frequently 
he will cough violently, and a catarrh will be set up. In the next place, we see 
persons have inflammation of the eyes, nose, mouth, throat, or chest, from wet and 
cold feet. And, thirdly, we continually observe pain in the ear, rheumatism of the 
shoulders, and the nose " running," when cold air is applied to these parts. 

I believe that sudden refrigeration, and the sudden application of cold after ex- 
citement, are more frequent causes of inflammation, than the application of heat 
after cold. Most of the cases of inflammation met with, are those in which per- 
sons have become suddenly cool, when they were overheated and fatigued. Per- 
haps, likewise, wet may have been added to this; or they may have been exposed 
to the influence merely of cold air. A rigor is frequently induced; and a slate 
arises which is soon followed by inflammation. The effect of sudden refrigera- 
tion, therefore, is greater in proportion to the previous excitement: it is also greater 
if it be pjytial than if it be general; and it is always greatest if there be much 
sweating and exhaustion. Sometimes, indeed, fatal results have instanfly occurred. 
Many persons, from taking ice when they have been not only hot, but sweating 
and exhausted, have at once fallen dead. The account of Alexander the Great 
bathing in the Cydnus, when exceedingly hot and exhausted, after great fatigue, 
is well known; — an occasion on which he nearly lost his life. How hot soever 
the body may be, there is comparatively little danger, if it be not fatigued. The 
Russians go from the vapour-bath to the snow, and roll in it. 

[It has long been a popular, as well as a professional axiom, that sudden vicis- 
situdes of temperature are dangerous; — that a previous hot state of the body aug- 
ments the hurtful effect of the application of cold, either externally or internally. 
But the proposition, thus broadly stated, is not universally true. Sir Charles 
Blagden, describing some of the experiments in which he was engaged, says, — 
*' During the whole day, we passed out of the heated room, (of which the temper- 
ature ranged from 240° to 260°,) after every experiment, immediately into the cold 
air without any precaution. After exposing our naked bodies to the heat, and 
sweating most violently, we instantly went into a cold room, and stayed there even 
some minutes, before we began to dress; yet no one received the least injury." 
And Captain Scoresby (speaking of the Arctic regions) tells us, that he has often 
gone from the breakfast-room of the vessel, (where the temperature was 50° or 60°,) 
to the mast-head, (where it was only 10°,) without any additional clothing, except 
a cap; — " yet," says he, " I never received any injury, and seldom much inconve- 
nience from the uncommon transition." It is plain, therefore, that the proposition 

» See Pase 84. 



INFLAMMATION. H5 

which ^assigns clanger to sudden vicissitudes of temperature, requires limitation. 
The effects of a sudden descent from one point to another, in the scale of atmo- 
spheric temperature, varies according to the state of the body at the time. Without 
going into any physiological discussion respecting the science of animal heat, I may 
just remind you of the faculty of evolving heat possessed by man, and the warni- 
blooded animals; by which faculty very nearly the same degree of inward temper- 
ature is steadily maintained under very different degrees of outward temperature. 
If the external temperature be lower than that of the body, the caloric thereby 
carried off is speedily replaced, in a healthy adult, by this evolution of heat from 
within, aided by clothing, or exercise. When the external temperature approaches 
the standard heat of the body, sweat soon breaks forth, and the superfluous heat is 
removed by evaporation; for so constant is the internal evolution of caloric, that an 
atmosphere which does not as constantly abstract any of it, is excessively incom- 
moding. An external temperature of 98°, which is about the average heat of the 
blood in man, is (as you know) extremely oppressive. The terms "hot," "warm," 
" cool," and " cold," as applied to the surrounding air, are regulated by the sensa- 
tions that it produces upon the average of persons. If the heat be carried off as fast 
as it is generated, and no faster, no particular sensation is fell; and the bodily 
powers are neither stimulated nor exhausted. This equilibrium is maintained, 
(supposing that no extraordinary exertions are made,) when the thermometer stands 
at 62®, or thereabouts. We call that point in the scale "temperate." All degrees 
above that point, up to 70°, are reckoned " warm," all above 70°, " hot." De- 
scending in the scale, we speak of the temperature denoted by any degree between 
the 60th and 50th, as being " cool;" and every lower degree of temperature is 
"cold." I am speaking of the average of healthy men; for remarkable diversities 
occur among individuals, with respect to the names which they assign, under the 
guidance of their sensations, to particular degrees of the thermometric scale; — their 
sensations differing according to the power which their constitutions respectively 
possess of evolving heat. Now, if this power of evolving heat (thus inherent in 
the system) be entire, and active, and persistent; — if it have not been awakened by 
any of those circumstances which are known to have the effect of weakening it, — 
no peril need attend even violent alternations of external temperature. Universal 
heat of the body, at the time when the cold is applied, so far from implying danger, 
is really the condition of safety; — provided the heat is steady and permanent. You 
may read, in Dr. Currie's book, numerous instances of cold affusion being employ- 
ed in the hot stage of fever, and particularly in cases of scarlet fever, not only with 
impunity, but with great benefit to the patient. The same holds true of the appli- 
cation of cold, when the body has been heated by exercise; and, indeed, whatever 
may have been the cause of the increased heat; — provided always that that cause 
remains steadily in action, that there is no local disease, and that the body is not 
fatigued and rapidly losing its heat. But if a person be already exhausted and 
weakened by exercise, — if he be sweating and rapidly parting with his heat, — and 
especially if the exercise is remitted, and he remains at rest immediately after the 
application of the cold, — then it becomes highly perilous, and likely to produce 
internal mischief. The more correct statement, therefore, respecting the applica- 
tion of cold is, that it is dangerous, not when the body is hot, but when the body is 
cooling after having been heated.'' 

Damp. — The effect of cold applied to the body, is much increased by damp. 
Very often, persons do not suffer from the application of cold, till dampness is con- 
joined with it. It may act simply by increasing the cold, — by lowering the tem- 
perature still more; but I cannot help thinking, that it injures to a greater extent 
than this circumstance will explain; — that its injurious ellect is out of proportion 
to the greater diminution of temperature which the dampness occasions. INlnny 
persons are not so strong, by any means, in damp weather. It is possible that it 

* Dr. Watson's " Lectures on the Principles and Practice of Physic;" Lecture 7; "Medi- 
cal Gazette," Volume 27, Pages 226 and 227. (No. 675; November 5, 1840.) 



116 INFLAMMATION. 

may act by conveying away the electricity in too gfreat a quantity. In dry weather, 
we are all active and vigorous; but in damp weather, there certainly is a degree of 
languor, — an inaptitude for action, both of body and of mind, which most persons 
notice. 

Sleep. — The effect of cold upon the body, is much increased by sleep. In sleep, 
the powers of the body are less; the pulse is slower; the heat is not so high; and 
all noxious agents are less withstood. It is a common remark, that if a person go 
to sleep in a draught, he is sure to take cold; but if he contrive to keep awake, he 
will most probably escape. 

Cold, too, appears to be more dangerous M'hen applied to the back part of the 
body, than to the front; — in consequence of the less endowed power ther6, than in 
the anterior parts. Persons will escape if a little draught fall upon the face; whereas, 
if it come to the back of the head or neck, they for the most part experience ill 
effects. 

Sympathy. — Inflammation is sometimes excited as a sympathetic occurrence. 
But when I say that inflammation is excited by sympathy," I do not explain^ the fact; 
I merely express the fact. When one eye is inflamed, the other, without any ex- 
ternal cause, may also become inflamed; and this is called a sympathetic result; — 
it is said to occur by sympathy. If a child's head be inflamed,, it is common for 
the abdomen to become likewise inflamed, either the intestines, stomach, or liver; 
and vice versa. It is of the highest importance, in practice, lo look out for this 
circumstance; or treatment may be addressed to only one inflammation, when two 
exist. 

• Metastasis. — Metastasis is also another mode in which inflammation occurs. 
When inflammation of the parotid glands in " mumps" ceases, the brain may be- 
come inflamed; or what is more common, the testicles, or one testicle; and this 
inflammation often aff'ords an illustration of atrophy, as the result of inflammation. 
It is very common, indeed, for a testicle, when it has been inflamed after mumps, to 
waste away; so that nothing will be left but the membranes. In gout, m'etastatic 
inflammation continually occurs. When the gout suddenly ceases in an extremity, 
it is very common for inflammation, of an apoplectic nature, to take place in the 
head; or for inflammation to occur in the stomach or intestines. 

Absorption of Morbid Secretions. — Occasionally inflammation is induced by 
the introduction into the blood of unhealthy or acrid matter. If pus, or any other 
diseased secretion, be absorbed, it is very common to find a deposition of it, at a 
distance from the part in which it was originally formed. We have a deposition 
of pus, or of lymph, at a distance; — in the various viscera, in the cellular mem- 
brane, or even in the secreting cavities; or we have inflammation and disorganiza- 
tion without deposition. Probably inflammation of the veins takes place.; since 
the pus formed in them does not cause inflammation in distant parts; here it is 
deposited; but pus, lymph, and other things, are there produced by extravasation 
only. If distant inflammation take place, there is of course a deposition of pus or 
lymph; marked by debility, great irritation, and a sallow hue- of the countenance. 

It has been said, that the predisposing causes to disease will sometimes become 

• From ffvy-Ttaa-xM, to suffer 'with. 

»» The reader is referred to Mailer's" Physiology," translated by Baly, and Bich^t's " Ge- 
neral Anatomy," for an exposition of the physiological laws upon which these sympathetic 
phenomena are explained. 

By the former eminent physiologist they are considered under the separate heads of— 

1. Sympathies of the different parts of one tissue with each other, ' 

2. Sympathiesof different tissues with each other. 

. 3. Sympathies of individual tissues with entire organs. . ' , 

4. Sympathiesof entire organs with each other. 

5. Sympathies of the nerves themselves, 

ft is most probable, as suggested by Bichat, that the apparent translation or metastasis oi 
disease from oneorgan to another remotelysitnated, isdueeiiher to ther(?/Zea;t'?i/Zwe'nce of the 
nervous system, or to the circulation throughout the system of some morbific agent;— induc- 
ing the same specific action in a distant organ, the structure of which is similar to that first 
affected.— T. Williams. 



INFLAMMATION. 117 

exciting, — merely by their continuance and increase; so that no "exciting" cause, 
properly so called, is necessary. This may be the case with regard to fulness of 
blood. A part may become more and more filled with blood, — congestion or de- 
termination of blood (whichever it is called) may increase, till at last inflammation 
occurs; or if it be the head that is affected, a state of apoplexy may be produced, 
without any actual exciting cause. In specific inflammation this cannot be the case; 
for no predisposition would have the effect of producing small-pox, unless the excit- 
ing cause were applied. 

Proximate Causes, — Such are the observations which I have thought it neces- 
sary to make, respecting the remote causes of inflammation. The exciting causes, 
— those which are essential to the existence of the disease, — in fact, the actual 
state of the parts in inflammation, have been already considered in a former section.* 



SECTION VIII.— DIAGNOSIS AND PROGNOSIS OF INFLAMMATION. 

The diagnosis of inflammation, when the inflamed part is visible during life, or 
"when we make an examination after death, has been already spoken of sufficiently;* 
but if it happen that we have to make a diagnosis, during life, respecting a part 
which we cannot see, then of course it must be founded upon something else than 
if the inflammation were visible. 

' Beep-Seated Jnflammation. — When an invisible part is inflamed, there is almost 
always pain increased upon sudden pressure, — frequently upon the most gradual 
pressure; and there is generally more or less pyrexia and "symptomatic fever." 
The pain' is often throbbing; and frequently there is a sense of weij^ht and tension. 
It is to be remembered, however, that although a part be inflamed, gradual pres- 
sure may sometimes be borne; and that, on the other hand, very slight pressure, 
— a mere brush of the surface, may cause pain, when there is no inflammation. 
In neuralgia,'' — when a person is labouring under tic douloureux, for instance, — 
we may sometimes produce the most agonizing pain, by brushing the surface in 
the slightest possible manner. But that is not the case where there is inflamma- 
tion. Such a slight touch does not produce such an intense effect; and (more than 
that) if a slight touch do produce so great an effect, it is only in inflammation of 
the skin; and that we can see. 

If we are in doubt, — notwithstanding that the pain is increased by pressure, and 
that there is pyrexia, — the best way, if the patient's powers will allow it, is always 
to treat it as an inflammation; and we frequently find, that the blood which is drawn 
away fully justifies our presumption. The blood is frequently buffed, or cupped, 
or both; but even if it be not, and there be strong reason to treat the case as in- 
flammation, we must not suppose there is less reason to imagine ourselves right, 
simply because the blood is not buffed. Generally, however, it will be found 
buffy, if there really be inflammation. 

Prognosis. — With regard to the prognosis of inflammation, we must consider, 
on the one hand, the age of the patient, and the evident powers of his constitution; 
and, on the other, the violence of the disease, the degree of disposition to it, and 
its seat. The danger of the affection depends on the power which the patient has, 
from the beginning, to sustain the attack. Much must depend upon his age, and 
upon the general state of his constitution; and much depends, likewise, not only 
on the intensity of the disease, and its liability to increase, but on its seat. An 
exceedingly violent inflammation, in an extremity, might not be half so dangerous 
as one. less violent in certain viscera. It is necessary, also, to calculate upon any 
idiosyncrasy, whether natural or acquired, in the individual. I have already men- 
tioned** a patient, who had merely a rheumatic affection of the external part of the 
head; but he had previously had his skull fractured; and the irritation on the out- 

» Section III, at Page 82. «> In Sections I and IF, at Pages 73 and 79. 

* From v£i;j(,v, a nerve; and <t\yoi, fain. <» See Page 113. 



118 INFLAMMATION. 

side of the head, produced sufficient irritation within, for violent delirium to ensue; 
so that he was in a most violent state of phrensy. There was no danger in this; 
—it gave way to the ordinary treatment of rheumatism of the external part of the 
head; but had there not been this idiosyncrasy, it might have been feared that an 
inflammation of the brain, of a highly dangerous character, was set up. When the 
man took a glass of spirits, the same effect, I understand, was always produced. 
We have therefore to consider, whether there is any idiosyncrasy or not; for, 
whether the disease be inflammation or any other complaint, if the patient be 
nervous, there may be great depression of the system; and the quickness of pulse, 
and the general disturbance, may unnecessarily alarm those not aware of the pecu- 
liarities of the constitution. 



SECTION IX.— TREATMENT OF INFLAMMATION. 

a. Active Inflammation, 

Stimuli. — In the treatment of active inflammation, the first point is to lessen 
the ordinary stimuli to which the body is subjected, both externally and internally. 
Excessive action is going on, or there is excessive activity and excitement; and 
our business is to lessen all the stimuli which maintain that activity. The external 
stimuli may be diminished by exclusion. In the first place, we exclude a high 
temperature; — so that its stimulus may act as little as possible. In attending to 
this point, however, great care must be taken not to allow the temperature to fall 
too low; for if we chill a patient labouring under inflammation, we not only cause 
great discomfort, but most likely increase the afl'ection. By diminishing the cir- 
culation in healthy parts ti>o much, it is possible we may increase the activity of 
those which are inflamed; so that in lessening the temperature around a patient, it 
is necessary to diminish it only so far as is comfortable to him. 

Cold Applications. — With respect to the part itself, the temperature there is too 
high; and to that part cold may be applied. Cold may be applied by means of 
plain water; which generally answers as well as any lotion that can be applied, if 
it be continually renewed; but, of course, we can procure a lower degree of cold, 
by the use of evaporating fluids, — those which evaporate more quickly than water. 
It is often of great use to employ real ice; and for this purpose a bladder may be 
half filled with it, and laid on the head after it has been shaved, or on the front of 
the chest, or on any other part of the surface that requires it. \{ we Jill the bladder, 
it will not accommodate itself well to the part; but if it be only /my-filled, it presses 
down in close apposition with it. If it be the surface itself which is inflamed, and 
not the interior of the head or chest, it is not well to apply ice in this way; because 
the pressure would do harm. Indeed, in inflammation of the chest, cold is not 
applied externally; it is only in cases of haemorrhage that we have recourse to it. If 
the surface, then, be inflamed, it is best to apply plain water, or iced water, or 
evaporating lotions; but, in the case of internal inflammation of the head, or haemor- 
rhage from the lungs, ice is one of the best things that can be resorted to/ In 
haemoptysis of a decidedly inflammatory character, I have never seen the applica- 
tion of ice attended with harm. Some have said that the application of cold, in the 
case of inflammation within the abdomen, has been of use; but I am not aware that' 
such is the case. Certain inflammatory pains of the head have given way to a 
stream of cold water applied to it, when nothing else would succeed. By means of 
a tube, a stream of water has been applied to the head, for many hours in the course 
of a day; and the complaint has been thus cured, when evaporating lotions did not 
answer the purpose. 

» The reason why ice is a more powerful refrigerant than water, is that a great quantity 
of heat is absorbed (becoming "latent" or "combined") in converting it from a solid to a 
liquid form. While any of the ice is unmelted, the water remains at the same temperature 
as the ice itself.- 



INFLAMMATION. 119 

When the surface is abraded, or when it is a mucous membrane that is inflamed, 
— such as the interior of the mouth, or the conjunctiva of the eyes (which is very- 
similar to a mucous membrane), — it is generally found of great service to combine, 
with the cold water, a small portion of the diacetate of lead; but not sufficient to 
irritate the part. When the surface, however, is not abraded, I doubt whether the 
employment of lead is more efficacious, than that of plain cold water, or an evapo- 
rating lotion. 

Warm Applications. — The very opposite treatment, however, is often equally 
beneficial. If we apply warmth and moisture together, we often produce as good 
an effect as by the application of cold. It is only a speculation; but I imagine that 
the reason why two such opposite agents produce the same effect, is this: — If we 
apply cold, we lessen the stimulus; — we lessen the heat of the part; — we lessen the 
quantity of blood in all the vessels; and, therefore, we lessen the tension; whereas, 
if we apply warmth and moisture, we cause a relaxation of the inflamed part; — we 
soften the solids, and in that way the tension is taken off. I presume the cold 
lessens the stretching cause; whereas the moisture allows the part to be easily 
stretched, — to give way to the distending fluids. Perhaps the warmth and the 
moisture applied to the surface, may relax the ends of the vessels, cause a free 
perspiration, and in that way ease the parts. Such, however, is the fact; — that one 
patient will be as much relieved by warm applications, as another will by cold. I 
have myself frequently suffered violent external inflammations; and one part of the 
day I have found the greatest relief from iced water, or from a stream of cold water 
constantly applied; and when that ceased to produce ease, or caused pain, then I 
have experienced the greatest comfort from the application of warm water and flan- 
nels. The feelings of the patient are the best guide, in the application of these 
means. I never apply cold when it is uncomfortable. If once the patient be allowed 
to become uncomfortable, it may not only produce general chilliness, but make him 
ill, and perhaps increase the inflammation. 

The temperature of the part, however, is not the only thing to be attended to. If 
we know that the part affected is one greatly influenced by other surrounding 
stimuli, (as the head, for example,) we should likewise exclude light and noise; 
and should, in all such cases, prevent conversation, — both of the patient and of 
others; so that he may be kept as free from stimuli as possible. The exclusion of 
light is an important point to be attended to, in all affections of the head, and par- 
ticularly of the brain. 

Diet. — Still pursuing the plan of exclusion, we should give the patient but little 
food; and even that should be of the most inert kind. In fact, we should starve 
him without letting him know it; — pursue starvation in disguise. Plain water 
would be the best thing, in many inflammatory complaints; but we must allow 
toast-and-water, or barley-water; — for the purpose of satisfying the patient. In con- 
sequence of the thirst, a great deal of drink must be taken. This should be cold, 
unless the patient wish to have it warm; and if the drinks be made acid, they are 
of course so much the pleasanter. A saline draught is a good thing; but a {e\v 
ounces only will be productive of little benefit. The patient should have a pint, in 
the course of twenty-four hours, if it be designed to exert a beneficial influence. 

Blood- Letting. — But although these things are highly important, the great remedy 
in this disease, is the loss of blood. That is, — we have not only to exclude tiie 
external^ but to remove the internal stimuli; and the great internal stimulus of the 
body, is the blood. Blood-letting may be performed anywhere. The object is to 
withdraw blood; and not merely so, but to make as great an impression upon the 
system, by a given loss of blood, as possible. Hence it is generally good practice 
to make a large orifice in the vein (if we open a vein); and to make i\\e patiejit sit 
up, — so that he may faint quickly. If the blood be drawn with great rapidity, a 
far greater effect is produced, than if it be drawn slowly. A large orifice tends to 
accomplish that object; and if a patient be sitting up, he is far more likely to laint, 
than if he belying down. When we are sitting up or standing, the blood finds 
more difficulty in returning to the heart, and escapes more easily from it; and there- 



120 , INFLAMMATION. 

fore, if there be causes tending to produce fainting, they are far more likely to occa- 
sion it in that posture, than if we are recumbent. If it be an object to spare blood 
very much, and yet make as great an impression as possible, it is well to have two 
veins opened at once, — one in each arm; and to make the patient stand up. The 
loss of a very few ounces will then produce fainting. 

The rule for taking away blood, in general, is not to consider the quantity, but 
to consider the effect; — to do every thing calculated to occasion a great effect from 
a given quantity; but, while doing so, to go on till the pulse sinks, till the patient 
experiences relief, or till an evident improvement takes places. In any of these 
circumstances, it is well to stop the bleeding, especially if the patient grow faint; 
lest the depression become too violent. If, however, the faintness cease, and yet 
the pulse continue ihe same; or if the patient feel no relief; or if, when he has not 
fainted, but there has been an improvement of the pulse, the pulse should fall back 
into its former state; or if, again, there have been no syncope, no improvement of 
the pulse, but a great improvement in the patient's feelings,— a great diminution of 
the disease, and yet the pain all returns; — then, in any of these circumstances, we 
should let the blood flow again. In general, one never orders a particular quantity 
of blood to be taken away, in an acute disease; but is rather guided by the effects 
produced.'' 

We sometimes find, on bleeding, that the pulse, so far from diminishing, will in- 
crease in volume; and so far from becoming slower, will become quicker; and will 
still retain its firmness. This circumstance may be a very great improvement. 
There are some diseases in which the puUe is oppressed; — in which the pulse may 
be large and firm enough, but seems to have scarcely any activity in it. It is not 
a fluttering pulse; but it moves heavily, — if I may so speak. In what is commonly 
called " an oppressed pulse," there is plenty of volume, — plenty of firmness; but 
very little impetus. This is often the case in affections of the head. The pulse is 
frequently, at the same time, very slow, but is not necessarily so. A pulse may 
be oppressed, and yet not slow; or there may be a morbid slowness, and yet the 
pulse may not be oppressed. The one or the other may be the case; and yet, on 
bleeding, the pulse will rise. It will be sharper, or quicker, or both; and this is 
as much to be considered an improvement, as diminished force and frequency in 
other instances; and I would arrest the flow of blood in both cases. I would theri 
wait and see whether things relapsed; and even if they became slower, or heavier, 
but still having sufficient volume, — it would be advisable to let the blood flow 
again. 

* Dr. Alison, in his admirable Essay on Inflammation, in the " Library of Medicine," 
observes that "the efficacy of blood-leiiing in lessening the extent andinlensity of inflamma- 
lion, would appear to depend upon two i)rincip]es;"~to which, indeed, the powers of all 
other aniiphlogisiic remedies , are referable;— first, "it Aveakens the heart's action," and 
secondly, " it causes a derivation of blood from the affected parts." " In both ways ii dimin- 
ishes the quantity of living matter in which the peculiar changes comprised under the term 
^ injiammation' are going on; and whatever be the precise nature of the changes, as it is 
certain thai ihe blood is an agent esseniially concerned in them, ii is easy to understand that 
the greater the quantity of blood sent to the affected parts in a given limej the greater amount 
of these changes, and particularly the greater quantity of effusion from the vessels (with 
which we have seen that the danger of inflammatory diseases is most connected) will lake 
place." He treats the first principle by considering it under two heads; — in the first place, 
he shows that, under certain sthenic forms of inflammation, "the heart's acti(m is weakened 
by the absorption of the stimulus by which its motion is habitually excited and maintained," 
and this quiie in conformity with all iliat has been established by the labours of Dr. M. Hall 
on " the effects of the loss of blood;" — a man than whom medical science has known no 
greater benefactor in modern limes. Dr. Alison then proceeds to show "that the difference, 
observed, of the effect of blood-letting in the erect and hojizontal posture, proves that the 
loss of blood may powerfully affect the heart through the intervention of the central portions 
of the nervous system." The second leading division includes the principle of derivation; 
— abstracting a portion of the diseased blood from the inflamed parts, and thus lessening the 
diseased action. On the important question of blood-letting, as a remedy in inflammatory 
disease, we earnestly recommend to the reader the perusal of Dr. Marshall Hall's works on 
the loss of blood.— T. Williams. 



, INFLAMMATION. 121 

The repetition of bleetling, after an interval of some hours, or of a day, must 
depend upon the- same circumstances. When the pulse becomes quicker or fuller 
again, or the symptoms become worse, then we should follow the same rules in 
repeating blood-letting, as we originally did. In violent inflammation there is, in 
general, more difficulty in making a patient faint, than when the inflammation is 
less violent, or when there is very little the matter with the patient. I believe it is 
true that very frequently in inflammation, a degree of bleeding will not occasion 
fainting, which in health, or in a state not far from it, would produce syncope." 
This great princij)le was established by Dr. Marshall Hall. 

But although these are the general rules to be observed, it may be necessary to 
act in the very opposite manner. If a patient be very plethoric, so that it appears 
necessary to take a large quantity of blood; if it appear that, without copious de- 
pletion, the disease can only be temporarily subdued; and that all the symptoms 
may return, on account of the great fulness of the system; or if it so happen that 
the patient is nervous, and thus easily disposed to faint; — in either of these cases, 
it may be a great point to prevent syncope, before the desired quantity of blood has 
been withdrawn; and therefore it maybe right to bleed from a moderate orifice, 
instead of a large one; and. to make the patient lie down for some time, and then 
proceed to take away blood. If nervous fainting be expected, instead of syncope 
from the absolute loss of blood; — if it be likely to rise more from emotion of mind, 
than from the abstraction of blood, a small orifice should be made; and the patient 
should also be made to lie down: — in order that the depletion may be carried far 
enough to make an impression on the system. If fainting occur when one or two 
ounces only have been taken away, cupping or leeches should be employed. When 
a patient does faint in ordinary bleeding, the latter should be slopped, and the patient 
laid down; — lest the fainting become excessive. 

P?/7se.— Though a quick, full, firm, wiry, or jerking pulse, with the symptoms 
of inflammation, may justify bleeding; yet the absence of any of these states of the 
pulse, will not forbid bleeding, if the symp.tomsthemselves demand it. If there be 
no extraordinary debility of the pulse, — no feebleness of the constitution; if there 
be neither tender years, nor extreme old age; — if none of these circumstances for- 
bid free bleeding, we may have recourse to it, notwithstanding that the pulse gives 
us no such indication. The pulse may not indicate bleeding; but still it may jus- 
tify bleeding. The pulse (as we have already noticed'') has been called by 
Celcus "res fallacissima," — "the most fallacious of all symptoms;"*" and, if we 
depend on the pulse, alone, we shallbe led into error. The pulse will give us 
highly important information; but if there be a sufficiency of other symptoms to 
point out the nature of the case, — to show that the person is labouring under an 
inflammatory aff'ection, though the pulse would not lead to such a conclusion, we 
must treat the case in spitB of the pulse; — provided, however, that the pulse does 
not indicate such debility, as would evidently make bleeding improper; or that the 
constitution and age of the patient do not forbid it. In the most dangerous cases of 
peritonitis, — when the patient was obliged to lie upon his back, with his body and 
even his thighs raised, so as to relax the peritonaeum as much as possible; and 
where the abdomen could scarcely bear the pressure of the bed-clothes, — I have 
known the pulse scarcely difl*erent in volume, or force, from what it was in a state 
of health. Notwithstanding that the peritonaeum is a serous membrane, I have 
"witnessed the pulse without any great firmness, — any wiryness, — any jerking 
state;— without any thing that would lead to the supposition that there was disease 
of this investing membrane. We continually see females, in a state of pregnancy, 
"with a small pulse;— such as would prevent the thought of bleeding, unless there 
were other modifying symptoms; but from pressing the part aflected, we find 
bleeding indicated; and from attending to the countenance, and looking at the pa- 
tient, we see that bleeding will be borne. In the cases of peiitonitis to which 1 have 

» From o-yv, with; and xctttiw, to strike down. •» See Page Gl. 

« Book 3, Chapter C. 



i22 



INFLAMMATION. 



just referred, I have seen the blood, after it has been taken away, both buffed and 
cupped; and the patient has speedily recovered after a loss, perhaps, of forty, fifty, 
or even sixty ounces. But it is the same with every other symptom. The symp- 
toms should be taken together, and reliance should seldom be placed on any one 
alone. Every one is important in itself; but every one has also its relative value. 

General bleeding is superior to local bleeding. It is speedy, and it is powerful. 
However local the inflammation,— however remote from the heart (even in inflam- 
mation of the testicle, or of the finger in paronychia or whitlow), — venesection* is 
more powerful and far more quickly productive of an impression upon the disease, 
than any local bleeding. 

Venesection and Arteriotomy. — In afTections of the head, I believe that vene- 
section in the arm is just as good as arteriotomy.* The great point, in an acute 
disease, is simply to get a large quantity of blood from the system in as short a 
time as possible; and venesection in the arm will generally answer every purpose. 
At least, I have never seen any thing to make me prefer opening an artery, in a 
case of inflammation of the head, or inflammation of the eyes. 

If a vein cannot be opened*, then I would certainly, in any case of dreadfully 
violent inflammation, open an artery. It is always safe to open the temporal artery. 
If blood could not be obtained from a vein, in a very dangerous complaint, instead 
of troubling the patient with cupping or leeches, the temporal artery should be 
opened; I know that some practitioners have opened the radial artery. But 
opening the temporal artery is safe; and generally affords as much blood as is re- 
quired. 

Quantity of Blood. — I have never had occasion to take away more than thirty 
ounces of blood at a time; except in one instance, in which forty were required 
to induce syncope; nor do I recollect having had occasion to take away more than 
eighty ounces altogether, in an acute complaint. Of course, many hundreds of 
ounces in chronic complaints have been taken away; — pursuing small bleedings 
for many weeks, or months. It is right to mention, however, that some practi- 
tioners have taken away an immense quantity of blood, in acute diseases, in a 
very short time; and with success. In inflammation of the lungs, one hundred 
and fifty ounces of blood are said to have been abstracted in a few days. In the 
tenth volume of the " Medico-Chirurgical Transactions,""" Dr. Blundell states that 
Mr. Hensley (a gentleman on whom he could rely) declared that, in two cases of 
inflammation of the lungs in men, he had taken away a gallon and a half of blood 
in five days; and they both recovered. Precisely such a case is mentioned in the 
*' Medical Gazette," for January 3, 1829.'* Dr. Badely speaks of having taken 
away five quarts in five days, in a case of peripneumonia; and with perfect success.® 
If a case be very obstinate, and will not yield to proper treatment, we see what 
there is authority for doing; for the above are undoubted facts. I do not condemn 
such practice; but I have never had occasion to have recourse to such profuse evacu- 
ations. 

Red Particles Diminished. — Two Swiss physicians, Drs. Prevost and Dumas 
(of Geneva), who have made many experiments on the blood, say, that when 
blood-letting has been employed, the red particles are found, after a certain interval, 
to be fewer in number. There is not only a change, in the disappearance of the 
buffiness; but venesection lessens the number of red particles in the blood. We 
know, indeed, that when blood is taken away from an individual in health, its 
effect is to impoverish the blood. It is now ascertained, however, in a scientific 
manner, that the red particles are diminished; so that in blood-letting we not only 
diminish the mass of the blood, but also lessen its stimulating qualities. We lower 
its quality, while its quantity is diminished. 

» From " vena," a vein; and " seco," to cut. 

^ From a^Tnjta, an artery; and TS/oiva;, to cut, 

«: Page 307. 

d No. 57; Volume 3; Page 158. 

« See the " London *Iedical Gazette," for March 1, 1828. (No. 13; Volume 1; Page 368.) 



INFLAMMATION. 123 

General^ and Local Bleeding. — Besides genera? depletion, however, it is some- 
times necessary to have recourse to local bleeding. The latter is usually employed 
on account of the less violence of the general symptoms; the smaller powers of'ihe 
patient; and the existence of mere congestion of blood, rather than of inflammation. 
if the general state of the patient's system be not much disturbed; if there be no 
great excitement or fulness of the pulse; if the patient be very weak; if there be a 
great accumulation of blood, rather than inflammation; or if the inflammation be 
rather of a passive or atonic character; — then, in proportion as this state of things 
prevails, local bleeding is usually preferred to general. But I believe that, in many 
cases where loccd bleeding is had recourse to, general bleeding would be found 
to answer the same purpose. At any rate, we are never to allow local bleeding, 
which is perform.ed by cupping or leeches, to stand in the way of general bleeding. 
It is frequently a better practice, even if the patient be weak, to bleed generally 
than locally; — to set him upright in bed, or to make him stand upright; and from 
a large orifice to detract four or five ounces of blood, and thus produce a great 
effect, — than to apply a number of leeches, and drain away perhaps a larger quan- 
tity of the vital fluid. I am satisfied that general bleeding is continually omitted, 
when it might be more advantageously adopted; — when it would produce a much 
more decided effect, and give far less trouble. 

General followed by Local Depletion. — I believe that local, is often of great 
use immediately after general bleeding. We lessen the load of blood in the part, 
very materially, by immediately applying a large number of leeches, or by 
cupping. I consider that this is really good practice. General bleeding fre- 
quendy answers every purpose; but I think I have seen the symptoms disappear 
still more speedily if, after making a great impression upon the system, and 
lessening the force of the blood sent to the part, I lessened the quantity contained 
in the part, by adopting local bleeding. 

Local Bleeding. — Local bleeding may be employed to produce general effects. 
Tf it be carried very far, a patient may become debilitated by it, — become blood- 
less. A child, during the operation of leeches, may become exceedingly faint. 
We may produce these general effects by local bleeding; but it is usually a slow 
process, and the effects of local bleeding are often very local. In a case of pain of 
the head, I have seen leeches applied to only one temple; which has been relieved, 
while the other has not. Frequently, when a patient has had pain of the head, I 
have seen the occiput cupped, and relief obtained there, while the front of the 
head has remained as before; and when leeches have been applied to the front, I 
have known the occiput continue painful. This certainly is not invariably the 
case; but we perpetually find the effects of local bleeding to be very local. I am 
not contending against local bleeding. I employ it extensively; but I am always 
anxious that it should never supersede general bleeding, if the latter be necessary. 
It is much better to take a decisive line of conduct, — to make a strong impression 
upon the patient in an acute disease; and then local bleeding, if employed subse- 
quently, has a far greater eff*ect. It is to be remembered that, I have been speak- 
ing, hitherto, o^ active inflammation. 

Local bleeding will sometimes succeed best at a distance from the afl^ected part. 
I have known chronic inflammatory diseases of the head, that had resisted general 
bleeding, and local bleeding at or in the neighbourhood of the head, yield to 
cupping of the hypochondria, or leeches to the anus. Some think highly of 
bleeding at the foot. 

It is certainly a fact, that the detraction of blood from a distant part, is fre- 
quently of great utility; and many think of even greater utility than from the 
immediate seat of the disease. The ancients, or, at least, the older writers, were 
very fond of it, and supposed that a revulsion was produced; — that the blood 
immediately rushed from the inflamed part, to that from which the depletion was 
made. In this country, the circumstance has been too much overlooked. I iiave 
had cases of inflammation of the head, (as I shall mention hereafter,) where 
repeated local bleedings, even till the patient became pale, proved of no avail; but 



124 INFLAMMATION. 

on taking away blood from the sides of the trunk, — far enough from the head, — 
the relief was perfect, and the patients recovered. 1 liave had several cases of this 
description. There can be no doubt that the application of leeches to the anus, 
Avill frequently produce the most decided relief, in affections of the head, and indeed 
even of the heart. Whether it be more efficacious than local bleeding from these 
parts themselves, I can scarcely say. On the continent, this mode is commonly 
resorted to; but, from delicacy, it is not usual in tiiis country. 

Bleeding from the Jlnus. — When two or three parts are affected at the same 
time, — as, for instance, the head and stomach, — it is frequently a good practice to 
lake blood from the anus. One can easily imagine why great relief should be ob- 
tained from blood being taken away from that part. The veins there go to form the 
" vena porta;;" and therefore a great load is taken from the liver, — a great load is 
taken from the whole venous system; and less blood goes to the heart. As the 
haemorrhoidal veins run to assist in forming the *'vena portae," and the latter 
branches through the hepatic veins to the "vena cava inferior," far greater relief is 
sometimes obtained by this means, than by any other, in diseases of the heart, and 
affections situated within the chest, as well as in jrreat congestion within the head. 
Still, however, it is easy to make assertions in medicine and surgery; and one ought 
to have a large number of cases registered for comparison, — showing where relief lias 
been obtained, and where not, — before we draw any conclusions. General assertions 
are frequently not to be depended upon. Extensive and accurate observations are 
necessary, to enable us to say that one mode of treatment is superior to another. 
WMiether the same quantity taken from other parts would be more or less beneficial, 
I cannot say; but in affections of the head, I have been frequently surprised on seeing 
the benefit derived from taking away blood around the abdomen, or from the rectum. 

Fosition. — We may frequently diminish the quantity of blood in a part by 
position; and this is always to be attended to. Position may increase, or diminish 
the quantity of blood in a part. If a patient have inflammation of the foot, it would 
be madness to allow it to hang down; or if a patient have inflammation of the hand, 
it would be equally absurd not to have it kept in a sling. But these things may 
often be carried farther. In inflammation of the foot, it is often of use, not merely to 
have it on a level with the body, but to have it raised; and the same is the case with 
regard to the hand. In inflammation of the head, it would be absurd to allow the 
patient to lie with his head low. By attending to these points, though we are not 
doing any thing which will cure the patient, we are doing that which will enable 
other things to cure him sooner; and we prevent other things from being counter- 
acted. 

Purging, — To bleeding, in the way of evacuation, purging may be considered 
next in importance, 'i'his, although inferior to bleeding, is highly necessary; for, in 
the first place, it removes from the interior of the body a quantity of irritating fceces, 
which are almost always diseased, and will most likely become putrid if allowed to 
remain. We also are sure to find the secretions themselves diseased; in removing, 
therefore, the remains of food, we also remove such diseased secretion as would be 
more or less poisonous, or at least irritating. Besides this, we produce an evacuation 
of liquids from the vessels of the body; and likewise cause a counter-irritation in a 
part distant from the inflammation. In all inflammatory affections of the head, chest, 
and various parts of the body, the intestines are disposed to become torpid; the ex- 
citement occasioned by the inflammation, causes a depression of excitement in the 
intestines; and if their excitement be increased, so far as to brina- them into full 
action, — in a proportionate manner we tend to lessen the distant inflammation. It 
is right, however, not to give any stimulating purgatives; lest we should increase 
the general excitement. The point is, to give those purgatives which thoroughly 
empty the intestines of their contents, and subsequently to exhibit such as produce 
a considerable drain; but, at the same time, we ought to select those which eflect 
the object without great irritation. 

Irritation produced by Purgatives, — I must here remark, that because very 
diseased stools are produced, it does not follow that purging is to be continued for 



INFLAMMATION. 125 

the purpose of bringing the diseased excretions away; for there cnn be no doubt 
whatever that purgatives, especially if acrid, will cauSe a diseased secretion. If a 
person in perfect healtli take an acrid purgative, his faeces will not exhibit the 
healthy character which they presented, previously to the purgative being taken. 
There can be no doubt that many purgatives, especially if they possess any acri- 
monious qualitys will disorder the secretions, and produce a feti(l discharge from 
the intestines, which would not otherwise take place. It is not necessary that a 
patient should have diseased secretions, in intlammation and other diseases, before 
we administer purgatives. It is often not the case; and it is to be remembered 
that, after a time, when the faeces would otherwise assume their natural appearance, 
they may be kept in an unnatural state by the administration of purgatives. 

Repeated Evacuations. — The repetition of purgatives, as well as of bleeding, 
must be regulated by the violence of the disease on the one hand, and the strength 
of the patient on the other." 

Diaphoretics. — With respect to other evacuants, I do not think much of them. 
Venesection and purging are by far the chief diaphoretics. Sudorifics are not 
always good; for the skin will resume its healthy function, and the patient per- 
spire without them. If we bleed the patient well, starve him, exclude stimuli, and 
apply such remedies as I shall presenUy speak of, we may generally neglect the 
skin'as well as the urine. In inflammatory complaints, when the disease is com- 
bated, the urine will come round, without any direct means; and so will the skin. 
At any rate, stimulating sudorifics do great harm. With regard to antimony, — as 
it is generally exhibited in inflammatory complaints, for the purpose of producing 
a moderate diaphoresis, — we may just as well treat the patient without it. A kw 
drops of" vinum antimonii potassio-tartratis," in a saline draught, cannot do mate- 
rial good in a severe inflammation. So trifling is the power of small doses of this 
medicine, that I had patients at St. Thomas's Hospital, who took two or three 
drachms every three hours to show how it can be borne, without the production 
of any sensible effect whatever. The idea of a few drops of antimonial wine pro- 
ducing any serious eff'ect, in inflammation, is absurd. If the disease be combated 
with local and general bleeding and purging, small doses of it are just as well 
omitted as not; and I never think of saline draughts, or a few drops of antimonial 
wine, or any other such petty things, for the purpose of curing inflammation. 

Counter-Irritation. — There is, however, another plan to be followed, in the 
treatment of this disease;— namely, to exhibit counter-irritants, or (as they are 
called) "contra-stimulants;" in order to produce a strong impression upon the sys- 
tem. The chief of these are colchicum, digitalis, antimony in very full doses, and 
mercury. Iri violent inflammation, and indeed in many violent morbid states of 
the body, all remedial agents are opposed. In fever, or inflammation, or insanity, 
or spasm, we may give far larger doses of medicine than could be exhibited in 
health. In the violent pain of tetanus, for instance, an ounce of laudanum may be 
given. In inflammation, an ounce of digitalis in twenty-four hours has been given. 
I never did; nor have I given a scruple, or half a drachm, of the powder, in the 
same time. As to mercury, we may give a quantity which, in the same individual 
in a state of health, would induce the most violent ptyalism,'' and cause all the 
teeth to drop out. In violent inflammation, the eflect of bleedinir is resisted by the 
heart. The system is in a new state; and many things will not produce that etfect, 
which they would if it were in its natural condition. 

Digitalis. — Of the first of the contra-stimulants which I have enumerated, I have 
had no great experience. I have little or no knowledge of the use of digitalis in 
inflammatory diseases. I know that some say they can cure inflammatory affec- 
tions with it, unaided by venesection; — but I have really a horror of digitalis. I 
have seen so many people die suddenly under its use, that wheiher they died from 
it or not, it is a medicine of which I am particularly shy; and — knowing the effect 
of bleeding, together with some other remedies — I have not had recourse to it, in 

» From TTTvahi^M^ to spit. 



126 INFLAMMATION. 

any quantity sufficient to control the circulation. I have exhibited it in the dose 
of a scruple, or half a drachm of the tincture, three or four times a-day; no useful 
effects^ however, have resulted in inflammatory affections. 

Colchicum. — With respect to colchicum, there can be no doubt of its extraordi- 
nary powers in active rheumatism and gout. So strong an anti-inflammatory 
remedy as colchicum, must produce sweating, purging, and vomiting; and nausea 
has a great tendency to lessen inflammation. Nevertheless, I cannot state that I 
have been so satisfied with it, as to place much confidence in it. With the excep- 
tion of its employment in gout and rheumatism, its utility has not appeared to me 
so decisive, as to induce me to exhibit it in preference to mercury. 

Antimony. — Antimony may be given in far larger doses than could be imagined. 
It is now nearly twenty years since I found antimonial powder* to be, in general, 
a very inert preparation. I have seen others give two or three grains three or four 
times a day, or five grain doses at night, with the view of promoting perspiration; 
— ordering the patient, at the same time, to take plenty of gruel, to bathe the feet 
in hot water, and put plenty of clothes on the bed; and if he has sweated profusely, 
it has been all attributed to the antimony. Seeing these things, I was in doubt as 
to its powers; and I went on until the dose exceeded a drachm, and even amounted 
to two drachms, three limes a-day. This satisfied me that its want of effect could 
not arise from the remedy being resisted; and I therefore gave it to patients labour- 
ing under itch. It is well, when a patient is rubbing in sulphur, to give something 
internally, to gratify his wish to have his "blood purified." In the cases to which 
I am referring^, I gave the antimony with no effect. I once prescribed one hundred 
and thirty grains three times a-day, without its even producing nausea. The 
patient took it to see how far we might go. There was little the matter with the 
man; and as I found that he took one drachm, and then a drachm and a half, of 
antimonial powder, three times a-day, with no more effect than would have re- 
sulted from " powder of post," I gradually increased the dose, till he took the 
quantity I have mentioned. This fact shows the uncertainty of the remedy. It 
contains a great deal of phosphate of lime, and peroxide of antimony; and some- 
times it contains nothing else; but if given with calomel, it may sometimes pro- 
duce nausea. I will not say that antimonial powder, as it ought to be, is an inert 
remedy; but as it is commonly procured, it may be given in the quantity I have 
just stated, in a large number of cases, without any effect. 

In reference to "antimonii potassio-tartras," it may be given in large quantities. 
Many patients in St. Thomas's Hospital took half-ounce doses of antimonial wine, 
in chronic bronchitis, every four hours, without experiencing nausea. They said, 
when first takmg it, that it made them sick; but such a state did not continue. 
Many persons give twenty grains of tartar-emetic, in the course of twenty-four 
hours; and in inflammatory complaints, I have given two grains every two hours. 
This at first induces nausea or vomiting, which soon ceases, though, after gomg 
on for perhaps a fortnight, the patients may be sick again. It has not produced 
the salutary effect I expected. Colchicum and digitalis, like tartar-emetic, cannot 
be depended upon like mercury. I have given colchicum and antimony repeated 
trials; and I am not contented without great success in inflammation; because I 
think it ought, generally, to be cured. It is an established truth, however, respect- 
ing tartarized antimony, that in inflammatory diseases it may be given in large 
quantities; and that, although a patient may be made sick at first, the sickness 
will go off, and the remedy be borne. I have generally, however, seen the sick- 
ness come on at the end of about a fortnight; and then persist as long as the remedy 
was continued. 

In administering antimony, the object is to depress the system, by inducing 
nausea. The dose required, however, in different cases, to bring about this result, 
will vary with individual peculiarities of constitution. In some there is a great 
tolerance of its effects. This is exemplified, although not strikingly, in a case 

* " Fulvis Anlirnonii Compositus." 



INFLAMMATION. 127 

« 

which occurred at St. Thomas's Hospital, a bronchial inflammation with a tendency 
to tuberculous deposit. The employment of mercury being contra-indicated by 
the latter circumstance, antimony was given; and the patient took it for several days, 
at the rate of a grain every four hours, without the occurrence of nausea. The 
frequency of the dose was afterwards lessened. This in addition shows that anti- 
mony, like digitalis, may produce cumulative effects. 

Mercury. — I have instituted comparative experiments with antimony and mer- 
cury; and I am quite certain that the success of those who employ antimony, in 
addition to bleeding, is very inferior to the success of those who employ mercury. 
In violent inflammation, I really make it, a matter of conscience to employ mercury. 
If there be great danger, as in violent inflammation of the larynx, — \vhere the 
patient, if neglected, would die in a few hours, — I do not hesitate to give ten grains 
of calomel, every two hours. In this case, if we do not bring our means to operate 
very speedily, the patient will be suffocated in a moment; — he will fall back in bed 
(from oedema in the glottis), and the case will be over. In other instances, 
however, there is no occasion to be so active. Five grains every four hours will 
do" very well; or, perhaps, rather less. In a case where life appeared to be in 
danger every moment, I have given as much as a scruple, every two hours. 
These, however, are extreme cases; in which we are very sure that, if we do not 
instantly save the patient's life, he will slip through our fingers. If the mercury 
begin to run off by the bowels, it is better to unite it with opium. It very soon 
does this; and we see the necessity of resorting to opium; or, if there be an objec- 
tion to this remedy, we. might give an infusion of catechu, which is one of the most 
powerful astringents, xistringents in tinctures must be injurious in inflammation; 
and it is therefore better to give an infusion. Kino, as far as I know, is as good 
as catechu. If the calomel run off in spite of all we can do, "pilula hydrargyri" 
may be exhibited; but ''hydrargyrum cum creta" is still less likely to do so; and 
with this a person may be salivated very readily. It is stated, in some books, 
that salivation cannot be produced by it; but I have salivated many with it. A 
dose of ten grains may be given every two or three hours; but I think it has a 
greater tendency to produce sickness, than any other of the three forms of mercury 
we have mentioned. More patients become sick while taking "hydrargyrum cum 
cretii," than while taking either calomel or blue pill. It is frequently necessary to 
unite it with opium. 

Salivation. — It may be light, also, to rub in mercury externally, — on the ex- 
tremities and abdomen, — as quickly as it can be done; for the best plan is, to get 
the mouth sore as quickly as possible. It is right, at every visit, to examine the 
gums; and likewise to press the glands under the lower jaw, and smell the breath. 
The moment any symptoms of an affection of the mouth appear, the remedy 
should be suspended; — it certainly should not be continued. In some cases, the 
affection of the mouth will exceed the point desired; but it is better now and then 
to have a violent ptyalism, and save nearly all our patients, than to be fastidiously 
particular. 

When the mouth becomes too much affected, the chloride of lime, or of so^Ja, 
are the best applications. If one ounce of the solution be mixed with six or eight 
of water, and the patient's mouth washed with this lotion every hour, you wilt 
find that the ptyalism will readily subside. If ulceration have taken place, time 
is required to heal it. If we employ the chloride before ulceration has occurred, 
no subsequent soreness, from the inflammation of the mouth, takes place. It 
should be employed of a strencrth just sufficient t9 be felt by the patient. It is also 
to be remembered, that if we maintain, a free state of the bowels, there is much 
less danger of a violent affection of the mouth;*and if the mouth become affected, 
and we open the bowels freely, we generally diminish the affection to a certn.a 
extent.* 

» In the Meath Hospital, Dublin, great relief was found to ensue (in cases of excessive 
ptyalism) from the application of leeches below the angle of the lower jaw. 



128 INFLAMMATION. 

I can state, as a positive fiict, that if bleeding be properly had recourse to, and 
we produce a certain degree of affection of the mouth, it is very rare indeed for a 
patient with acute inflammation to be lost; — unless there be some organic disease 
which keeps up the irritation; or ujiless our efforts be counteracted by something 
wrong in diet, or by some violent emotion of the mind, which must be more than 
a match for all the best remedies. 

The use of mercury, I beg particularly to state, is not to make us employ less 
bleeding beforehand, or at the time of exhibiting it. So far as there is occasion 
for bleeding, it should be put in practice whether mercury or any other remedy be 
' employed; but it will be found that, as the mercury produces its effect upon the 
mouth, the necessity for bleeding will diminish. Bleeding is the great remedy, — 
the " sheet anchor;" we therefore should bleed according to the necessity of the 
case, without considering whether mercury is being administered, or not. But the 
addition of mercury causes the bleeding, which is put in practice, to be tenfold 
more efficacious, and so lessen the necessity for its repetition; but it can never 
become a substitute for bleeding. Dr. Armstrong used to say, that bleeding was 
the right arm, and mercury the left arm of medicine, in the treatment of inflamma- 
tion; — a pithy declaration of an important fact. 

I would strongly advise the perusal of Dr. Duncan's " Medical Commentaries," 
published in 1788. All we know now, relative to the use of mercury, was known 
then; though it has been considered, that the facts known, with respect to the use 
of mercury, in many local inflammations, were first generalized by Dr. Armstrong. 
The general fact is fully stated by Dr. Hamilton. It is singular how often many 
of us, who know excellent practical things, do not bring .them into use when we 
come into practice. It is a sort of inertness which is apt to come over us. The 
paper to which I refer, is by Dr. Hamilton, of Lynn-Regis. He says that he learned 
the use of mercury from a navy surgeon; — that having been informed by a navy- 
surgeon of the great use of mercury in inflammation, he gave it in pleuritis, in 
hepatitis, and other inflammations; which yielded in the most extraordinary manner 
under its use, — in a way that he never found before by any practice he adopted. 

Opium. — There are some cases, in which it would be very wrong to employ 
opium; — for instance, in phrenitis. But in cases where it is not specially contra- 
indicated, it is a practice with some to give a full dose of opium, after a copious 
venesection; and, as far as I know, it is a very good practice. Two or three grains 
of opium, after venesection to syncope, will frequently prevent the necessity of 
another bleeding; or, at any rate, will send the patient into a quiet sleep, by which 
he will be very much refreshed. Unless there be inflammation of the head, this 
practice is not objectionable. If the bleeding be likely to cause great irritatio-n, or 
if the patient be weak, it may be a highly proper practice. It may be wTong to 
omit it; because it may prevent that morbid irritability, — that restlessness which 
sometimes takes place after bleeding; but it ought not to take the place of mercury. 
The chief point should be, to endeavour to airest the inflammation by free bleeding, 
which, if it be thought advisable, may be followed up by the local detraction of 
blood; and a dose of opium may then be given. We should also be as anxious to 
give mercury, as though that were itself the chief remedy. Mere bleeding will 
cure many cases; and so will mere starvation; but if we give mercury, the excep- 
tions to a cure will be reduced to a very small' number indeed. With respect to 
opium, it is better to give one full dose, than repeated small doses; for it is found 
that opium has a stimulating eflect over the body. Hence the pulse becomes fuller, 
and there is thirst. Under smaH and repeated doses of opium, both thirst and 
heat will continue. Dr. Wilson Philip made experiments illustrative of this sub- 
ject. He applied, to a denuded brain, a small quantity of opium, and likewise of 
tobacco; and, on looking at the distant capillary vessels in the extremities, he found 
them very much excited; but if he applied a large portion of either of these ingredi- 
ents, he found the action diminished;— just the opposite effect. This demonstration 
of the effect of large and of small doses, is perfectly in harmony with what we all 
observe, when we give large and small doses of these remedies. A small quantity 



INFLAMMATION. 129 

of tobacco, for example, will excite feverishness; — will make a person hot and 
thirsty during the whole of the night; whereas a considerable quantity will depress 
the pulse, produce a cold, chilly sweat, and lower all the powers of life. So with 
respect to opium; if its sedative effects be wanted, it should be given in one full 
dose. This would be dangerous, if we did not bleed; but it is perfectly safe if we 
have depleted the patient copiously in the first instance. 

Excessive Depletion. — Supposing, however, (as is very likely to happen,) that 
the patient has been bled too much, even then we find opium of the greatest use. 
If too much blood has been lost, and the patient has headache, throbbing of the 
temples, frequent syncope, deadly faintness, great rapidity of pulse, vertigo, — and 
this is a state frequently seen in women who have lost a great deal of blood during 
or after labour, — then the chief remedy is opium. All these symptoms are much 
diminished by it. Stimulants, of which ammonia is one of the best, and good 
nourishment, are highly proper; but the extreme resdessness of the body is very 
much alleviated by the addition of opium. In such a case as this, if we cannot 
prevail upon the patient to eat, it is necessary to use the stomach-pump; and strong 
broth should be injected, both into the stomach and the rectum. 

Local Depletion. — But notwilhstandmg this state of the system, a local conges- 
tion of blood occasionally takes place; — so as to render it necessary to apply 
leeches. When the body has lost so much blood, that we are obliged to give 
ammonia, and nourishment, and opium, we sometimes find such a tightness of the 
head, — such a degree of heaviness from local congestion, that the application of 
leeches, or of ice, is indispensably required. These matters, however, cannot be 
learned minutely by precept. The requisite knowledge can only be acquired by 
personal observation. Cases present themselves in which the abstraction of four 
ounces more blood, would certainly precipitate the patient into the grave. 

Local Counter-irritants. — Mercury, co^chicura, and the other remedies men- 
tioned, are general counter-irritants; but in the treatment of inflammation, we have 
also frequendy to put in practice local counter-irritation; — that is to say, to set up 
a new action in the neighbourhood, or at a distance. I slated* that purgatives 
chiefly act in this way; — not only in removing a quantity of stimulating faeces, but 
by exciting the action of the intestines, and so far diminishing action elsewhere. 
But we also employ certain downright stimulants to the surface; and of these, 
blisters and sinapisms^ are perhaps the chief. 

Blisters. — It is best, I believe, to apply a blister on the surface over the internal 
part inflamed; — as over the right hypochondrium, in inflammation of the liver; 
and over the thorax, in inflammation of the lungs; but with respect to the head, 
this is a dangerous practice when there is any active inflammation going on. The 
application of cold to the head is beneficial in inflammation of the brain itself, or 
of its membranes; but early stimulating the vertex, by a blister, is highly injurious. 
Nothing can be worse practice, than to apply blisters to the top of the head in 
phrenitis, in the early stages of the disease; when, however, the patient has been 
sufl^icienUy evacuated, then such a measure is very proper. But with respect to 
other parts of the body, it is best to apply blisters immediately over the internal 
part which is inflamed. 

Sinapisms. — If it be desired to produce an eflfect rapidly, a mustard-poultice is 
one of the best applications. Some persons excite blisters, by causing the steam 
of boiling water to play upon the part; and others by putting boiling water in a 
jug, with a napkin in it, and suddenly inverting it; but I think a strong mustard- 
poultice, beat up with hot vinegar,'' will produce an effect as speedily as, in general, 
is to be desired. In young children, ordinary blisters are often very dangerous; 
and a mustard-poultice, — applied to the abdomen, or the back of the head, or the 
chest, — will produce as great an irritation as is desirable; and one which can be 

a See Page 124. 
b From "sinapis," mustard. 

c Some experiments at the Hotel Dieu have tended to show, that the mixture of vinegar 
rather diminishes, than adds to, the stinaulating properties of the mustard. 
VOL. I. — 9 



130 INFLAMMATION. ' 

controlled, by removing the sinapism, when the child expresses great distress. A 
niustard-pou]ti(;e, applied for ten minutes or an hour, over the chest or abdomen, 
oftentimes proves useful. 

Solution of Cantharides. — Some persons have introduced a solution of cantha- 
rides, as a substitute for blister-plaster. I made some extensive trials with it at 
St. Thomas's; because it appeared a desirable thing to be able to produce a blister, 
by merely varnishing a part with a brush. It is a much cleaner application than 
that of an offensively-smelling plaster, which a patient has to keep in bed with him 
for twenty-four hours; but it does not well answer the purpose. A blister was 
produced, but not imfhediately; — frequently not till the next day; and then, when 
it was going to heal, a fresh blister would arise. In many instances, a far more 
violent blister was induced than I desired; and sometimes it did not succeed in 
causing any vesication. Upon the whole, it appeared very unsatisfactory; I con- 
sidered it, therefore, preferable to continue the old practice, of applying a common 
plaster of cantharides. 

b. Monic and Passive Inflammation » 

Atonic Inflammation. — In that form of inflammation in which there is little 
power,— in inflammation which is called " atonic" (where there is not only in- 
flammation, but likewise a state of debility), — we must employ less evacuants, 
and trust more to mercury and opium. Where patients are debilitated altogether, 
I should certainly place great reliance upon mercury (combined with opium), for 
the purpose of lessening the morbid irritability of the system; and should make the 
evacuant means chiefly local. I should employ local bleeding; or perhaps should 
frequently trust much more to blisters, or the application of cold, than even to 
local bleeding. Still, as I mentioned before,* it sometimes may be a better prac- 
tice, even when there is debility, to produce a momentary effect upon the system, 
by causing fainting; — by taking away a few ounces of blood suddenly, in an up- 
right posture. But, as a general rule, when patients are of very weak constitution, 
one would trust more to local than to general detraction of blood. In these cases, 
while we take away blood locally, or. while we are producing syncope by the 
detraction of a few ounces, it may often be necessary to give good nourishment. 
When there is violent inflammation in a part, and litfle power in the system at 
large, it is not at all inconsistent to lessen the inflammation of the part by local 
evacuants, and by cold; and yet to support the whole powers of the system by 
beef-tea, milk, and other nourishing articles of diet. The latter, but not stimulants, 
are admissible. 

Passive Inflamm,ation, — The same remarks apply to what is called *^ passive 
inflammation;" — that is, when a part is not actively inflamed, but rather in a state 
of congestion; aud the affection is not so much in the constitution, as in the part 
itself. In inflammation of the throat, where the throat is very much swollen, and 
of a dingy colour, without active symptoms; and frequently in inflammation of 
the eyes, in which there is more congestion than real active inflammation, local 
means are by far the best. It is not desirable to produce an impression on the 
system; but to unload the part, — to remove the congestion of blood; and therefore 
local means are exceeding^ly proper. In such cases, even stimulating applications 
to the parts are useful. They are in a state of atony; and by stimulating applica- 
tions, and by astringents, we may frequently remove the unhealthy condition, even 
better than by mere local evacuations. 

It is of the highest importance to make a correct diagnosis between an active 
inflammation, and one of an atonic kind, and a state which is hardly, perhaps, 
to be called "inflammation." After an inflammation has been very active, the 
symptoms will continue; but they are very much modified; — being attended with 
great debility, and great morbid irritability. Here the remedies of inflammation 

» See Page 123. 



1 



INFLAMMATION. 131 

will make bad worse. It is necessary to remember that, in almost every case of 
inflammation, this stage may arrive; and it is also necessary to remember, that 
this set of symptoms may happen in the first instance; — bearing so great a resem- 
blance to inflammation, that one not practised in it might fall into error. This 
particularly occurs in inflammation of the brain. Cfiildren sometimes display 
many of the symptoms of arachnitis, or acute inflammation of the membranes of 
the brain (" hydrocephalus acutus"), but without that disease; — we see patients 
labouring under sudden and violent delirium, without the presence of inflammation; 
or at least so little, that debility, inducing morbid irritability, is the prominent 
feature of the attack; and if, in these cases, blood were taken away, life would 
most likely be destroyed. The mode of distinguishing these cases, is by observing 
that there is no great pain; or that, if there be any pain, it is slight and transient; 
and that, in the next place, the pulse, although it may be quick, is feeble; — it is not 
a pulse which, upon careful examination, would appear to justify us in resortmg 
to depletory measures. Then, again, the surface is frequently by no means hot; 
or, if it be hot, it is only so in a transient manner; and the expression of the face 
altogether is one of weakness. I shall have to speak upon this subject at greater 
length, when, in the consideration of particular diseases, I come to treat of hydro- 
cephalus and delirium tremens; but in every case of inflammation it is possible, 
that after we have treated it actively, and subdued its active nature, the patient may 
fall into a state of morbid irritability; and local symptoms, though not of an active 
kind, may still exist. We can judge of it only by finding that, whatever local 
symptoms there may be, still the pain is not sharp; that if not gone entirely, it 
is much reduced; and that the pulse is one which will not justify bleeding. There 
is a degree of feverishness, so that the pulse may be very rapid; but still it is a 
pulse of irritability; — one that may be almost extinguished by the finger; and an 
expression of feverishness is observable. 

^Administration of Stimulants. — In these cases, we must no longer go on with 
evacuant means. They are highly dangerous. It is necessary to administer good 
nourishment, and even stimulants; and sometimes to give opium. Such a case 
may occur, not only after excessive bleeding, but after inflammation has subsided 
spontaneously. It is particularly seen in children, in spurious hydrocephalus* (if 
I may so call it); and likewise in delirium tremens (a spurious sort of phrenitis); 
•^not invariably, however; but in many instances. In such cases we have some- 
times even to give wine, and also brandy; but the utmost care is required, and 
we continually meet with cases, in which we cannot satisfy our mind how far 
active inflammation may still exist; or how far it is a mere case of irritation; — 
where we may sit anxiously pondering over every circumstance, and be unable 
after all to determine what course to pursue. In these instances, I should advise 
a combination of both plans; — that is to say, support the strength, give moderate 
stimuli with the greatest caution, and anxiously watch their effects; and, at the same 
time, cautiously employ evacuants locally. After the use of any remedy, we should 
carefully observe the effects; and draw our conclusion from its action. For ex- 
ample: if leeches were applied while giving nourishment, it may be soon seen, 
by the effects, which is the more proper; and that must be afterwards steadily- 
pursued. 

c. Chronic Inflammation, 

With regard to chronic inflammation, its treatment must depend entirely upon 
the circumstance of its being active or passive. We have little to do wilii the 

a This slate of the system frequently involved the physician in confusion and malapraxis, 
previously to the discovery of its true nature, by Dr. M. Hall and Dr. Gooch. Dr. H;ill, 
by whom these affections of children were first described, called them '•hydrocephaloid 
diseases." He has graphically shown them to depend upon an exhausted and anffininted 
condition of the body, — the very opposite of that which accompanies inflammation; and re- 
quiring, therefore, remedies of an opposite character;— support and nourishment, rather 
than depletion.— T". Williams. 



132 INFLAMMATION. 

duration of ihe romplaint. We are not to consider whether it is acute or chronic; 
but whether it is active or passive; and what are the powers of the patient. We 
frequently have occasion, for example, to bleed in rheumatism which has existed 
for a year or two. I have met with cases where, after rheumatism has existed 
two or three years, the parts have been so hot that it would iiave been vain to 
attempt to cure them without local bleeding. It is true that, when the disease has 
continued 50 long, the powers of the patient will seldom be very great; but we 
are not to consider what is likely to be the case, but to ascertain what the patient's 
powers really are; — what is the degree of activity of tlie disease; and what pro- 
portion it bears to the strength of the patient. In these chronic cases, we shonld 
make use of chronic remedies. We can apply, not only leeches and cupping- 
alasses from time to time, but also means which are not serviceable in active in- 
flammation; — that is to say, issues, setons, and caustics, — so as to produce external 
ulceration. In acute inflammation, whatever is done must be done rapidly; but 
in the chronic form, we can apply setons or moxae; — we can burn the part, or 
apply caustic and repealed blisters, or keep blisters open; and we can also produce 
great irritation by the application of tartar-emetic. Any of these applications may 
be serviceable in the highest degree. 

Nitrate of Silver. — There is one form of caustic which is frequently of great 
nse, even in certain acute inflammations, which is nitrate of silver. In certain in- 
flammations of the skin, the application, wetted and rubbed on the part, or a strong 
solution applied with a brush, is frequently of great use. There is sufficient testi- 
mony in its favour; but I have not employed it extensively myself. In one form of 
violent inflammation of the skin, however, I have made a circle all round the in- 
flamed part. I have not touched the inflammation itself, but a certain portion all 
around, — so as to blacken it; and I have seen it put a limit to inflammation, which 
threatened to spread to a great extent. Inflammation is thus arrested which, in all 
probability, would have run on to destruction of life. 

Organic Diseases. — I have remarked* that, in acute inflammation, wben deple- 
tion (both general and local) has been carried as far as is admissible, — the pulse 
being still quick and compressible, with considerable irritation, — there is reason to 
suppose that the case is now one of irritation; and we therefore have to support the 
"patient well; — perhaps to give stimulants, and quiet him by opium. So, too, in the 
treatment o{ chronic inflammation; when we have persevered for a great length of 
time; and when, notwithstanding all we have done, — constant evacuations, — con- 
stant draining, — constant abstinence, we find that the signs of local inflammation 
still continue, we have reason to suppose there is something more than mere in- 
flammation; — that it is not simply chronic inflammation we are treating; but that 
there is organic disease, which keeps up this chronic inflammation. In disease of 
the liver, it is impossible, for the most part, to say whether there is mere chronic 
inflammation, or organic disease of various descriptions, as tubercles, unless we can 
feel tubercles forming upon its surface, or can feel a considerable enlargement of the 
oro-an. It is only when we find, notwithstanding all the rational means employed, 
that no progress is made against the disease, we begin to suppose that there is some- 
thing more to be dealt with than inflammation. 

In this case it is wrong to go on with mercury, or with antiphlogistic measures, 
to any extent. Such measures only increase the mischief. The patient must be 
well supported. For the most part, he will gradually sink under his complaint; 
but we must take care not make him sink sooner than he otherwise would. In 
tubercular, and most other organic diseases, by supporting the patient well, tran- 
quillizing him with opium, and attending to the general state of the constitution, we 
may protract life, and mitigate suflering; although we cannot cure the disease. If 
we take it up too hastily, inflammation that might otherwise be subdued, will not 
be overcome; but if it be taken up too late, and the disease be treated as inflamma- 
tion that may be subdued, dissolution will certainly be hastened, and the patient 
will sink so much the sooner. 

» See Page 131. 



INFLAMMATION. 133 

d. Terminations of Inflammation. 

In the treatment of what are called " the terminations of inflammation," it is well 
to remember what I stated formerly;'' — that it does not necessarily happen tliat the 
inflammation ceases, because the (so called) "terminations'' take place. They are 
circumstances which take place; but the inflammation does notecase because these 
circumstances occur. When any of these circumstances take place, — as effusion, 
suppuration, or mortification, — we must always inquire whether inflammation is 
still present or not, and if it be present, to what extent; and likewise of what 
character, — whether active and tonic, or attended by debility; for the same remedies 
may be necessary, as were requisite in the treatment of mere inflammation, before 
these " terminations" took place. We have to treat the inflammation present accord- 
ingly as it is active, or more or less passive; as it is tonic, — attended with strength 
of constitution; or according to the power of the constitution, whatever may be 
the activity of the part itself. 

Effusion and Suppuration.— '^ e have also to treat efl'usion and suppuration as 
inflammatory or not inflammatory; because there is sometimes no inflammation. 
If it so happen that fluid is generated, — whether that circumstance has taken place 
which is called "efl'usion;" and which is merely an excessive secretion or collec- 
tion in a serous membrane; or whether suppuration has taken place, so that matter 
has collected, — in either case, it may be necessary to let out the fluids; because fresh 
symptoms may arise from their pressure. This is frequently necessary in a collec- 
tion of pus; and also in the case of mere eflfusion, or of fluid collection, in a serous 
membrane. We may liberate the lungs, and avert impending danger, by allowing 
the escape of fluid efl'used in great quantity into the thorax; and some say we may do 
the same with respect to the pericardium; but of that I never knew an instance. It may 
sometimes be necesary in the case of the peritonseum. With respect to pus, how- 
ever, the escape of it by art is of the utmost importance; because it not only injures 
by its mechanical pressure and distension, but frequently causes great mischief to 
the constitution, by its peculiar properties. If the matter be confined, the system 
is sometimes in a state of great depression (the tongue brown, and the pulse feeble); 
but on making a free incision, and letting out this fluid, the constitution will rally, 
— perhaps in the course of a day. When there is a mere collection of serous fluid, 
(whether diseased or not), diuretics are frequently very useful; but for the most 
part, the remedies of inflammation, moderately continued, are among the best 
means. By still giving mercury, and by continuing low diet, we cause absorption 
of the fluid to take place; and, what is-much better, we prevent its increase; and 
if we can but effect that object, nature, in a large majority of cases, will herself 
accomplish the evacuation. Among the remedies that answer both purposes, col- 
chicum and digitalis will be found useful. They will perhaps lessen the action that 
is going on, keep down the fluid, and also tend to lessen previous eflfusion. Col- 
chicum — owing to its exciting the kidneys and alimentary canal — is particularly 
suitable; and so is mercury. 

Nourishment ivithout Stimulation. — If a discharge has been accomplished by 
art, or if nature herself have efl'ected a new opening, then we find it necessary to 
support the constitution well, for the purpose of enabling her to bear this copious 
discharge; but still it is frequently necessary to adopt more or less of an antiphlo- 
gistic regimen; — to give abundant nourishment; though not, indeed, of a stimulat- 
ing kind. 

Ulceration. — We may see good reason for not supposing that the necessity ot 
antiphlogistic treatment is over, even in the instance of ulceration and of mortifica- 
tion; which are also called "terminations of inflammation." An ulcer is frequently 
due to nothing more than the surrounding inflammation. In the case ol a sore 
nipple, I have oftentimes seen this. When the breasts have been so sore, that the 
mother dreaded the agony of suckling her child, the ulceration has frequently been 

* See Pa^e 93. 



134 INFLAMMATION. 

cured, by merely applying leeches at some little distance from the spot, but still on 
the breast; — subduing the inflammation there, and afterwards keeping it down. So 
in the legs; — it is very common for an ulcer to take place in them, and yet not to 
heal; simply because there is so much inflammation around. Here plasters and 
ointment are of no use; but if we bleed the patient well, and purge him, we take 
oflf the tension and fulness of all the vessels. We subdue the inflammation, and 
then nature has power of her own to heal the ulcer. It may be just the same with 
respect to all the terminations of inflammation. 

Mortification. — Even in mortification, we have to consider whether or not in- 
flammation is going on; and whether it is attended by tolerable strength of con- 
stitution, or not. Inflammation may attend mortification after it has begun, and 
when it is decidedly going on. The inflammation may be really active; — there 
may be great redness of the part, great pain, and great heat; and there may be 
tolerable strength of the constitution at large. On the other hand, the inflammation 
may be more of a passive kind; — the part may be dingy, swollen, and not in much 
pain; and the constitution may be in a deplorable condition as to strength. It is 
often necessary, particularly in mortification, to employ local'antiphlogistic means, 
while supporting and sustaining the system at large. The system itself is in a 
bad state; and therefore we have to give the best of nourishment, and perhaps 
wine, or even brandy; whereas the part itself is disposed to run into a state of 
excitement; and mischief arises from such treatment, unless we prevent the action 
of the part itself; — perhaps by the application of leeches, or of cold. Occasion- 
ally, in mortification, it is wrong to employ soothing measures. We must adopt 
means of the most stimulating description; but it is to be remembered that, fre- 
quently, the more we stimulate the part, the greater will be the mortification. If 
there be great irritation, a poultice of carrots or turnips answers a very good pur- 
pose. The more we irritate, in many cases, the greater will be the extent of the 
mortification. If, however, a stimulus be absolutely necessary, I consider the oil 
of turpentine the best. Sulphuretted oil is often very good. When the constitu- 
tion was well supported, I have seen the mortification stop, apparently through 
these applications; but these things are to be employed only when there is no vio- 
lence of local inflammation. 

Fcetor. — It is always an object to prevent the gangrenous parts from injuring 
those which are not yet in a mortified condition. There can be no doubt that 
putrid animal substance is, in the highest degree, poisonous; and it is very neces- 
sary to prevent it from acting on the living part, and also to prevent the stench 
which proceeds from it. The latter may be removed, pretty easily, by charcoal- 
powder put into a fermenting poultice. Stale beer-grounds and yeast are very 
serviceable; but, above all, I should recommend the chloride of lime, or of soda, 
to be continually applied. In using these applications, however, it is necessary to 
remember, that they must be continually applied; — not two or three times a day; 
but as one portion of the solution of the chloride dries, so a fresh portion must be 
employed, — to counteract the putrescent tendency. For the most part, they are 
inefficiently employed; and, unless you look after nurses and attendants, they will 
not apply them sufficiently to remove the stench. 

Bark, Ammonia, and Musk. — In mortification, bark was formerly much prais- 
ed; and was even thought to be a specific. But that cannot be the case; for there 
is sometimes great excitement of constitution, — requiring antiphlogistic means. 
At other times, however, in an opposite state of the system, — where there is mor- 
tification with debility, — bark may be of great use, and especially sulphate of 
quinine; for, in mortification, it is common for the stomach to reject bark. I have 
frequently seen mortification apparently arrested by a combination of musk and 
ammonia. I say ^^ apparently f^ because, in such a case, it is our duty to support 
the constitution. Musk and ammonia united, and given every hw hours, have 
been particularly extolled by some practitioners. In nearly all these cases of 
mortification, opium is useful. There is great general suffering, — great general 



INFLAMMATION. 135 

restlessness; and it is an object to lessen the suffering, and tranquillize the system 
at large. 

Amputation. — It might be supposed, that the removal of the gangrenous part 
would put a stop to the mortification. On reflection, however, it will appear to be 
bad practice. The mortification of a part depends, generally, upon the state of the 
constitution; and the fresh wound caused by amputating (he mortified part, will 
fall into the same condition; because it is not the part that is so much in fault, as 
the constitution. If, however, the mortification depends entirely upon local cir- 
cumstances, the mortified part may be cut off with safety. Supposing an artery 
has been injured to such an extent as to cause its obstruction, and that the part 
supplied by it dies from the want of blood, the part may be removed without any 
danger whatever of the disease spreading; because the mortification depends upon 
a local cause, and not upon the constitution; and the fresh wound will not fall into 
the same predicament as the mortified part. In almost every case, however, where 
the mortification does not depend upon a local cause, it is the best practice to wait 
till nature herself has pointed out tliat the mortification will not spread; — till a line 
of separation has begun; and till we see that the powers of the constitution are 
sufficient to repair the injury;'— that the constitution is not in a condition for the 
mortification to spread higher up; but that, on the contrary, nature is capable of 
the healing process. Then we remove the part, and effect the object that nature 
herself was carrying on. It is of great importance, in the treatment of mortifica- 
tion, to recollect these few particulars. 

e. Specific Inflammation. 

The observations that I have now made refer to common inflammation; but I 
stated that inflammation may also be specific; — and that we term inflammation 
*' specific," when it runs a very peculiar course, or arises from a peculiar cause. ^ 
Gout is termed " a specific inflammation;" because it runs a very extraordinary, 
and very peculiar course. Small-pox is also an instance of specific inflammation. 
It not only runs a peculiar course; — beginning on a certain day, and undergoing 
certain changes on others; but it arises from a special cause, which will produce 
no other disease. Gonorrhoea, also, is a specific inflammation; — having its origin 
in a cause that will induce no other disease. 

Prophylactic Treatment, — We sometimes adopt prophylactic measures, and 
can prevent these affections altogether. Small-pox may be prevented, in the ma- 
jority of instances, by the cow-pock. 

Specific Remedies. — For some of these diseases we have a specific remedy. 
For itch, which is a specific disease, sulphur is the remedy; for syphilis, mercury. 
For the greater part of these specific inflammations, however, we have no specific 
remedy; and even if we had, it would still be of the highest use to treat them on 
the principles of common inflammation. Even where certain remedies are at com- 
mand; — as in the case of itch or syphilis, — we must, notwithstanding, keep in view 
the remedies of common inflammation; because it must be recollected that specific 
is common inflammation, with something superadded to it; and by adopting com- 
mon treatment, in addition to specific, the cure is much accelerated. 

Mixed Inflammations. — Some inflammations are specific at one time, and not at 
another. There can be no doubt, that, in general, ophthalmia is not a contagious 
disease; but we have every reason to believe that sometimes it is. Even erysi- 
pelas has appeared to be contagious. I think I have seen a person die from erysi- 
pelas caught in this way. Some strong reasons (which I shall notice more par- 
ticularly hereafter) for supposing it to be contacjious, will be found in a paper 
published by Dr. Wells, late of St. Thomas's Hospital. Catarrh is sometimes 
specific. A common " cold" is an instance of common inflammation; but now and 
then there is an epidemic catarrh, which depends upon some peculiar cause in the 

* See Page 111. 



136 HEMORRHAGE. 

atmosphere, and not on the common causes of inflammation. It is a singular fact, 
that inflammation may be specific at one part of its course, and not at another. 
Gonorrhoea is an instance of specific inflammation fit first; but no doubt, after a 
time, it ceases to be contagious. When that time arrives, we do not know; and 
therefore it would be bad policy to speculate on the presumption of its having oc- 
curred; but I think it is pretty certain that inflammation in the urethra, sufficient to 
keep up a discharge, will continue long after any contagion is to be feared. 



CHAPTER II. 
HEMORRHAGE. 



Not only do the essential symptoms of inflammation (such as swelling and paiii) 
sometimes arise from other causes; but even other circumstances that usually 
occur in the course of inflammation, and what are called its " terminations," are 
sometimes present without it. Among the circumstances which take place in the 
course of inflammation or its terminations, are discharges and collections. These 
may sometimes be mere results of inflammation, or closely connected with it, and 
sometimes they may occur without any inflammation at all. One of these dis- 
charges consists of blood; another is a discharge of mucus; another is not a dis- 
charge, but a collection of serous fluid. A discharge of blood is called haemorrhage; 
a discharge of mucus is called a Jlux, or a catarrh, or a gleet, or a prqfliivium; 
and an excessive collection of serous fluid, that cannot be discharged, is called a 
dropsy. 

[The term ^^ hsemorrhage^^^ signifies the bursting forth of blood from the living 
body; — the escape of the blood from those vessels in which it is always contained 
in a healihy state of the system. 

In the present day a very large class of important diseases is collected together, 
and described under this title, — ^^ Haemorrhage.''^ Whether the extravasated 
blood escapes from the body by some of the natural external openings, or remains 
pent up in some closed cavity or viscus; — whatever may be the cause of the extra- 
vasation of the blood, still the morbid phenomenon would, in the present state of 
medical science, be classed among the hsemorrhages. It frequently happens that a 
very considerable loss of blood is sustained, in consequence of some accidental 
injury of the arteries or veins, or by ulceration of their coals. Whenever the ves- 
sels so injured, or the trunks from which they arise, are v/ilhin the scope of the 
senses of sight and touch, the surgeon is called upon to arrest the haemorrhage by 
the application of the ligature. It is not our intention to consider any of those 
forms of haemorrhage which more properly belong to the province of surgery; we 
simply state, that all those haemorrhages which are consigned to the care of the 
surgeon, are the result of ap})reciable injury of the blood-vessels. Those forms of 
haemorrhage which are usually committed lo' the care of the physician, are much 
less perfecUy understood; they frequently take place without any perceptible alter- 
ation in the anatomical condition of the part whence the blood escapes; and are 
therefore controllable with less facility and certainty. They arise from some 
pathological condition of the body itself, and may be entitled spontaneous.^^ 

Tissues from which Haemorrhage occurs. — There is scarcely a structure of the 
body which may not sufler from the spontaneous effiision of blood from its vessels. 
Haemorrhage frequently occurs in inflammation of a mucous membrane — particu- 
larly of the mucous membrane of the intestines and of the urethra, and less fre- 

* From aTfAct, blood; and pnyvufuti, to break forth. 
•> " Library of Medicine;" Volume 5; Page 1. 



H-EMORRHAGE. 137 

quently in inflammation of the bronchia; but it is a common occurrence to see the 
most violent inflammation of a mucous membrane, without the escape of a single 
drop of blood. Why it happens that inflammation of a mucous membrane should, 
in one case, be attended by haemorrhage, and in another not, I do not think we 
can explain; but such is the fact. A discharge of blood, whether profuse or not, 
will frequently take place without any violent inflammation. We see that inflam- 
mation exists; but we cannot believe it is the sole cause of the hremorrhag-e. That 
the haemorrhage is accompanied by inflammation, is all that we feel justified in 
saying; nor can it be stated that it is the result of an inflammation. 

Although it is generally the mucous membranes which pour forth blood, the skin, 
without any abrasion, has been known to do the same. I never saw an instance 
of the kind, but I have read of bloody sweats; and they occur in persons who have 
been bitten by some poisonous animals. Curious cases are to be met with in 
authors, of blood oozing from various parts of the body. In an American journal 
there is an account of a person from whose cheek blood suddenly oozed in consider- 
able quantity, without any abrasion. 

Vicarious Discharges. — Ulcers will frequently afford a great quantity of blood; 
but this especially occurs in women whose menstruation is deficient. 'Fhere have 
been some curious instances of the vicarious discharge of bloody fluid. If menstru- 
ation be suppressed, it is not uncommon for an ulcer to break out on the legs, and 
to bleed once a month; or, if there have been an ulcer before, it may take on a 
bleeding character. I have seen haemorrhage from the chest take place in the same 
way. Haemorrhage has taken place once a month; simply because the menses 
were suppressed. 

On some occasions, though rarely, haemorrhage occurs from the serous coverings 
of the lungs, heart, brain, and abdominal viscera. Jt likewise occurs in the cellular 
tissue of many parts of the body; as in the parenchyma of the brain, lungs, liver, 
and testicle. 

Mode of Escape of the Blood. — [It wnll be interesting, and productive of a 
better understanding of the pathology of haemorrhages, if we first consider the 
conditions under which the blood escapes from the vessels of the different tissues. 
It is true that haemorrhage from some of the before-mentioned organs, — as the sto- 
mach, the intestines, the lungs, and the brain, — does occasionally result fnmi the 
rupture of some vessel or vessels of cognizable magnitude; but it is no less certain 
that, in by far the greater number of these spontaneous haemorrhages, there is no 
lesion of structure, either of arteries or veins, so far as the most careful dissection 
informs us. To "break or burst a blood-vessel," in the most literal meaning of 
those words, is thought by the public, and by some at least of the profession, to be 
a misfortune of very common occurrence; yet, relatively to the frequency of haemor- 
rhage, it is certainly a very rare one. (" Cyclopasdia of Practical Medicine.''^) 
The opportunity here afforded of dissipating a widely entertained error, ought not 
to be neglected; and we shall therefore not hesitate to reproduce the principal ar- 
guments by which the doctrine of haemorrhage by exhalation is supported. A^s 
haemorrhages from mucous membranes are far more frequent than from other tissues, 
so will they afford us the readiest means of establishing this principle in pathology. 
Thus, where haemorrhage has occurred so profusely from the stomach or bowels, 
that the death which ensued has been sufficiently accounted for by the mere loss of 
blood, the whole tract of the alimentary canal has been diligently examined, and 
has exhibited no breach of surface, nor any perceptible alteration of texture. Some- 
times the mucous membrane appears, here and there, of a red colour, and (as it 
were) surcharged with blood: sometimes it is pale and transparent, while the vas- 
cular network, visible immediately beneath it, is jjorged and turgid; sometimes the 
whole is colourless, — the same network of vessels having been completely emptied 
by the previous haemorrhage; and sometimes, again, (and this is illustrative ol the 
mode by which the blood has issued,) vast numbers of small dark-coloured masses, 
like grains of fine sand, can be made to start from the surface of tlie membrane by 
slight pressure. There can be no doubt that these are minute portions oi blood, 



138 HiEMORRHAGE. 

which had remained and coagulated in the vessels or apertures forming the ultimate 
channels of the h?emorrhage. (Watson; Andral's " Precis de Pathologic;" Volume 
2; Page 151.) Numerous and conclusive observations, of a similar kind, might 
be cited from the records of morbid anatomy, which is so extensively cultivated in 
the present day, and in this way direct proof is obtained, not only that haemorrhage 
may take place from the surfaces of internal mucous membranes by exhalation, but 
that this is the mode in which it most commonly happens; — that the effusion of 
blood by any of the natural outlets of the body, can seldom be ex{>lained by the 
detection of any rupture of the coats of a blood-vessel. Bichat also supported this 
doctrine of haemorrhage by exhalation by the following considerations; which, 
although full of physiological interest, are by no mearis so convincing as the former. 
He states, that if the uterus of a female who dies during menstruation be carefully 
examined, we cannot discover either any actual erosion of vessels, or any of those 
scars which ought to be so numerous, if at each menstrual period the uterus were 
re ally the seat of so many successive lacerations of its internal membrane. It may 
b.; observed, however, that the process of menstruation cannot be looked upon as a 
morbid process; as in the unpregnant female, during a certain portion of her life, it 
is not only consistent with perfect health, but actually essential to it; and as the 
fluid so poured out is not strictly blood, the analogical argument drawn from the 
preceding facts in favour of haemorrhage by exhalation, though it may afford a strong 
presumption, is not decisive. But any deficiency in the cogency of the two pre- 
ceding arguments, is supplied by the careful observation of those rare but well- 
authenticated cases of cutaneous haemorthage, where a dew of blood appears upon 
some part of the surface of the body;' and which, being wiped away, again appears, 
without any perceptible change in the bleeding surface beyond a blush of redness. 
But it is not only from the observation of mucous membranes and the skin pouring 
forth blood from their surfaces, that we are assured that haemorrhage takes place by 
the process of exhalation. Bichat states, that he had upon many occasions scru- 
pulously examined the internal surface of tlie peritoneum, of the pleura, and of the 
pericardium, in cases of haemorrhage from those membranes; and that their surface 
appeared to him entirely free from any laceration; so that it was very evident to 
him, that the exhalants had poured forth the blood, in place of the serum which 
they previously secreted.**] 

When haemorrhage occurs from a mucous membrane, I believe it is, for the most 
part, from a large number of minute vessels. The profuse haemorrhage which may 
lake place in a very short time, — so as to prove fatal in a minute or two, — without 
any vessel whatever being found injured, is surprising. I distinctly recollect having 
a patient with some pulmonary disease, who was sitting up in bed. Suddenly 
blood came from his mouth; he fell back, and was dead. On opening him, we 
found the stomach filled with blood; — there was an immense coagulum, exactly 
forming a mould of the stomach; but, after examining every part of that organ, with 
the most minute attention, I could not discover the orifice of any vessel whatever. 
The same has been observed in the case of the pericardium. I think it is mentioned 
in Dr. Baillie's work on " Morbid Anatomy," that cases have occurred, both in 
mucous and serous membranes, in which he was unable to find a vessel which ap- 
peared to have poured forth blood. The pericardium, for example, will suddenly 
allow the escape of an enormous quantity of blood. 

p* If it be demonstrated," says Chomel, " that there docs not exist any rupture 
of the blood-vessels in these cases of haemorrhage from the mucous and serous mem- 
branes and the skin, there remains open to us, in the present state of medical 
science, only one mode of explaining the escape of the blood; — it can only take place 
through the same channels as pour forth the mucus, the serum, and the sweat." 
(Didionnaire de Medexine.) There seems no more necessity, under the action 
of disease, for a rupture of vessels to give exit to the blood, than to give exit to 
these fluids. What the vessels or outlets to which we give the name of "exha- 

» " Library of Medicine;" Volume 5; Pages 2 and 3. 



HEMORRHAGE. 139 

lants" are, how they are distributed and arranged, in what manner they are con- 
nected with the ordinary capillary circulation of red blood, or under what influences 
they are placed, are points concerning which we have little or no certain know- 
ledge. We know, indeed, that such channels must exist, though we cannot see or 
demonstrate them; and that whilst the health is good, they do not allow the blood, 
as such, to pass through them. Having thus produced facts and arguments which, 
as we believe, establish the truth of the doctrine of haemorrhage by exhalation, it 
would seem that this class of diseases should be regarded as analogous to morbid 
secretions, and in any nosological arrangement be placed in the same class with 
dropsies and mucous discharges; and it is in this light that they have been regarded 
by Andral. 

Another mode in which the occurrence of liEemorrhage has been explained 
(Andral; "Precis de Pathologic;" Volume 1), and which is principally applicable 
to the passive forms of the disease, is by a supposed alteration in the consistence or 
composition of the blood itself; which becomes attenuated, and capable of passing 
through channels or orifices that healthy blood cannot permeate. In defence of 
this supposition may be adduced the facts, that haemorrhages are known to occur 
where the blood is obviously more thin, pale, and serous than natural; and, still 
more remarkably, where that fluid has undergone further demonstrable changes in 
its chemical nature, or is even visibly altered in its sensible qualities;' as, for ex- 
ample, in purpura hasmorrhagica, scorbutus, typhoid fevers, malignant small-pox, 
and erysipelas. These hypothetical attempts to explain the processes by which 
haemorrhage may take place, deserve (as Dr. Watson has observed) more attention 
than has sometimes been paid to them. The views which they involve can scarcely 
be regarded as mere speculative refinements; for they often exercise a real, though 
perhaps an unacknowledged, influence upon our practice. At any rale, if they do 
not, prior to experience, justify certain modes of treatment, they accord wonderfully 
with what experience has taught concerning the means by which haemorrhage may 
sometimes be stayed or prevented. In some cases we succeed by measures which 
tend to abate the general force of the heart and arteries, and to lessen general 
plethora; or by diverting partial plethora and restoring the disturbed balance of the 
circulation, or by directly emptying the turgid capillary vessels. In other cases, 
we rely chiefly upon expedients which we believe to have the effect of constringing 
the extreme vessels: — styptics to the bleeding part; cold to the surface of the body, 
— producing a sympathetic shrinking in other related membranes; or internal 
medicines, which use has shown to have the property of restraining the natural 
exhalations when in excess. And, finally, there are cases where we seek, and not 
in vain, to repair the blood; — to restore it to its natural condition by improvements 
in diet, or by food of a peculiar kind, such as the juice of lemons; and thus the 
tendency to haemorrhage is cured. {Cyclopedia of Practical 3Iedicine.^'y] 

Active Haemorrhage. — If haemorrhage occur with signs of inflammation, — with 
pyrexia, — with a full, hard, or quick pulse; together with pain and heat, — it may 
then be termed " active haemorrhage;" — ^just as inflammation is called active, in 
similar circumstances. The disease is then to be treated simply as inflammation; 
and the haemorrhage will subside. We have, in general, to bleed the patient; and 
the blood will generally be found buflfed and cupped. As in inflammation, purging 
will be required; and it is often quite safe and proper to give mercury, keep the 
patient on low diet, and apply cold. The latter is particularly useful in such a 
case. 

Passive Haemorrhage. — But, like inflammation, haemorrhage may be passive. 
There may be no pain, or but little; no heat; no pyrexia; no quickness and fulness 
of pulse; or, if there be quickness, the pulse is at the same time feeble. There 
may be congestion in a part, or there may not; — that is to say, all the veins may 
be distended; or the extremities of the vessels only may be pouring forth blood, 
without any congestion. When haemorrhage takes place without any symptoms 

» " Library of Medicine;" Volume 5; Pages 4 and 8. 



140 HEMORRHAGE. 

of inflammation, — without pain, without heat, without fuhiess or quickness of 
pulse, — the part itself may be in a state of congestion; but the latter condition is 
sometimes absent. We may, on opening a patient, find great congestion of all the 
vessels; wliile, in other cases, we find extreme paleness. Where there is a con- 
siderable discharge of blood, without signs of inflammation, but with symptoms 
of great fulness of blood in the part, I believe in general it is venous. Haemor- 
rhage of this kind will sometimes be altogether mechanical. There may be an 
obstruction in some of the leading veins; and the blood may be poured forth 
mechanically. An obstruction in the spleen, or in the liver, is a common cause of 
a discharge of blood from the intestines; but this discharge will sometimes take 
place witiiout any obstruction; in which case there is a peculiar state of the circu- 
lating fluids. In typhus fever, in exanthematous fevers, in scurvy, and in that 
peculiar disease called " purpura," there are peculiar vitiated conditions of the 
fluids, — inducing corresponding changes in the tissues of the body: which enable 
ws, in a great measure, to account for. the constant tendency to haemorrhage. In 
bleeding from a wound, the discharge is merely passive, — from the want of me- 
chanical resistance. The want of mechanical resistance, however, will not explain 
•all cases of passive haemorrhage; because we have cases of the most extreme 
debility of body, where the patient has no haemorrhage; and frequently there is 
hcEmorrhage of a passive kind, without inflammation, where there is not such an 
intense degree of debility. 

Inflammation and Relaxation. — In these two forms of haemorrhage, the stale 
of the system is totally different. \n active haemorrhage, — that which resembles 
active inflammation, — the blood is, as it were, forced out; whereas, in passive 
haemorrhage, the blood is let out. In active inflammation, there is an intense cir- 
culation going on in the part; that is, the blood is moving more energetically than 
natural, — and the quantity of blood moving through the part is increased; the 
action of the heart is strong, and the blood is forced out of the extreme vessels. 
We have, therefore, only to moderate the force of the blood; and the haemorrhage, 
for the most part, ceases. But in passive inflammation, the force with which the 
blood is impelled to the part is not increased. There is no great impulse behind; 
the blood is altered in quality; and the extremities of the vessels are so relaxed, 
that it escapes. It becomes, tlierefore, necessary to employ diff'erent means; — not 
to stop the force of the blood, but to improve it, and restore tone to the extremities 
of the vessels as much as possible, and to diminish their diameter; so that the blood 
may not be ihus let out. In active inflammation, all the astringents, stimulants, 
and compression which can be employed would do little or no good; for there is 
an active hccmorrhagic tendency. The blood is driven on with great force; and if 
we merely treat it as inflammation, the haemorrhage generally ceases; whereas, in 
passive inflammation, if we were to annihilate the force of the blood from behind, 
by debilitating measures, we should only increase the relaxation of the vessels, and 
make them more liable to give way than before. 

Mixed Cases. — It must always be remembered, that a great number of cases are 
inflammatory; and that others depend entirely upon relaxation, combined with 
certain conditions of the blood. In these mixed cases we are under the necessity 
of resorting to both plans; — of keeping down activity in the part, while we mode- 
rately support the system at large. We have to adopt just the same treatment that 
I mentioned, as necessary in a doubtful, combined case of aciive and passive, or 
tonic and atonic inflammation." According as the pulse is not quick, — or as it is 
not full and strong, or as there is litUe pain or heat, we may adopt the remedies 
for passive- or atonic inflammation. In proportion as the pulse is strong or quick, 
and the amount of heat in the part is great, so we must adopt more vigorous anti- 
phlogistic measures. Local means must sometimes be had recourse to, for dimin- 
ishing excitement; while, at the same time, we support the constitution. But if 
the haemorrhage be decidedly of a passive character, — so that to treat it as inflam- 

« See Page 133. 



HEMORRHAGE. I4l 

matory by bleeding and purging is out of the question, — we must trust more to 
the application of cold to the part itself; and to local, and perhaps even general, 
astringents. 

Jipplication of Ice. — Cold may be applied to the exterior of the chest, in spitting' 
of blood, wilh the most perfect safety. I have known phthisical patients to sit up 
in a chair, with scarcely any thing upon them, and to have ice laid on their chest; 
without the least suffering being produced, or any unpleasant circumstances result- 
ing. In haemorrhage from the kidneys, also, it is a good practice to apply ice to 
the loins; and in cases of profuse discharge from the alimentary canal, I should not 
hesitate to give ice by the mouth and rectum, and to place it on the abdomen. 

jlstringents. — I very much doubt the efficacy of nearly all internal astringents, 
except in the case of haemorrhage from the alimentary canal; in which case catechu 
or kino may be employed with great advantage; for then we apply the remedies as 
locally to the part itself, as if they were applied to the surface of the body, in cases 
where the latter is diseased. But with respect to those astringents, which are in- 
tended to be absorbed, and thus to operate on a distant part of the body, I very 
much doubt their effect; — unless they are of a saline character, or are readily 
absorbed. The efficacy of acetate of lead is unquestionable. I have oftentimes 
proved it to my own satisfaction. But with regard to vegetable astringents, I very 
much doubt whether, in a case of profuse haemoptysis, for instance, we can do good, 
even if we fill the stomach and intestines with catechu and kino. 

Jicetate of Lead. — We may operate, however, on distant parts by means of 
metallic astringents, — provided we give those that may be quickly absorbed; and 
the acetate of lead is certainly the chief of these. With regard to the dose, it would 
not be imagined beforehand (knowing the ill effects of lead), that we could give the 
large quantity that really may be borne. Not only may one or two grains be given 
every six hours, but two or three grains may be exhibited every two or three hours, 
for some days, with the m.ost perfect impunity. I know we may give a scruple of 
it in the twenty-four hours, and even more, — nearly half a drachm, with perfect 
safety; — provided we carefully attend to the stale of the patient's bowels; and I 
know that such doses are sometimes necessary, because I have found no effect pro- 
duced till the dose has been brought up to that point. For some time, there is no 
occasion to push on the doses so quickly; but if the haemorrhage be obstinate, it is 
then necessary to do so. I have seen a stop put to the haemorrhage, when the dose 
had arrived at a certain point; and when the dose was lessened, the haemorrhage 
returned. The only inconvenience I have known to occur, has been violent pain 
of the limbs. It is especially necessary, however, to attend to the patient's bowels; 
— to take care that they are freely opened every day; for otherwise it would be 
madness to give it. With this precaution, however, I consider it perfectly right, 
in passive haemorrhage, to give acetate of lead very freely. The pain of the limbs 
is of no consequence, if life be saved. A patient, on such terms, may well bear 
pain for some litde time after his recovery; but even that pain may generally be 
removed by employing the warm bath, once or twice a-day, and by the adminis- 
tration of colchicum. 

Sulphuric Jcid. — Sulphuric acid is another astringent, which exerts an influence 
over a profuse discharge; — not haemorrhage, but profuse srveating The same 
effect may result from nitric acid; but sulphuric acid will undoubtedly check the 
most profuse perspiration. 

Oil of Turpentine. — The application of cold, of astringents combined with cold, 
and the administration of astringents internally, are among our chief measures in 
passive haemorrhage; but the oil of turpentine frequently answers a most exrellent 
purpose. We have all seen it stop profuse ha^morrhaire from the nostrils, by being 
introduced wilh a plug of lint; and I have seen a similar effect produced, in lia^uior- 
rhage from mortified parts. I do not know that it will stop haemorrhage from inicrual 
parts, except the alimentary canal and the kidneys; — but it will stop ha?iuatemcsis 
and melaena; — that is, a discharge of blood from the stomach. I have had cases, 
almost innumerable, illustrating the great utility of this remedy. Oil of turpentine. 



14?2' HEMORRHAGE. 

whicli has proved a most efficacious medicine, should not be exhibited in large 
doses; — as by producing vomiting and purging it might prove injurious; which, in 
such cases, might be fatal to the j)atient. Twenty drops should be given, every 
three or four hours. I have known people take it of their own accord, where I 
should have been afraid to give it. I have known it taken in active haemorrhage 
from the kidneys, and put a stop to it; but where the haemorrhage was active, I 
would first treat it as inflammatory; and then, after a time, give oil of turpentine. 
If the haemorrhage proceed from a part which can be reached, and we cannot 
succeed in stopping it by other measures, compression (by means of a ligature, 
com|)ress, &c.) may be necessary; or even the apphcation of the actual cautery. 

Predisposing Causes.< — With respect to predisposing causes, it is in young 
persons that we have active haemorrhage; and it is in middle age and advanced life, 
that the passive form generally occurs. Of course, there may be exceptions to 
this general rule. In children, it usually takes place from the nose; in young 
adults, from the lungs and air-passages; in elderly people, chiefly from the abdo- 
men; but they are likewise subject to haemorrhage within the head, — producing 
apoplexy. 

Women — old, young, and middle aged — are very subject to haemorrhage from 
the stomach; and also, though in a much less degree, to haemorrhage from the 
intestines. This haemorrhage from the alimentary canal in females, is generally of 
a passive kind; and will generally bear astringents from the first. It does not 
require any great extent of bleeding. In the menstruating period of a woman's 
life, however, the uterus is very subject to haemorrhage; which is often inflamma- 
tory. Many cases of menorrhagia* — without pregnancy, — without delivery — have 
yielded to one or more bleedings, combined with low diet; whereas all the astrin- 
gents that could be given, would be of no use in this inflammatory haemorrhage, 
— attended with pain of the loins, heat of body, and quickness of pulse. 

Hatmorrhagic Diathesis. — ^Besides this predisposition to haemorrhage from cer- 
tain parts, depending upon age, there are others depending upon other circumstances. 
There is sometimes a constitutional tendency. Certain persons are known to be 
subject to haemorrhage from certain parts; and some persons are subject to haemor- 
rhage in general; so that if they have a tooth extracted, they will always bleed 
profusely; or if they cut their finger, it will continue to bleed for many hours, in 
spitf3 of the remedies used. There is certainly, in many people, an hereditary 
predisposition to haemorrhage. In some of these, an extreme thinness of the 
arteries has been found. After a tooth has been extracted, it has been found neces- 
sary, from the profuse haemorrhage, — notwithstanding that the actual cautery was 
employed, — to tie the carotid artery; and it has been found that the arteries were 
even thinner than the veins in other people. 

[The haemorrhagic diathesis, is a remarkable state of the blood and sanguiferous 
system, and by no means uncommon in this country; but it seems to be a more 
common aflfection in the West of Germany, where all the boys of a family will 
frequently die with it. It is hereditary; and has been observed to afiect males more 
frequently tlian females, although it may be transmitted by the mother. The blood 
is of the ordinary colour, but unusually fluid; and, although it is coagulable, the 
coaguhim has little firmness. The consequence of this state of the blood is, that 
most of the tissues, including the capillary parietes, are extremely attenuated and 
relaxed; and, accordingly, this lax stale of the vessels allows the blood readily to 
transude, upon the application of the slightest force. In many instances, where 
this latter circumstance happens, no eflbrls of nature, or means of art, are capable 
of restraining it. Mr. Wardrop has collected several cases of this description; and 
mentions several examples, in which this diathesis was evidently hereditary. 

In the aggravated form in which this disease is described as occurring in Germany, 
the symptoms are — the appearance of ecchymoses (spontaneously, or from the 
slightest pressure), which slowly disappear, leaving a yellow tint behind; — episj 

' From /unvja, the menses; and piywfjii, to break out. 



HiEMORRHAGE. 143 

taxis; — profuse loss of blood from the slightest puncture; — liasmoptysis from a 
slight cough; — diarrhcea with clots of blood in the stools. The patients, moreover, 
are subject to frequent attacks of pain and swellino^, with ecchymosis of the wrist, 
ankle, and knee-joint, attended by fever. On the examination of the bodies of 
those patients, the vessels were found extremely thin and softened. 

Mr. Wardrop remarks, that those substances which dispose the blood to coagu- 
late, seem to have more effect in restraining the bleeding, than those which excite 
the artery itself to contract. A lad who exhibited this haemorrhagic tendency, was 
reduced to the most extreme state of anaemia, — threatening immediate dissolution, 
— from a trifling surgical operation, Mr. Lane, by whom the case is given,* per- 
formed the operation oi transfusion; — the boy was soon reanimated, and ultimately 
recovered. 

Vitiated states of the blood — predisposing to, or causing haemorrhage — are fre- 
quently acquired: these are generally passive and symptomatic haemorrhages; and 
for the most part they are not, properly speaking, haemorrhages at all; — being 
merely exudations of serum, holding the colouring matter of blood in suspension, 
or solution; and the result of various morbid conditions of the blood. This is 
exemplified in the petechiae, ecchymoses, and sanguineous effusions occurring in 
malignant diseases. Andral remarks, " that it is sufficient for haemorrhages to 
occur, that its molecules lose their natural ybrce of cohesion. ''^^ With respect to 
many of these cases, and the curious subject of the sudor sanguinis, it is to be 
regretted, that no microscopic observations of the fluids have been made; — the first 
question which suggests itself to the mind, being — " Are the red particles of the 
blood effused as such, or do they previously undergo solution?" From the rapid 
advances which are now being made in organic chemistry, there are some grounds 
for the hope that these states, depending upon the vitiation of the fluids, will soon 
be more definitively understood. — T. Williams.~\ 

Exciting Causes. — The exciting causes of haemorrhage, are whatever propels 
the blood violendy, either generally or locally; and whatever mechanically accu- 
mulates it; such as posture, the application of a ligature, or obstruction in any part. 
Another exciting cause of haemorrhage, is the suppression of a discharge, or the 
sudden cessation of a natural discharge; such as the entire or occasional suppres- 
sion of the menses, the suppression of haemorrhoidal discharge, or the suppression 
of diarrhoea. Indeed, the sudden cessation of any disease to which a patient has 
been very subject, is sometimes attended with haemorrhage from an internal part. 
A solution of continuity is a common cause of haemorrhage; and, of course, it is 
then of a passive kind. 

Arteriat and Venous Hsemorrhage. — In haemorrhage which proceeds from the 
nose or the lungs, the blood is generally florid; while that which comes from the 
stomach and intestines, is generally of a venous character. But the circumstance 
of the blood being black, does not necessarily prove that it comes from a vein. It 
may assume that colour from remaining some time in the stomach or intestines, 
before it escapes; for blood, if allowed to be perfecUy still, and not exposed to the 
air, will become black. 'If we tie an artery in two places, the blood between the 
ligatures becomes venous in its character; and therefore blood discharged from the 
stomach and intestines, though it may be venous in its characters, may yet be 
arterial in its origin. In apoplexy, the blood effused within the head appears to 
be venous; but its black colour may arise merely from the reason Ihave jusi stated. 
The uterus is particularly subject to haemorrhage during pregnancy, and parturi- 
tion; but the reason of this is, for the most part, mechanical. Inflammation, if not 
the cause of menorrhagia in women who are not pregnant, and have not lately been 
delivered, is, at any rate, a very common attendant circumstance. Menorriiagia 
that has nothing to do with impregnation, is generally of an inflammatory character. 

a "Lancet," 1840-41, Volume 1; Page 825. 
b " Lancet," 1839-40, Volume 2; Page 843. 



144 PROFLUVIA. 

An inflammatory state very often produces haemorrhage from the intestines and 
urethra. 

In the head, and from the kings, the stomach, and the intestines, haemorrhage 
often arises from merely mechanical causes; — from ulceration, or solution of con- 
tinuity. One cause of haemorrhage in the head (apoplexy), is brittleness of the 
vessels, or tenuity of them, or ulceration of the blood-vessels of the head. Haemor- 
rhage from the lungs often arises from a mere inflammatory state of the bronchia, 
or of the air-cells, — constituting pneumonia. In phthisis, nature endeavours to pre- 
vent haemorrhage by forming adhesions, and plugging and contracting -arteries; but 
sometimes an ulcer will pro(hice haemorrhage, and even sudden death. With re- 
gard to the stomach, haemorrhage will sometimes occur from ulceration; and death 
may be the consequence. The same thing will take place in the intestines. There 
may be an ulceration of even a malignant character; and, every now and then, pro- 
fuse haemorrhage is the consequence. It will also come on, in many of these parts, 
from mechanical violence. It is very common for a person to spit blood after a 
blow on the chest, or a fall. It is also common to void bloody urine after a blow 
upon the loins; and to discharge blood from the intestines after a fall. 

Not only may there be profuse haemorrhage from the mucons membrane of the 
bronchia, from the stomach, from the intestines, — from the interior of the kidneys, 
and from the urinary bladder; but other parts are sometimes the seat of fatal haemor- 
rhage. I have known haemorrhage take place into the pericardium, and prove 
almost instantly fatal; and cases of sudden and fatal haemorrhage into the spinal 
sheath, without any evident cause, are recorded. In fatal cases of haemorrhage into 
the pericardium, the heart and the pericardium have been found soft. It was so in 
the case which I saw; and, as far as I can ascertain, it was so in other instances. 



CHAPTER III. 
PROFLUVIA. 



Fluxes, catarrhs, or profluvia,* form the next class of aff*ections which we shall 
notice. They are precisely similar, in principle, to haemorrhage; and occur from 
those parts which are most frequently the source of the latter; — namely, the mucous 
membranes. Fluxes occur particularly from the nose, the bronchia, the intestines, 
the bladder, the urethra, and the vagina. Those parts which, during inflammation, 
frequently pour forth blood, will also, during the same period, pour forth a much 
increased secretion. In the first instance, their secretion is increased; it afterwards 
declines, but does not come down to the standard of health; and then, as the inflam- 
mation subsides, the secretion becomes excessively abundant. Inflammatory or 
catarrhal fluxes may therefore occur from the mucous membranes; — like the in- 
flammatory haemorrhages; and, after all the signs of inflammation have subsided, 
these discharges frequently continue. There is, however, another form, in which 
no inflammation is to be discovered;^ — the mucous membrane pouring forth a con- 
siderable quantity of liquid, for some time; and that without the occurrence of any 
signs of inflammation. There are passive fluxes; — exactly as there are passive 
hsemorr hashes. The only diflerence is, that in the one case blood is poured out, 
and in the other a secretion. 

Jnjfammalory and Uninjlammatory Discharges. — I mentioned, that the skin — 
which has some relationship to mucous membrane (since it is developed from the 
latter) — will occasionally, tliough in very rare cases, pour forth blood." The skin, 
however, will every day pour forth an immense quantity of its own secretion. The 

* From " profluo," to run down. *• See Page 137. 



I 



PROFLUVIA. 145 

term "^wa?," ^^ catarrh,'''* or ^'' prq/Iuvium,^^ would not be given to a discharge 
from the skin; but, just as the mucous membranes pour forth their discharges in 
excess, so frequently does the skin. Profuse sweating is analogous to profuse dis- 
charges from mucous membranes. We have sufficient proof that excessive discharge 
from the skin is, more frequenUy than not, quite devoid of an inflammatory charac- 
ter. In fact, in the highest debility, that of syncope, — or of death, the skin will 
secrete most abundantly. Just so it is, undoubtedly, with respect to the mucous 
membranes. They will secrete most abundantly, without any signs of inflamma- 
tion at all. It has been imagined, that whenever the mucous membrane secretes in 
excess, it must be in a state of inflammation; but I think the instance of the skin, 
which is alluded to by Andral, is sufficient to show that the mucous membranes 
likewise may be in a similar state, without any inflammation. He remarks, that 
the skin will secrete in the greatest abundance, — will sweat profusely, without any 
marks of inflammation. This instance of the skin would enable us to say, a priori, 
that the same thing is possible with respect to the mucous membranes. But I 
think, a posteriori, we can assert that mucous membranes will secrete most abund- 
antly, without inflammation; for after fluxes these membranes are often quite pale 
after death; — just as they often are after passive haemorrhage. It appears to me to 
be a case analogous to that of inflammation- itself; and also to that of haemorrhage. 
I think there may be an active secretion from the mucous membrane, and from the 
skin, as in acute rheumatism; or that it may be entirely passive, — without any 
mark of inflammation. 

Treatment. — The treatment of these fluxes is precisely the same as the treatment 
of inflammation or of hsemorrhage. If they be of an active kind, — attended with 
strength of pulse, pyrexia, heat of body, pain of the mucous membrane itself, — the 
pain that is characteristic of inflammation of a mucous membrane, and is increased 
by pressure, — astringents are altogether improper. At any rate, they are altogether 
useless; — just as they are in active hsemorrhage. It would be as absurd to attempt 
to cure these discharges by astringents, — to stop the discharge of gonorrhcea, for 
example, during the violence of the inflammation, by an astringent injection, — as 
it would be to attempt to stop by such means an active haemorrhage. We have 
only to lessen the inflammatory state by bleeding, and the discharge will become 
diminished, or be put into a course of diminution. Perhaps there will be a moment- 
ary increase; but it is followed by a diminution, similar to that which occurs in an 
active haemorrhagic process. When there is no inflammation present, or the in- 
flammation is subsiding, we may apply local means, as stimulants and astringents, 
with the greatest advantage. If it so happen that no inflammation occurs from the 
very beginning, we may at once apply stimulants and astringents. The instance of the 
urethra is a good illustration of all that occurs in the various mucous membranes of the 
body. I have remarked** that, in inflammation, an increased secretion may happen, 
both of which are only to be subdued by anti-inflammatory measures; but that at last 
there may be only a passive discharge; and then anti-inflammatory measures will in- 
crease the mischief: stimulants are therefore to be resorted to. Sometimes there will 
be so little inflammation, that it may be disregarded from the very first. It is quite 
the same in diarrhoea. In diarrhcea, frequently, the best remedy is to bleed the pa- 
tient, to starve him, to leech the abdomen, and to blister him; to give no astringents 
whatever, but sometimes even moderately to purge, — in order to increase the effect 
of the treatment: the inflammatory state will then subside. In other cases, w^e have 
to give astringents and opiates, and support the patient well; and in tliat way he re- 
covers. It is the same, too, in bronchitis. In active bronchitis, any remedies 
which stimulate the air-passages, would be highly injurious. It is only necessary 
to bleed the patient well, to enjoin abstinence, and to treat him as labouring under 
inflammation; and the discharge of mucus gradually subsides. In an old man, 
however, a profuse discharge may take place from the bronchia; — forming what is 
called "catarrhus senilis;" without inflammation, but accompanied with emaciation 

» See Page 144. 
VOL. I. — 10 



146 DROPSY. 

and paleness. Tonics and good nourishment form essential steps in the treatment. 
Such stimulants as snakeroot [Poly gala Senega) answer the purpose best. 



CHAPTER IV. 
DROPSY. 



Definition, — ^The next class of affections that we have to consider, belong en- 
tirely to serous membranes, and the interstices of the serous cellular tissue. In these 
cases, fluid is secreted in such excess, that the ordinary powers of absorption are 
inadequate for its removal; and as the serous cavities of the body are shut sacs, the 
fluid does not escape, as it does from mucous membranes; so that, instead of a dis- 
charge or flux, dropsy is the result. 

[But the term " dropsy^'' has likewise been applied to collections of serous or 
other liquids in cysts; which are themselves preternatural; — having been formed, 
or greatly enlarged and altered, by some morbid process. Those effusions which 
occur in serous cavities, as the direct result of inflammation, ought not to be denomi- 
nated " dropsy." Nor is every collection of serous fluid found in the shut cavities 
of the dead body, and independent of inflammation, to be considered a dropsy. For 
this is oftentimes only a physical, post-mortem phenomenon, — arising from the ac-* 
cumulation of blood in the venous system; the tissue of which, becoming lax from 
commencing decomposition, allows the serous portion of the blood to transude with 
greater facility. 

Ought Dropsy to be considered a Disease? — It has been said, with much truth, 
that dropsy is rather a symptom of disease than a disease itself; and that it would 
be more philosophical to treat of the original malady on which the accumulation of 
fluid depends, and to withdraw dropsy altogether from the class of substantive dis 
eases. But there are considerations which entide us to regard dropsy as still con- 
stituting a genus of diseases, and particular dropsies as specific forms of disease. 
For, allowing that dropsy is often or always a symptom, it is one which, in many- 
instances, we cannot trace home during life, or satisfactorily ascribe to any organic 
change discoverable after death; so that, practically speaking, the dropsy in such 
cases is the disease and sole object of our treatment. Moreover, the liquid accu- 
mulation is a symptom very obvious and striking in itself, while it results from va- 
rious physical alterations, differing both in their seat and in their nature; and it will 
be useful to study dropsies collectively; — if it be only with the view of analyzing 
them, and of referring them, as often and exactly as possible, to the pre-existent 
disease. 

Dropsy is, in fact, to a medical eye, in all cases something more than an effect or 
symptom of disease. The fluid collection itself is a cause of various other symp- 
toms; — of symptoms which often constitutes the greater part, or the whole, of the 
patient's distress and danger. The imprisoned liquid, by its weight or pressure, 
may embarrass important functions, or even extinguish life. The removal of the 
dropsy will frequenUy restore the patient at once to comparative comfort; or indeed 
to what, so far as his sensations and powers and belief are concerned, is for the 
time to him a state of health; although the original bodily cause, of which the 
dropsy was a symptom, may remain behind untouched; — to be again productive of 
simUar consequences, under circumstances favourable to its operation. Sometimes 
it happens that the bodily change which is the immediate cause of the dropsy, is 
slight or temporary; while the patient's comfort, and very existence, are compro- 
mised by the mere accumulation of the water; and if this accumulation can be 
remedied by art, its temporary producing cause may cease, or be removed, or 



DROPSY. 147 

admit of compensation; and so the patient may be strictly restored to sound health. 
In a dropsical person, then, whose dropsy results from organic disease, there are 
plainly two sets of symptoms to be distinguished; namely, those which depend 
upon the primary disease, and those which are caused by the collection of water. 
And these two sets of symptoms differ, perhaps, not only in their gravity and im- 
portance, but also in their obedience to treatment. The latter, usually the most 
grevious, may often be got rid of; the former are frequently but little complained of 
or felt by the patient, but are generally permanent. 

Dropsy would perhaps be thought by many a more attractive subject, if it were 
not so commonly considered incurable. But the preceding remarks may suffice to 
show that, as far as itself is concerned, it often is curable; and some of its forms 
will hereafter appear to be curable in a more absolute sense; — the serous collection, 
and the condition from which it proceeds, both admitting of remedy. Besides: it 
is our business and aim to cure it when we can; and, whether we can cure or not, 
to remove or mitigate human suffering; and this we are able to do, to a very con- 
siderable extent, in many or in most cases of dropsy. 

Liferent Forms of Dropsy. — Wherever there is a shut sac, or wherever there 
is loose and permeable cellular tissue, there we may have dropsy. Thus, there 
may be dropsy of the ventricles of the brain, or of the meshes of the pia mater, — 
producing death by coma; of the cellular tissue of the lungs, or of the submucous 
tissue of the larynx, — both leading to death by apnoea;^ or of the pericardium, — 
causing death by syncope. Almost every mode of dying, therefore, may result 
from dropsical accumulations. 

When the cerebral ventricles are distended with water, we express the diseased 
condition by the term ^'■hydrocephalus.'''' When serous fluid occupies the pleura, 
or the pericardium, we say the patient has hydrothorax, or hydropericardium. If 
the cavity of the peritoneum be the seat of the collected water, we call the com- 
plaint ''ascites.''^ When the cellular tissue of a part becomes infiltrated with serous 
liquid, the part is said to be oedematous; and " anasarca''^ is the name given to the 
more or less general collection of serum in the cellular tissue throughout the body, 
and especially to visible subcutaneous oedema of much extent. Under the term 
^'general dropsy''^ we signify the simultaneous existence of anasarca, and of dropsy 
of one or more of the larger serous cavities. 

Certain forms of dropsy — for example, dropsy of the tunica vaginalis testis 
("hydrocele"^) and dropsy of the joints and bursse (" hydrarthrus'"') — belong to 
surgery, and need only to be glanced at for the sake of elucidating the general 
subject. 



SECTION L— GENERAL PATHOLOGY OF DROPSY. 

Under what conditions, and by what mechanism, do the hollows and interstices 
of the body become thus filled and oppressed with water? In other words, what 
is the general pathology of dropsy? It is an ultimate fact, that from all the surfaces 
of the healthy living body there is continually going on a kind of secretion, or ooz- 
ing forth of fluids. The inner surfaces of the shut cavities, and the partitions of 
the cells of the cellular tissue, furnish no exceptions to this law. If we examine 
the interior of an animal just slaughtered, or observe a cavity laid open in the hu- 
man body, (by accidental injury,) we find that their inner surfaces are moist; and, 
indeed, we may see the fluid escape into the colder atmosphere, in the form of 
vapour. We perceive, also, that the surface is merely moist. The fluid in these 
shut cavities, during life and health, being taken back again into the circulating 
blood as fast as it exudes, the two processes of exhalation and absorption are 
accurately balanced. The disturbance of this equilibrium would account for dropsy. 

* From a. (privative) without; and tntan, to breathe. 
^ From v^o)^, icater; and x»iX»j, a tumour. 
*From iJwj, water; and a^Q^ov, a joint. 



148 DROPSY. 

Now considering the matter hypothetically, we perceive that the balance may 
be deranged, and the dropsy arise, in one or both of the two following ways. 
Either the quantity of fluid exhaled may be over-abundant; or the amount of ab- 
sorption may be deficient; or both these deviations from the natural state may occur 
together. It is obvious, that dropsy will ensue whenever the exhalation takes 
place faster than the absorption; and this may happen when both are in excess, 
or both defective. The inquiry may be reduced, however, in the first instance, 
to these two questions: — " Is there ever a preternatural amount of exhalation? 
Is there ever defect of the natural absorption?" An affirmative answer to either 
question, would explain the occurrence of dropsy. So, a fortiori, would an affirm- 
ative answer to both. 

These inquiries being satisfied, another point would require to be investigated; 
namely, whether the product of the exhaling process may not be liable to variation 
in quality, as well as in amount; — whether the liquid actually accumulated in 
dropsy, is essentially identical with the liquid naturally exhaled. Are there, then, 
any known facts which accord with the hypothesis of a preternatural exhalation 
or pouring out of the serous liquid? There are; and in order to appreciate them, 
it will be necessary to bear in mind some further physiological truths. Reference 
has already been made to the perpetual separation of watery fluid from all the 
surfaces of the body; — the external, and those which communicate with the air, 
as well as the inner faces of the closed cavities. The flu*ids that exhale from the 
former class of surfaces are, for the most part, excretions. They are thrown out 
of the system; and, with respect to these, something more has been ascertained. 
It is observable, that when the escape of aqueous fluid from one such external 
surface is checked, exhalation becomes more copious from some other excreting 
surface or organ. And there are special sympathies of this kind established 
between certain secreting parts. It is probable that, so long as other circumstances 
remain the same, the aggregate amount of water thus expelled from the system 
cannot vary much, in either direction, without detriment to the individual,— mani- 
fested by symptoms. But we are sure that the quantity furnished by each secret- 
ing surface, may vary and oscillate within certain limits consistent with health; — 
provided the defect or excess be compensated by an increase or diminution of the 
ordinary expenditure of watery liquid through some other channel. Sound health 
admits and requires this shifting and counterpoise of work between the organs 
destined to remove aqueous fluid from the body. The sympathy, or compensating 
relation here spoken of, is more conspicuous with regard to some parts than others. 
The reciprocal but inverse accommodation of function that subsists between the skin 
and the kidneys, afl'ords the strongest and the most familiar example. In the warm 
weather of summer, when the perspiration is abundant, the urine is proportionally 
concentrated and scanty. On the other hand, during winter, when the cutaneous 
transpiration is checked by the operation of external cold, the flow of dilute water 
from the kidneys is strikingly augmented. All this is well known to be compati- 
ble with the maintenance of the most perfect health. But supposing the exhalation 
from one of these surfaces to cease or to be diminished, without a corresponding 
increase of function in the related organ, or in any organ communicating with the 
exterior, then dropsy, in some form or degree, is very apt to arise. The aqueous 
liquid, thus detained in the blood-vessels, seeks, and at length finds, some unnatu- 
ral and inward vent; and is poured forth into the cellular tissue, or into the cavities 
bounded by the serous membranes. 

If water be injected, in some quantity, into the blood-vessels of a living animal, 
the animal soon perishes; — generally dying by coma, or by suflbcation: and when 
ihe carcase is examined, the lungs are found to be charged with serous liquid; or 
water is discovered in the cellular tissue of some other part, or in the shut serous 
membranes. If, however, the animal be first bled, and then a quantity of water, 
equal to the quantity of blood abstracted, be injected, the injection is followed by 
no serious consequences. 

It has been ascertained, that animals (dogs, cats, and rabbits) survive the extir- 



DROPSY. 149 

pation of both kidneys for a spice of time varying between ten honrs and nine 
days. Copious and very liquid evacuations from the intestines, vomiting, and 
fever precede their death. Clear serum is found in the cavities of the brain, the 
bronchi are full of mucus, the intestines of liquid faeces, and the blood is more 
than naturally aqueous. So in the disease called " ischuria* renalis,'"' the secretion 
of urine is suppressed; death by coma ensues; and the web of the pia mater, or the 
cerebral ventricles, are often found full of water. In cholera, there is suppression 
of urine for as long a space; but the brain is unaffected; for the system is drained 
of its water by the profuse discharges from the stomach and bowels. Conversely, 
in diabetes the skin is permanently dry; — the kidneys pour forth their altered se- 
cretion with a fatal prodigality. 

The several classes of facts which have now been briefly brought into view, 
throw a strong light upon a confessedly obscure part of pathology. It appears 
that, in various circumstances, the blood-vessels may receive a considerable and 
unwonted accession of watery fluid; and that they are very prone to get rid of the 
redundance. When they empty themselves through some free surface, their pre- 
ternatural distension is relieved by a flux; if, on the other hand, the surface be that 
of a shut sac, in disharging their superfluity they cause a dropsy. Why some- 
times one organ, and sometimes another^ is selected as the channel by which the 
superabundant water shall be thrown- out of tlie vessels, is a matter concerning 
which we can seldom render any satisfactory account. We often find it difficult 
to determine which of the two facts in question is to be considered the antecedent, 
and which the consequent. For not only is it true that, when the blood-vessels 
become overloaded with serous fluid, they readily deposit a part of it; but it is also 
true, that when they are in the opposite condition of comparative emptiness, — 
when they contain less blood than is natural, they are equally ready to replenish 
themselves by absorbing fluids from any source to which they can find access. In 
the case of an individual who was cured of his hydrocele upon the occurrence of 
profuse watery discharges from the stomach and bowels, it seems clear that the 
expenditure of serous liquid from one part, led to its absorption into the blood from 
another. When anasarca suddenly leaves the extremities, or ascites the abdomen, 
and fatal coma follows, it appears probable that the absorption is the first of the 
changes, and the effusion the second; and had this effusion been determined to the 
mucous membrane of the intestines, to the skin, or to the kidneys, it would have 
brought relief and safety to the patient, instead of causing his death. 

We have obtained, then, a glimpse of one or two most important principles, 
with respect to the pathology of dropsy: — tlie blood-vessels, when preternaturally 
full of aqueous fluid, have a strong tendency to empty themselves; when preter- 
naturally empty, they readily drink up watery fluid wherever they come into 
contact with it. From the discharge of their superfluity of water, arises a dropsy 
or a flux. Tiie cause and the cure of many dropsies, lie in these propositions. 

Active Dropsy. — The dropsies hitherto considered, — resulting from the rapid 
as well as preternatural pouring out of fluid by tlie blood-vessels, — compose an 
especial class of dropsies; in which tlie arterial system is more concerned than the 
venous; and to which the term "^active''' has sometimes been applied. For the 
sake of convenient distinction, and in conformity with established usage, we shall 
retain that epithet. But the number of these active dropsical effusions quite inde- 
pendent of inflammation, is small when compared with tlie whole number of drop- 
sies. The state of the part from which the effusion proceeds, borders closely 
upon inflammation. The condition of its capillary circulation, has been regarded 
as intermediate between that in which the ordinary quantity of secretion is main- 
tained, and that in which inflammatory effusion takes place. The increase of 
secretion is analogous to what we observe in other parts of the body; — to abundant 
perspirations, for example, that are occasioned by violent exercise; to the increased 
flow of tears caused by any irritation of the eye, or by the passion of grief; lo the 

• From jiTjj^a), to restrain; and eujsv, urine. •> From " ren," the kidney. 



150 DROPSY. 

augmented watery discharges from the mucous membrane of the bowels, produced 
by purgative drugs; — all of which may be independent of inflammation, but all of 
which are attended by congestion, that may easily be pushed into inflammation; 
and it is obvious, that if the secretions just referred to were poured forth into closed 
cavities, instead of proceeding from surfaces that are situated on the exterior of the 
body, or communicate readily with the exterior, they would constitute dropsies.*] 

Inflammatory Dropsy. — By far the larger number of those dropsies that are 
called " active," are of an inflammatory character; and require to be treated, not by 
diuretics, but simply by the remedies of inflammation. In the arachnoid, the 
pleura, and the pericardium, for instance, dropsy is frequently attended with the 
most decided inflammation, both acute and chronic. Sometimes, though not so 
frequently as in the cases just mentioned, we see dropsy in violent inflammation 
of the abdomen; but very often ascites itself is a decidedly inflammatory disease. 
In such cases, the usual signs of inflammation of a serous membrane occur. When 
the afl'ection is situated in the arachnoid, we have pain of the head, intolerance of 
light, perhaps squinting, and great quickness of pulse. In inflammatory dropsy 
of the pleura, pain in the side, dyspnoea, and cough, form conspicuous symptoms. 
With respect to the pericardium, we have pain in the region of the heart, perhaps 
a rapid pulse, palpitation, and pain darting from that organ in various directions. 
In the case of the abdomen, the pain is considerable, and is increased on pressure. 
All these aflections are of an inflammatory character, and tend to induce more or 
less efl'usion in every case; but occasionally the eff'usion is very considerable; and 
then the word "Jrops?/" is applied to the collection. 

Passive Dropsy. — [A much larger class of dropsies commence in defective 
absorption. There is no sudden and profuse gush (as in the former class) from 
the overladen blood-vessels; but the fluid which is healthfully and unceasingly 
exhaled from the serous surfaces, fails to find its way back again into the blood, 
and gradually accumulates. The mechanism of the morbid process is commonly as 
follows: — Some cause retards the current of venous blood: hence the veins, and the 
capillaries by which they are fed, become distended; and this distension constitutes 
an impediment to the further admission of liquid. Absorption is sluggish, or at a 
stand. To dropsies thus originating, we give the name of ^^passive.^^ The 
venous system is more concerned in them than the arterial. 

But we have still to show more clearly, that dropsies may and do originate in 
this manner. The agency of the blood-vessels in the production and removal of 
dropsy, has not been sufficiently recognised till of late; or perhaps it should rather 
be said, that more importance used to be assigned to the agency of the lymphatic 
absorbents, than they are really entitled to. Pathologists, even of recent date, 
speak of a want of tone or energy in the absorbing vessels — of the superfluous fluid 
of the part not being adequately taken up by the enfeebled absorbents; — meaning, 
thereby, the absorbents properly so called. And this view of the matter — connect- 
ing dropsy always with debility as its cause — has infected the whole pathology of 
the disease, and led to a corresponding mode of treatment; — the object aimed at 
being the stimulation of the absorbents to more vigorous action. This obvious 
difficulty, however, presents itself at once to the theory, that dropsy results from 
deficient activity of the absorbents: namely, that absorption goes on, and to a very 
great degree, in dropsical patients. Their adi|)ose matter disappears; — they get 
miserably thin. There is no complaint in which emaciation goes to a greater ex- 
tent than in dropsy. It is found, also, that persons afflicted with anasarca become 
readily enough aff'ected by mercury; which, of course, must be absorbed before it 
can produce any of its specific efl^ects. 

Physiology of Jib sorption. — It must be confessed, that our knowledge respecting 
absorption is neither complete, nor absolutely certain; but there appears good reason 
for supposing, that the process is shared between the lacteals, the lymphatics, and 
the vems; and, probably, somewhat in this manner: — that the lacteals absorb the 

• " Library of Medicine;" Volume 5; Pages 97 to 101. 



DROPSY. 151 

chyle from the surface of the intestines, and convey into the blood the materials 
for its renovation; that the office of the lymphatics is to take up and carry into the 
blood, that effete portion of the solid constituents of the body which requires to be 
removed, to make way for a fresh deposit; while the veins imbibe the serous fluid 
exhaled from the surfaces of serous membranes, and into the meshes of the cellular 
tissue, as well as poisonous and other substances that are soluble and dissolved in 
that fluid. 

Now, if this be so, one of these last sets of absorbini^ vessels, — the lymphatic 
apparatus or the venous, — may continue to perform its ofTice, while the other fails 
to do so. This theory is sufficiently consistent with the actual phenomena of 
dropsical disease; and, whether it be altogether true or not, a part of it is certainly 
true; — that, namely, which assigns to the veins a large share in the whole process 
of absorption. The experiments of Magendie, Fodere, and others, are quite con- 
clusive upon that point. It has been proved, that fluids may pass into and out of 
the veins through their parieles, independently of any vital process, and by mere 
physical imbibition and transudation; so that when the veins are distended to a cer- 
tain point with watery fluid, the introduction of more of the same fluid through 
their coats is impeded or prevented; and when the distension is still greater, the 
aqueous part of the blood may even pass, in the other direction, out of the vessel. On 
the other hand, when the veins are comparatively empty, the serous fluid passes 
readily into them; or, in common language, is absorbed. Venous absorption is 
explicable, therefore, upon the principles of endosmose and exosmose, — as laid 
down by Dutrochet; or rather (according to professor Daniel's happy generalization 
of Dutrochet's facts) by the theory of heterogeneous attraction. Imbibition, being 
a form of that attraction, belongs in various degrees to all the tissues of the body. 
Its rapidity, and even its direction, with respect to the sides of a vessel surrounded 
by fluid, and also carrying fluid of a certain consistence, must vary with the varying 
distension of the vessel. When the vessel is moderately full, the exterior fluid 
passes uninterruptedly inwards, and is conveyed away by the internal current. 
When, on the other hand, the vessel is much distended by its contents, the con- 
tained fluid, or its thinner part, passes continually outwards. And there is an in- 
termediate degree of distension, at which the pressure is just enough to prevent the 
transit of fluid in either direction. Magendie found, accordingly, — in an ample, 
well conducted, and conclusive series of experiments, — that by regulating the 
conditions of comparative emptiness or fulness of the circulating system, he could 
accelerate, retard, or altogether suspend the operation of a poison dissolved in the 
humours of the body. In other words, he could thus accelerate, retard, or prevent 
the process of absorption or imbibition through the blood-vessels. If we are once 
satisfied of the absorbing and transmitting property of the sides of the vessels, we 
shall have no difficulty in perceiving how any mechanical obstacle, occuring in a 
venous trunk, may give rise to dropsy. 

Having then deduced, from physiological data, that dropsy may occur from 
mechanical obstruction in any of the larger venous trunks, let us, in the next place, 
ascertain whether, in point of fact, it ever has this kind of origin. The truth of 
this was first determined, experimentally, by our countryman Dr. R. Lower; who, 
though these experiments were not instituted with any reference to the pathology 
of dropsy, perceived their bearing upon that subject; — as appears from the follow- 
ing remark: — " Quantum haec ad ascitis et anasarcae causas investigandas conducant, 
aliis judicandum relinquo."* In one of these experiments, he applied ligatures to 
the jugular veins of a living dog; in two days the dog died; and the cellular tissue 
about the head and face was found to be distended, not with blood (as Lower had 
anticipated), but with clear and limpid serum. In another experiment, lie tied the 
v^na cava just after it emerged through the diaphragm; in a few hours the animal 
died; and a large quantity of fluid, precisely similar to the fluid of ascites, was 
found in the peritoneal sac. These results have been confirmed by more modern 

■ " Library of Medicine;" Volume 5j Pages 101 to 103. 



152 DROPSY. 

and conclusive experiments; and afford a satisfactory explanation of nearly every 
form of local dropsy, or even general anasarca.*] 

Dropsy from Obstruction. — As in many cases of haemorrhage the flow of blood 
proceeds from mechanical obslriiciion, so does the same occurrence take place in 
dropsy. If great obstruction take place in any of the veins, dropsy must be the 
consequence. Local, and more or less extensive plethora take place, in all the 
vessels on the other side of the obstruction. As a mere physical effect, the watery 
parts of the blood ooze forth from their extremities; and the part becomes more or 
less turgid, — from the great serous congestion. There is every reason to believe, 
that the swelling of ihe leg after parturition, called "phlegmasia dolens," depends 
upon mere mechanical obstruction. There is more or less oedema of the leg; and 
it usually arises (according to Dr. D. D. Davis and others) from obstruction.* 
There is an obstruction of the veins at the upper part of the extremity; and per- 
haps, also, in the veins still higher up. The pressure of a very enlarged womb 
Avill often, in this way, induce dropsy of the lower extremities. In cancer affect- 
ing the axillary glands, or when the breast is attacked by cancer or scirrhus, an 
upper extremity becomes oedematous; — simply from mechanical obstruction. It is 
not necessary that the absorbents should be affected; for if the veins be obstructed, 
the same effect is produced. A local plethora takes place; — both of veins and 
capillary vessels. These pour forth a watery secretion; and dropsy is sure to occur 
at last; — simply as a mechanical effect. 

If the obstruction occurs at that point where all the veins of the body meet, 
anasarca of the universal cellular tissue, and an accumulation of fluid in all or most 
of the serous cavities, supervene. 

Dropsy from Debility. — It frequently happens, however, that general dropsy 
arises from debility. The patients are exceedingly pale, with a very weak pulse, 
and extreme debility of the whole frame. In these cases, the more they are 
weakened, the worse they become; — the more does the dropsy increase. When 
there are no signs of inflammation, — no fulness of pulse (for there may be 
quickness without fulness), but (on the other hand) debility, and when the powers 
of the patient are becoming exceedingly reduced, the disease must be put upon a 
footing with passive inflammation, or passive haemorrhage, or a passive discharge, 
— a gleet from a mucous membrane; and every thing which debilitates the body 
will make the matter worse. This will be the case if the dropsy arise from visce- 
ral disease; such as disease of the liver, — a liver full of tubercles, or indurated; 
scirrhus, or carcinoma of the womb; or ulceration of the lungs. 

[But, independently of debility arising from organic disease, dropsy may arise 
purely from debility of the heart; — producing a serious retardation of the venous 
circulation. We see this every day in weak, chlorotic girls, with bloodless cheeks 
and pale lips. Such persons have weak and flabbly voluntary muscles; and it is 
reasonable to presume that the involuntary muscles (of which number the heart is 
one) sliould partake of the general feebleness of the muscular system, and become 
incapable of performing their oflice with proper energy. 

Nay, it is credible and likely, that a feeble heart may in these circumstances 
yield a little, and dilate under the resisting pressure of the blood which enters its 
chambers; and that, in th.is way, the occasional but temporary bellows-sound may 
arise; — in consequence of the altered relation between the cavities of the heart and 
their outlets. And the juvantia and Isedentia confirm this view of the matter. 
If, tempted by the pain complained of by the patient, or by the violence with 
which her overtasked heart is throbbing, we take away blood, we find that, Vv'hat- 
ever present relief she may experience, she is ultimately weakened by the deple- 
tion. On the other hand, if we give her steel, feed her well, and administer the 
cold shower-bath, we find that she regains her lost strength; — that colour returns 

* " The bearing of these investigations on the causes of ascites and anasarca, 1 leave to 
the judgment of others." — " Tractatus de Corde," by Richard Lower, M. D.; 1669; Page 82. 

^ It is, however, the belief of more recent pathologists, ihat there is, in addition to the 
obstruciion, a peculiar inflammation induced in the casts of the affected veinsj-— having no 
tendency, like common phlebitis, to spread. 



DR0P3T. 153 

to her lips and cheeks, her palpitations cease, and her dropsy departs. In propor- 
tion as the muscular system in general receives fresh tone and vigour, does that 
particular muscle, the heart, recover the degree of power necessary for tlie effec- 
tual discharge of its proper function; which is very much that of a forcing-pump. 
Such is the way in which we would explain both the dropsy and its cessation. In 
such cases our patients do not simply recover; — they are cured; and we would 
apply the same explanation to some other forms of dropsy. Andral describes a 
certain cachectic condition of the body, as being a cause of dropsy; — persons may 
be bled into a dropsy, and starved or weakened into a dropsy. These are genuine 
instances of dropsy from debdity; — such as the ancients conceived all dropsies to 
proceed from. It may be that the thin or watery condition of the blood, — induced 
by frequent bleedings, by insufficient nourishment, by poisons, or by other causes, 
— may facilitate its escape through the sides of the vessels; but it seems more pro- 
bable, that all dropsies arising in the circumstances just referred to, and without 
any apparent organic disease or change, are mainly, if not entirely, to be ascribed 
to debility of the heart; and, viewed in this way, they are all brought under the 
same general principle; namely, the retardation of the blood in the veins, and the 
consequent preternatural fulness of the blood-vessels. All passive dropsies, at 
least in our opinion, may ultimately be referred to this principle. This principle 
being once admitted, several other phenomena, which could scarcely be adduced in 
proof of its soundness, may find in it their explanation, and thus serve to confirm 
its truth. Persons of a full habit are observed to perspire readily and profusely; 
and it is asserted, that if such persons are bled, the tendency to perspiration either 
yields entirely, or is sensibly diminished. 

Different Forms of Dropsy Contrasted. — In the preceding remarks, extreme 
cases have been taken to elucidate the two classes of dropsy, that have been re- 
spectively denominated " active" and "passive." It may help towards a clearer 
notion of the pathology of which we are in search, if we contemplate the points of 
resemblance and the points of distinction between the two forms. They resemble 
each other in the result; namely, in the collection of serous liquid in the circum- 
scribed cavities and vacuities of the body. They differ in the rate at which the 
collection augments. 

In well-marked acute cases the liquid is rapidly effused, in quantity much ex- 
ceeding the natural amount of exhalation. In well-marked chronic cases, the exha- 
lation goes on as usual; but the fluid exhaled is not taken back again into the cir- 
culating vessels with sufficient facility. In the one case, the circulation is disturbed 
and tumultuous; in the other, it remains tranquil. It is probable that, in the more 
acute forms, the serum passes through the coats of the arteries, or of the capillary 
vessels next adjacent to the arteries. In the completely chronic form, there is a 
defect of absorption by the veins. 

But there are intermediate degrees, in which it appears that the full veins are 
not only unable to admit a new supply of aqueous liquid, but also to retain that 
which they already hold; and serosity exudes from them also. 

What connects all these forms of dropsy, is a preternatural fulness in some part, 
or the whole, of the hydraulic machine. And this seems to be the great key to 
the entire pathology, as well as to the remedial treatment, of the disease."] 

Characters of the Fluid. — With regard to the fluid of these various dropsies in 
the chest (the pleurae and the pericardium), in the peritoneum, and in the head, it 
is sometimes perfecUy clear; but more frequently it is at least turbid; — not trans- 
parent, though translucent. Sometimes it is very turbid indeed; and sometimes 
bloody. The fluid which forms the swelling, in anasarca, is perfectly clear; as is 
proved by the operation of acupuncture. If we make a minute puncture of the 
skin, with the point of a needle, (which is acupuncture,) ahead of fluid, beautifully 
transparent, follows. In the case of chronic dropsy within the head, — chronic 
hydrocephalus, — the collection of fluid is almost like rock-water. In chronic 

* "Library of Medicine;" Volume D; Pages 105 lo 107. 



154 DROPSY. 

hydrocephalus, more frequently than otherwise, the fluid is collected within the 
ventricles of the brain; and this fluid is very little difl*erent from pure water. It 
contains the least possible quantity of animal matter and salts. I believe the fluid 
of chronic hydrocephalus comes nearest to pure water, of any fluid that is morbidly 
collected in the body. 

The Fluid sometimes Shifts its Place, — The swelling, of course, is most con- 
siderable where gravity directs the fluid in the greatest quantity; so that any part 
which is dependent, becomes much more swollen in consequence; and we may 
regulate the swelling, by regulating the posture of the part. But sometimes the 
swelling will shift, independently of any particular position. Where a person is 
lying straight in bed, one day one arm will be swollen, and the next day the other. 
Sometimes it will shift to the leg, and then return to the arm again. This is a 
remarkable circumstance; but one that does occur continually, without any con- 
nection with posture. 

Prognosis. — I did not mention any particulars for forming a prognosis, in cases 
of haemorrhage, or in the case of the various fluxes; because the prognosis is only 
to be made by observing the degree of disturbance on the one hand, and the 
strength of the patient on the other. In dropsy, we must of course follow the 
same rule; but as dropsy, when it is not inflammatory, so frequently depends upon 
organic disease, our prognosis will depend, in a great number of cases of a chronic 
character, upon the evidence which tliere is of organic afl'ection. We have also 
carefully to note, in giving a prognosis with regard to dropsy, whether, although 
the dropsy improves, some other symptom does not continue or get worse. Dropsy 
will sometimes diminish rather suddenly; and the patient, so far from being better, 
(although that is apparently the case,) will die within a very short lime. Some- 
times, a short period before death, all the external symptoms of dropsy have di- 
minished. Sometimes ascites will nearly disappear, or greaUy improve at last; 
and oedema of the legs and the whole body diminish very considerably; and yet 
the patient will speedily die; — perhaps of apoplexy, perhaps of effusion into the 
chest. W^e must not be satisfied with the disappearance of any of the symptoms 
of dropsy. We must also carefully observe whether there are not still sufficient 
symptoms of mischief within, to make us fear the result of the case. Very fre- 
quently the severest symptoms may still exist; and may soon exhibit the most 
dangerous character, after a dropsy has spontaneously diminished. 

Having now given a sketch of the general pathology of dropsy, — let us, in the 
next place, trace out the peculiar features of each of its leading varieties. 



SECTION II.— ACUTE OR FEBRILE DROPSY. 

Anasarca frequenfly exists alone, as an acute febrile dropsy; sometimes as a 
chronic affection; — without, however, any indication of organic disease during life; 
though perhaps, after death, we may find extensive organic disease of the kidney 
or heart. 

Signs of Febrile Dropsy. — When dropsy occurs in the cellular membrane, — 
that is to say, when it contains a preternatural quantity of fluid, — we have a white, 
soft, and inelastic swellmg of the surface; which swelling pits upon pressure. The 
swelling may sometimes be red; because the skin may become inflamed, as well as 
the cellular membrane beneath. It sometimes is not soft, but intensely hard; — 
owing to the high degree of inflammation of the cellular membrane, and the 
fibrinous nature of the eff'usion. 

When this dropsy of the cellular membrane is sudden and febrile, it generally is 
more apparent in the face, than anywhere else; and I believe the reason to be, that 
it generally arises from cold, and the cold is more frequently applied to the face 
than any other part. Usually, when these collections take place, — wherever they 
may be seated, — the urine is scanty; but when the cellular membrane is the seat of 
the afl^ection, and the afluction is of an inflammatory nature, it is very common to 



DROPSY. 155 

See the urine of its natural quantity; — nay, very frequently, I have seen it more 
than it should be.* If we inquire into the state of the head, we commonly find 
that the patient says it is heavy; — perhaps he has violent pain there; but generally 
it is heavy. If we press the abdomen, we frequently find tenderness; but, above 
all, there is generally an inflammatory state of the chest. The patient complains 
either of pain in the chest or of cough; or if the naked ear, or the stethoscope, be 
applied to the chest, either the sonorous or sibilous rattles of the bronchia will be 
detected; or the crepitous rattle which indicates inflammation of the air-cells. 

State of the Pulse. — The pulse, in dropsy of the cellular membrane, is fre- 
quenfly hard and full; and it is from the occurrence of the local symptoms of in- 
flammation in the head, chest, or abdomen; from the strength of the pulse; from 
the suddenness of the occurrence of the dropsy; together with the nature of the 
causes which have produced it, being such as produce inflammation; it is from 
these circumstances that we judge the disease to be of an inflammatory kind.* For, 
although the aflection is so decidedly inflammatory, the cellular membrane is not 
tender. Patients, in general, do not complain of pain, when pressure is made on 
the surface of the body. Yet the inflammatory nature of the dis'ease is snfiicienfly 
shown by the relief experienced on free bleeding, by the bufled and perhaps cupped 
state of the blood, and by the nature of the causes which produced the disease. 
The local inflammation that exists within the head, lungs, or abdomen, may gene- 
rally account for the bufl'y state of the blood, and the relief that is experienced by 
bleeding; but when the dropsy itself ceases so rapidly as it does after bleeding, it 
is impossible not to believe, that the dropsy itself was of an inflammatory kind. 

Causes. — This inflammatory dropsy of the cellular membrane, more frequently 
arises from cold and wet, than from any other cause; whereas inflammatory efl'u- 
sion into the arachnoid, pleura, pericardium, and peritonaeum, may or may not arise 
from that source. I hardly recollect a case of dropsy of the cellular membrane, of 
an inflammatory kind, which did not arise from cold and wet; and it is generally 
accompanied by inflammation of some internal part; or, if not by inflammation, at 
least by an inflammatory state. Perhaps it is combined with an inflammatory 
state of the head; — not with decided phrenitis; but with heaviness, giddiness, and 
pain. Sometimes it is united with an inflammatory state of the abdomen; but, as 
far as I have observed, it is much more frequendy combined with an inflammatory 
state of the lungs; either in the form of bronchitis (which is by far the most com- 
mon) or of pneumonia. 

The more chronic kind of dropsy, which appears independent of inflammation, 
is sometimes united with, and is one of the last symptoms of, structural disease of 
an internal organ In disease of the heart, it is very common for a person to 
become dropsical. In a large number of instances of phthisis, there is oedema of 
the legs, towards the conclusion of the afliection; and when the liver, the uterus, or 

* In febrile dropsy, the urine is scanty, deep-coloured, brown, and more or less turbid, like 
muddy beer. It is full of albumen, also; and its specific gravity is somewhat diminished. 
Often it deposits a brownish or black sediment, — consisting of small black grains: and some- 
times it is red; — either appearance evidently resulting from an admixture of the colouring 
matter of the blood, more or less changed in its characters. These, indeed, are the phe- 
nomena that constitute the link of alliance between febrile and renal dropsies. — ^^ Library 
of Medicine ;^^ Volume b\ Page IZX. 

^ If the serous fluid be the product of inflammation, what is the part inflamed'? It cannot 
be the distended cellular tissue itself; for if so, the inflammation must shift its quarters under 
the influence of gravity. We are far from denying the frequent agency of inflammation in 
producing changes which, in their turn, lead to dropsy; but it will be well not to confound 
those collections of serum mixed with blood orcoagulable lymph, which are distinctly events 
or products of inflammation, with other collections of serum which resemble ihe former in 
thai respect only, but differ entirely from them in every other particular. To those cases 
of dropsy occurring suddenly from" obstruction of one or more of the usual channels ot 
aqueous excretion, and which are usually attended with considerable disturbance of the whole 
system, the epithet ''febrile" would not be inappropriate; though the hot and dry skin, thirst, 
flushed cheeks, full and hard pulse, and furred tongue, render it necessary, practically, to 
regard it as an inflammation.— T. Williams, 



156 > DROPSY. 

the spleen is diseased, dropsy is exceedingly common. But anasarca, as only one 
form of dropsy, often follows others. When a person has fluid in the cavity of 
the pleura, it is usual for the legs, and perhaps the whole body, to become (Ede- 
matous. When there is effusion into the peritoneal cavity, it is very common for 
this ascites (as it is called) to be, sooner or later, followed by cedema of the lower 
extremities; and at last the eff'usion may become general, and constitute anasarca. 

All these particular dropsies closely resemble haemorrhage and fluxes. Haemor- 
rhage and fluxes, as already mentioned,* are frequently of an active inflammatory 
kind; and are to be treated, not by remedies calculated to arrest the flow of fluid, 
but by the remedies of inflammation; — not by astringents, but by antiphlogistic 
measures. On the same principle, inflammatory dropsy is to be treated, not by 
remedies calculated to carry off the fluid, or stop up the mouths of the vessels 
which pour forth the secretion, but by remedies calculated to remove inflammation. 

Renal Disturbance. — [That the functions of the kidneys — which are, in so great 
a measure, complemental of the functions of tlie skin- — should sustain a proportional 
derangement, is what we might expect; and the altered qualities of the secretion— 
the bloody or albuminous condition of the urine — testify, invariably, the strain 
which these organs undergo. Sometimes, though not often, death is the early 
result of the attack; and it is usually preceded by an extreme deficiency, or an 
absolute suppression of the urinary secretion, and by coma. In all the fatal cases 
of febrile dropsy that have fallen under our observation, the kidneys have been 
found large, of a dark chocolate or purplish red colour throughout; — turgid with 
blood, that seemed to be venous. We regard these appearances as being evidences 
of excessive congestion, rather than of inflammation; because neither the ordinary 
and striking symptoms of nephritis, nor the unambiguous products of inflammatory 
action, are usually observed in such cases. We have been informed however, upon 
good authority, of one instance in which coagulable lymph was found effused in the 
pelvis of the kidney. 

When the disease does not prove fatal at once, the dropsical and other symptoms 
give way; — either spontaneously, or under the treatment to be hereafter described. 
But there is much reason for thinking that, unless the overcharged system be 
speedily relieved, the germ of future and progressive disorganization of the kidneys 
may be sown. " Febrile dropsy," and " acute renal dropsy," may be considered, 
without much risk of error, as convertible terms.''] 



SECTION III.— RENAL DROPSY. 

Having, thus far, shown that febrile dropsy is intimately connected with a dis- 
turbance of tlie renal function, we shall next proceed to the consideration of that 
form of dropsy, which arises from organic disease of the kidney, and to which the 
term ^^ renal dropsy''^ has been specially applied, 'i'he following are the chief 
indications which guide us in the diagnosis of these cases: — 1. The absence of any 
direct symptoms of cardiac disease. 2. The complexion of the patient. 3. Occa- 
sionally, certain parts of his previous history. 4. Certain conditions and qualities 
of the patient's urine. 

The morbid conditions on which this form of dropsy depends, have been pointed 
out by Dr. Bright; to whom, indeed, we owe most of our knowledge on this sub- 
ject. They relate to the size, figure, and consistence of the kidney; and also to 
the colour and consistence of its surface and interior. 

«. Morbid appearances of the Kidney. 

Size and Weight'. — [The size of the kidney varies greafly. The average 
weight is about four ounces. M. Rayer has met with some kidneys, in this dis- 

*See Pages 139, 144, and 145. ^ " Library of Medicine;" Volume 5; Page 132, 



DROPSY. 157 

ease, weighing twelve ounces. The increment and the decrement of the natural 
bulk belong principall5^ if not altogether, to the outer secreting portion of the 
gland. If a longitudinal section of an exaggerated kidney be made, the cortical 
part is seen to be unduly broad; and the same part is evidently narrow when the 
whole organ is smaller than common. For this reason, in the latter case, the radiat- 
ing medullary parts approach nearer to the surface than they are observed to do in 
a healthy kidney. Furthermore: it would appear that the enlargement is most 
commonly coincident with the earlier, and the contraction or shrinking with the 
later, periods of the renal disease. 

Consistence and Form. — The consistence of the diseased gland is also variable. 
Sometimes, and for the most part in the earlier periods, it is soft and flabby; some- 
times, and especially in the later periods, it is remarkably compact and hard. The 
size and tiie consistence of the kidney may be said to be, in most cases, inversely 
proportional to each other. Again: the/orm of the kidney, in the disease in ques- 
tion, often undergoes some modification. As the special change proceeds, the 
exterior of the gland shows a tendency to become indented by linear depressions, 
and to present a lobular shape. This, however, is by no means a constant phe- 
nomenon, even in the most advanced stage of the malady. 

Colour and Condition of its Surface. — When the proper investing tunic is 
stripped off, and less distincdy through the same tunic before its separation, the 
surface of the kidney appears mottled, marbled, or stained; of a yellowish gray 
colour in one place, and of a dark or purple tint in another; occasionally it is pale 
throughout its whole extent; more commonly of divers hues, and variegated with 
little streaks; which are portions of veins containing red blood. Sometimes the 
surface is curiously speckled; often uneven, as if strewed with prominent grains; 
and, in some instances, quite rough and scabrous. These several appearances 
are usually the more conspicuous, in proportion as the complaint is the more ad- 
vanced. 

Appearance of the Cut Surface. — The most uniform and characteristic of the 
morbid appearances, however, are those presented by the cut surface of the kidney, 
when it has been divided into two symmetrical portions by a longitudinal incision. 
We then perceive that the cortical substance is the main seat of the morbid altera- 
tion. It has lost in a greater or less degree, or sometimes almost entirely, its 
natural red colour and uniform aspect; sometimes it puts on a speckled or granular 
appearance; but this, in our experience, is less common than a pale homogeneous 
surface^ streaked in general by linear marks; and bearing, when well pronounced, 
a near resemblance to the section of a parsnip. The view of the incised surface 
conveys to an observer the notion of some deposit having taken place; whereby 
the natural texture of the part is obscured, and its blood-vessels are (many or all of 
them) emptied or obliterated; while the healthier medullary masses are displaced 
and pushed aside, — sometimes compressed and encroached upon, — sometimes 
exhibiting the same yellowish appearance interposed between, and opening out, 
their radiating striae. In several instances, along with these changes of appearance 
and structure, we have found the veins that emerge from the kidney blocked up by 
firm coagula of blood. 

Cysts. — The kidney, in some rare cases, is studded, both on its surface and 
througliout its interior, witii numerous small cysts or ceils containing a thin trans- 
parent fluid. These cysts have been inaccurately called " hydatids." It is not 
at all uncommon to meet with one or two such cysts in this diseased state of 
the organ. 

Sanguine Congestion. — There is still another state of the kidney very difl^brent, 
in its appearance, from any that have yet been mentioned; which is thought how- 
ever to be in some cases, if not always, the first stage of all in the disorganizing 
process. Without prosecuting for the present the inquiry how far this notion may 
be founded in truth, we shall describe the state in question. It may be hriclly ex- 
pressed in two words; — " sanguine congestion.''' The whole organ is gorged 
with blood; which sometimes drips freely from it when it is cut open. The kidney 



158 DROPSY. 

is in general somewhat flabby, of a deep and dark red, even of a chocolate or pur- 
plish colour, nearly uniformly diff"used; except that the exposed surface is usually 
diversified by still darker tuft-like spots, which have been ascertained to be the 
Malpighian bodies filled with blood. 

b. Signs of Renal Dropsy during Life. 

Let us in the next place investigate those circumstances which, during the life- 
time of the patient, conduce to the conclusion that the dropsy under which we see 
that he labours is renal. 

1. There is nothing, that we are aware of, very peculiar or distinctive in the 
characters of the anasarca itself. When the renal disease sets in suddenly and with 
acute symptoms, dropsy usually supervenes soon. So also, during its more 
chronic progress, anasarca is apt to show itself, or to increase, whenever inflam- 
mation of any part, or febrile disturbance, may happen to ensue. The more rapid 
and copious the efl'usion, the less do the dropsical parts pit upon pressure. Of this 
renal form of the disease it may also be stated, that an accumulation in the larger 
serous cavities is not, in general, a prominent feature. 

2. We naturally look, in a case of general dropsy, for evidence of disease in the 
thorax, especially of the heart; and, most particularly, of retarded circulation in 
the veins. If we find no material or adequate embarrassment of the respiratoiy 
functions, no deviation from the natural sounds of the heart, no derangement of its 
regular movements, no alteration in the force of its pulsations, or in the space over 
which they may be heard and felt, no distension of the large veins of the neck, — 
we then have reason to suspect, at least, that the anasarca is connected with some 
vitiated state of the kidney. 

3. Again: our judgment is guided or assisted, in some degree, by the complex- 
ion of the patient. When general dropsy depends upon disease of the heart, the 
cheeks and lips are occasionally florid, often purplish or livid, frequently dusky and 
loaded: sometimes the face and mucous membranes are pale (as in chlorotic women, 
■where the heart may be temporarily distended without any strictly organic disease, 
and the blood is thin and poor): but, in the renal variety of dropsy, there is com- 
monly a strikingly characteristic hue — an evident want of red blood, indeed, in the 
capillaries; but an unhealthy, dingy sallowness withal; — an aspect such as reveals, 
to an experienced eye, the existence of some visceral disease in the abdomen. 

4. Our suspicion that the kidney is the organ in fault, is strengthened if we trace 
certain accidents in the history of our patient; — an attack of illness, for example, 
attended perhaps with temporary swelling of the body and disturbance of the 
urinary functions (acute dropsy, in short), soon after some exposure, in unfavoura- 
ble circumstances, to the influence of cold, either applied to the external surface, 
or to the stomach by a draught of cold drink. For there is reason to believe, that 
in acute dropsy is often laid the foundation of those peculiar changes in the kidney, 
which, since they were first pointed out by Dr. Bright, have been chiefly studied 
in their connection with chronic dropsy; — that as rheumatic carditis may occur, and 
become latent as to its eff'ects for some time, and yet implant the germs of future 
cardiac dropsy, so the stress or strain (of whatever nature it be) that befalls the 
kidney, in cases of febrile dropsy, may set on foot a morbid process which long 
works silently and unobserved; but which, at last, gives notice of its operation by 
symptoms; — the reproduction of dropsy in a more chronic form being the most sig- 
nificant symptom of all. The acute attack may have been forgotten; there have 
been no obvious (though there may have been ill understood) indications of the 
renal afl'ection; and its existence has been unsuspected. 

The previous history of intemperate habits, also, would be of importance in aid 
of our diagnosis, if these same habits had not a like influence in causing disease of 
other organs as well as the kidneys, and especially of the heart. There may, 
however, be no such episodes as these in the history of the patient: the dropsy 
may have come on immediately after some exposure or obviously injurious 






DROPsr. i5j 

influence; yet not with acute symptoms, and in a temperate subject: in which case 
it is probable that the renal disease had pre-existed in a latent state; or the anasarca 
may have arisen by degrees, and without any apparent exciting cause. Suppres- 
sion of the catamenia, and blows on the loins, have each been precursory of this 
form of dropsy, sufficiently often to raise a suspicion that the change in the kidney 
has been somehow a consequence of these accidents. 

5. The most remarkable and sure evidence of the existence of the renal disease, 
is to be found in the state of the urinary secretion. Some of the characteristic 
qualities of the urine are very obvious, or easy of detection when sought for; others 
require for their discovery some little chemical knowledge and skill. 

c. Characters of the Urine in Renal Dropsy. 

The more obvious characters of the unhealthy urine relate to its quantity, its 
sensible qualities, the presence of albumen, and its specific gravity; and, because 
th^y are obvious, these are the circumstances which, for the generality of practi- 
tioners, are of chief importance, and most require to be attended to and understood. 

Its Quantity. — The quantity of urine secreted in this disease of the kidney, is 
inconstant. It always falls short of the ordinary standard, in the outset of the 
dropsy. In the acute cases, also, and whenever febrile symptoms supervene in 
the chronic, it is invariably diminished; and by this deficient expenditure of aque- 
ous fluid through the kidneys, while the exhalation from the surface is also scanty 
or annulled (as in most instances it is found to be), may be explained, in great part, 
the occurrence of the dropsical accumulation. As the disease advances, the urine 
often returns to its natural amount; and not unfrequently is secreted in excess. 

The average quantity of urine voided in the twenty-four hours, by a healthy 
adult, has been variously estimated. It may safely be put at about two or two and 
a-half imperial pints; that is, from forty to fifty fluid ounces. Sometimes in the 
disease in question it does not exceed one or two ounces, or is even suppressed 
altogether; and when this is so, the patient must be considered in imminent danger 
of some fatal affection of the brain. More generally, the patient voids from half 
a pint to a pint and a half of urine daily. In certain cases, or in certain stages 
of the disease, and chiefly in the advanced stages, the quantity may reach four or 
five, or even six, pints daily. These observations are to be understood as having 
no reference to the effects of diuretic medicines. 

It may be stated as the rule, that the dropsy lessens as the urine becomes more 
copious, and contrariwise. But to this rule there are numerous exceptions. The 
dropsy may even augment while the quantity of urine is increasing. In such 
cases, other agencies are probably in operation besides tlie mere kidney-disease;— 
such as debility of the muscular parietes of the heart, engendered by the disease; 
or an altered and more aqueous condition of the blood; — to be more particularly 
described hereafter. 

AVhenever we find anasarca steadily persisting, or perhaps extending, while the 
quantity of urine (uninfluenced by diuretics) exceeds the average proper to the 
patient, we have reason to suspect the dropsy to be renal. The same phenomenon 
is, however, sometimes to be observed in the cardiac form of the complaint; as 
well as in the anasarca that occasionally supervenes in the latter stages of diabetes. 

Its Sensible Qualities. — The sensible qualities of the urine are variable al^^o, 
and differ at different periods of the disorder. Often it is dingy and dark-coloured, 
— brown, like slightly turbid beer; sometimes it is distinctly, sometimes obscurely, 
tinged by the colouring matter of the blood; frequently it deposits a dark-brown or 
soot-like powder; which is evidently composed of the coloured particles of the 
blood, changed in appearance, and probably blackened by the acid in the urine. 
Often, also, the urine is of a pale hue, not quite transparent, hazy, exhaling hut 
little of the characteristic smell of healthy urine, frothing readily, and long retain- 
ing its head of froth. This depends on the copious presence of an unusual ingre- 
dient; — to be presently mentioned. Sometimes, but not very frequently, the urine 



160 DROPSY. 

throws down more or less of the common lateritious sediment, and paints the 
bottom of the vessel pink. Sometimes, again, the secretion does not deviate mate- 
rially, or appreciably, in its appearance from that which belongs to health. Of 
these several appearances, that which manifestly arises from the admixture of a 
greater or less quantity of blood, is most to be relied on as indicative of the renal 
disease. It is most common in the early stages of the dropsy; and in the acute 
variety these sanguineous impregnations are rarely, if ever, absent.^] 

Presence of Mlbumen.—K still more important quality of the urine, in these 
cases, is the presence of albumen; and we have been told that our guide for bleed- 
ing in dropsy, — that our guide in forming a judgment as to whether it is inflamma- 
tory or not, — is to be taken from the appearance of the urine. It has been stated 
in a work published by Dr. Blackall, that the quantity and firmness of the coagulum 
of the albumen, is usually proportionate to the existence of inflammation, and to 
the necessity for carrying into practice anti-inflammatory means; but that never- 
theless albuminous urme may, in some cases, be associated with an opposite state, 
— that of debility, — where the use of tonics is clearly indicated. Subsequent 
writers however, more especially Drs. Bright and Christison, have corrected the 
results of, and added much to, the original observations of Dr. Blackall. 

[While Dr. Christison directs attention to the different appearances of the coagu- 
lum of albumen, he does not appear inclined to refer them to any variation in the 
intensity of the inflammation. At the same time, he proposes a very scientific 
nomenclature for the different degrees of coagulability shown by albuminous 
urine when subjected to heat: — 1. Gelatinous by heat. 2. Very strongly coagula- 
ble; — the precipitate separating by heat, and in twenty-four hours occupying 
the whole fluid. 3. Strongly coagulable; — the precipitate occupying half the volume 
of the fluid. 4. Moderately coagulable. 5. Slightly coagulaljle. 6. Fully coagu- 
lable. 7. Hazy by heat; — where the urine becomes cloudy, but does not form 
visible flakes a few seconds after being boiled.^] 

Method of Detecting Jllbumen. — [Its presence may be established by the ma- 
jority of re-agents, which serve for its detection in pure water. The combination 
of the three characters, — coagulability by heat and nitric acid, and its rzon-precipi- 
tation by acetic acid, — aff'ords alone incontestible evidence of the presence of albu- 
men. But these three characters must co-exist; — since a mistake might arise from 
the circumstance, that urine containing milk will coagulate with heat and nitric 
acid; but, unlike albuminous urine, will also coagulate on the addition of acetic 
acid. When the urine contains alkaline materials, although albumen may be pre- 
sent, it will not coagulate by heat. Nitric acid, however, by removing the alka- 
linity, will induce coagulation. Some curious results have been made out by 
Rayer and Guibourt'' on albumen. They have shown, that nitric acid in minnte, 
acetic acid in large, and phosphoric acid in small or large proportions, wfll deprive 
albumen of the property of coagulating by heat. But — what is remarkable — 
larger quantities of nitric acid will immediately precipitate it. These are practical 
facts, that should be known, in the examination of the urine. It may here be 
stated, — on the authority of recent microscopic discoveries and researches by 
Quevenne, Donne, and others, — that the epithelium of the genito-urinary mucous 
surface, undergoes continual desquamation, and that in some diseased states this 
desquamation increases very much; so that, unless carefully examined, the turbidity 
of the urine dependent upon their presence may be mistaken for albuminous 
opaci ty. — Thomas Williams. ~] 

BrighVs Discoveries. — We are indebted to Dr. Bright for a knowledge of the 
fact, that, in organic disease of the kidney, the urine is generally in this albuminous 
state. Andral, in his " Clinical Reports," had previously mentioned a case where 
he found the urine albuminous, and the kidney in a granulated state; but as he 

" " Library of Medicine;" Volume 5; Pages 117 to 121. 
^ Dr. Chrisiison, on Granular Degeneration of the Kidney; Page 44. 
c " Traii^s des Maladies des Reins, et des Alterations de la Secretion Urinaire." Par M. 
P. Rayer. Tome Premier; Page 625. 



DROPSY. 161 

had no more facts in his possession, he came to no general conchision; nor would 
he have been justified in doin^ so. Dr. Bright, however, has collected a lar^e 
niimber of cases; and he finds, that when the kidney is in a disorganized state, ihe 
urine is generally albuminous. 

Organic Disease not necessarily present. — When the urine is albuminous, it 
does not follow that the kidney must be in a state of organic disease. But still, 
even in Andral's case, the kidney was affected, and stated to be gorged with blood. 
Some have gone farther than this; and declared that nobody can have albuminous 
urine, without organic disease of the kidney. I cannot subscribe to this assertion; 
for I have seen patients who were perfectly well a day or two before, but who 
have been exposed to cold and wet; symptoms of inflammatory dropsy have come 
on; the urine has become albuminous; but, on bleeding them, the dropsy has pre- 
sently been got the better of, and the urine has recovered its healthy appearance. 
Why these poor people should be supposed to have had diseased kidneys, merelv 
because they had albuminous urine for a week, is not easily understood. I could 
not open them, to ascertain whether their kidneys were diseased; but as they are 
in perfect health now, and had been in perfect health just before, and the urine is 
no longer albuminous, I do not believe there is any more foundation for supposing 
the existence of organic disease, than there is for supposing that cancer of the 
stomach is present in every case of temporary dyspepsia; because, when people 
die of dyspepsia, we find more or less organic disease. Although a person may 
die with albuminous urine, and we find structural disease of the kidney, it does 
not follow that, when the urine temporarily presents the same phenomenon, and 
the person recovers, he has had any thing more than a functional complaint. Be- 
cause the affection of the kidneys may arrive at such a degree of intensity as to 
destroy life, and organic disease is then always found, it does not follow that the 
temporary formation of albumen in the urine, should be any thing more than a 
functional disturbance of the kidneys. I should draw just the opposite conclusion; 
and should suppose, that if the symptoms were temporary, the disease must be 
functional. Dr. Mackintosh informed me, that some medical students in Edin- 
burgh ascertained, that when they ate pie-crust, and it produced dyspepsia, their 
urine became albuminous. They frequently repeated this experiment, and the 
circumstance is nothing more than I should expect. Dr. Graves has done much 
to dissolve the supposed invariable connection between albuminous urine and dis- 
ease of the kidney. He shows that it often depends on disease of the liver.^ 

If, however, no organic disease whatever can be discovered, in any of the other 
viscera of the body, and there are no indications of acute febrile action; — if the 
patient be evidently sinking under dropsy, and the urine is albuminous, I believe, 
in the majority of cases, (provided the urine is constantly albuminous,) that there 
is organic disease of the kidney. It is generally found granulated, mottled, or 
labouring under great sanguineous congestion. 

Specific Gravity. — [We ascertain, in the next place, the density of the sus- 
pected urine. The same discrepancy is to be regretted in the statements of d>f- 
ferent authors respecting the average specific gravity, as respecting the average 
quantity, of healthy urine. While Dr. Prout places it anywhere between 1010 
and 1015 (that of distilled water being 1000), M. Solon describes it as ranging 
from 1020 to 1024, and Dr. Christison estimates it at 1024 or 1025. We shall 
assume the latter to be the nearest to the truth; — both because it is avowedly 
founded upon the result of numerous trials; and because, if it be not exact, it is less 
likely than the number given by Dr. Prout, to lead us into erroneous conclusions 
in reference to the disease in question. 

Perhaps it is scarcely requisite to admonish the reader, that the question of 
specific gravity must always be contemplated in relation to the absolute quantity 
of urine secreted. The specific gravity depends upon the proj)ortion of the solid 
constituents of the urine contained in a given quantity; if the aqueous portion be 

» See his valuable papers in the " Dublin Journal of Medical Science.' 
VOL. I. 11 



162 DROPSY. 

augmented, the effect upon the absohite density will be the same as if the solid 
contents were proportionally diminished. But when, as frequently happens in 
this renal disease, the specific gravity decreases while the quantity of urine de- 
creases also, that conjunction of phenomena becomes especially significant. 

The three circumstances that have now been mentioned (all of which it is easy 
to determine) — namely, the quantity of urine secreted in a given time, its impreg- 
nation with albumen, and its specific gravity — constitute, together and by compari- 
son with each other, a very accurate and trustworthy test of the presence or absence 
of the renal disease. 

The albumen, not unfrequently, disappears for a time, even early in the disease. 
Sometimes it ceases altogether, although the renal disease may be fixed. This is 
most frequendy the case in the advanced stages of the disease. The general rule 
is, that the albumen is plentiful and almost constant in the outset of the malady; 
less certainly present as it proceeds; and sometimes entirely absent in its latter 
periods. Now it is of importance to remark, that the alteration in the specific 
gravity of the urine follows a contrary law. The declension of density, so far 
from being corrected, augments with the progress of the disorder. Hence the one 
of these morbid phenomena is a valuable check upon the other; — considered as an 
index of what is going on in the kidney. 

At first the specific gravity is not much below the natural standard; but it sinks 
from 1020 perhaps to 1016; and at length, as the renal malady increases, to 1010, 
1008, and even lower. Solon once noticed it as low as 1003, when the di6rnal 
quantity was forty-four ounces. The lowest density ever noted by Dr. Christison, 
— the quantity not being in excess, — was 1004. We may, with Solon, place the 
average specific gravity of the urine in this complaint at 1013. 

Allowing always for the quantity of the secretion, if we find that albumen ceases 
to manifest itself on the application of the proper tests, and the density be decidedly 
low, we must not be led to infer or hope, merely from the absence of albumen, that 
the kidneys are sound. 

These characters of the urine, rightly weighed and interpreted, reveal therefore 
not only the existence of the renal disease, but also, with great probability, the 
stage or degree it has reached. 

d. Changes in the Blood in Renal Dropsy, 

It has also been ascertained, in the disease we are now considering, — 1. That 
the blood often contains urea. 2. That the serum of the blood is apt to be of a 
lower specific gravity, and to be less albuminous, than in the healthy state. 3. 
That the proportion of its fibrin varies. 4. That the colouring matter of the blood 
gradiially decreases in quantity during the progress of the disease. 

Urea in the Blood. — Modern physiologists are agreed, that urea is not formed 
by the kidneys; but merely abstracted by those organs from the blood, as fast as 
it is received or generated there. Whenever this process of separation is sus- 
pended or defective, a portion of urea remains in the circulating blood, and may 
be delected by its proper tests. Urea has been thus discovered in the blood of 
animals after the extirpation of their kidneys. In the blood of patients afflicted 
with renal dropsy, it has been found as plentiful even as in their urine; and not in 
the blood only, bat in the various fluids derived from the blood; and particularly 
in the liquids effused into the ventricles of the brain, the pericardium, pleurae, and 
peritonaeum. According to Dr. Christison, whenever there is a material reduction 
of the daily discharge of urea by the urine, it may be distinctly found in the blood; 
but not otherwise. And he considers the reduction to be material, if the quantity 
excreted be diminished to about one-third of the natural amount. 

Deficiency of Jilbumen. — Again: the serum of the blood has been ascertained 
to contain, in this disorder, a less than common share of albumen, and to be of an 
unnaturally low density. The average specific gravity of healthy serum is 1030. 
It is apt to be reduced to 1024, 1020, and even to 1013. Dr. Babington declares 



DROPSY. 163 

that, in cases of coagnlable urine, he has always found the specific gravity of the 
serum much below the healthy standard. The quantity of albumen in healthy 
blood averages from 65 to 69 parts in 1000. In this disease, Dr. Babington has 
met with as little as 16'10 parts. The general truth of these statements is corrobo- 
rated by the results of Dr. Christison's experience; but the information which he 
renders is more precise. He has noticed that a definite but inverse relation subsists 
between the coagulability of the urine and the density of the serum; — that the more 
albumen there is in the former, the lower is the specific gravity of the latter fluid. 
Hence it is, that the density of the serum is most diminished in the earlier periods 
of renal dropsy; inasmuch as the urine is then most highly charged with albumen. 
In proportion as albumen, with the progress of the malady, becomes less percepti- 
ble in the urine, it becomes more abundant in the serum; the specific gravity of 
which retvirns towards, and may reach, the degree that belongs to health. But in 
all stages ot" the disease, whenever albumen appears plentifully in the urine, — as 
during febrile reaction, — the density of the serum sinks. 

Increase or Decrease of Fibrin. — Again; it results from the concurring expe- 
rience of Dr. Chrislison and Dr. Babington, that the ratio of the fibrin in the blood 
is usually increased in the early stage, and during the existence of febrile disturb- 
ance in any stage of the disease. At the same periods, the blood presents the huffy 
coat. In ordinary circumstances, after the early stage has gone by, the quaniity 
of fibrin most commonly reverts to the natural proportion. In healthy human 
blood. Dr. Christison has found the quantity of dry fibrin to vary from 25 to 52 
parts in 10,000. During the early stage of the renal malady, he has known it as 
high as 82, and as low as 30 parts. Reaction being present, he has met with as 
much as 85 parts in the middle stage, and 56 parts in the advanced stage. In 
other circumstances, it commonly ranges between 27 and 43 parts. 

Decrease of Hsematosine. — Lastly: the colouring matter of the blood, which is 
but little if at all aff'ected in the outset, diminishes gradually where the disease con- 
tinues; and at length is so much reduced, as to form less than a third of the healthy 
average. If venesection be occasionally employed, this process of depravation is 
accelerated; but it takes place, whether blood be artificially withdrawn from the 
system or not. " I am acquainted," says Dr. Christison, " with no natural disease, 
— at least of a chronic nature, — which so closely approaches haemorrhage, in its 
power of impoverishing the red particles of the blood." In the male sex, the 
healthy proportion of the haematosine is 1335 parts in 10,000. In a young man, 
ill three months and a half, subsequently to scarlatina, — who had never been bled 
before, — Dr. Christison has seen this reduced to 427. This change in the blood is 
invariable. 

e. Complications of Benal Dropsy, 

With Cerebral Derangement. — One of the most common and most important 
of these complications, is the occurrence of what are compendiously called "head- 
symptoms;" — various manifestations of derangement in the cerebral functions; — 
headache, — drowsiness, — delirium, — epileptic seizures, — or apoplexy. So fre- 
quently, indeed, is the death of the patient preceded by convulsions or coma, that, 
Dr. Christison has rightly considered this to be the " natural termination" of the 
disease, or "the mode in which it proves fatal, when life is not cut short by some 
other incidental or secondary aff'ection." Of seventy fatal cases observed by Dr. 
Brijrht, death was ushered in by well-marked cerebral symptoms in thirty. 

The circumstances in which these affections of the brain take place, have been 
ascertained with tolerable accuracy. They are almost always preceded by a great 
diminution, or an entire suspension, of the secretion of urine. This connection of 
coma with suppression of urine, has long been recognised; and it is well exemplified 
in the disease under consideration. If the quantity of urine becomes very scanty, — 
so as to amount to no more than two or three ounces in the twenty-four hours; and 
especially if the deficiency occurs suddenly; and more particularly if there be a 



164 DROPSY. 

total cessation of the secretinir function, we may reckon upon the speedy dissohi- 
lion of our patient, and that he will die comatose, and perhaps after convulsions. 
But this rule is not so strict as to offer no exceptions. Occasionally (though sel- 
dom) it happens, that the urine is reduced to a very small amount, while the head 
remains unaffected. Of this Dr. Ciiristison records a remarkable instance: — One 
of his patients passed no more than two ounces of liofht urine daily, for nine days 
before his death; yet he remained sensible to the very last minute of his existence, 
and died simply of inanition. Somewhat less unfrequently, apoplectic symptoms 
arise and carry off the patient; although there has been no extreme or material 
reduction in the quantity of urine. 

When a case has terminated in this manner, serum is sometimes found accumu- 
lated in unnatural measure in the cerebral ventricles, and in the tissue of the pia 
mater. The dropsy has extended to the brain; and, in these circumstances, 
although it may be difficult or impossible to determine when and with what rapidity 
the serum has been effused, its presence and its pressure may fairly be assumed 
to have produced the fatal symptoms. 

In many instances, however, there is found no morbid collection of water within 
the skull, nor any appreciable change: and in some instances there is no dropsy of 
any part: and this fact — taken together with the usual failure in the quantity of 
urine, and the asceitained presence, sometimes, of urea in the blood, and even in 
the natural serosity of the encephalon — has led to the construction of a theory, 
which refers the ultimate symptoms (the stupor and the death), to the poisonous 
influence of the-urea of the unpurified blood upon the brain and nervous system. 
Another not improbable iiypothesis connects the supervention of stupor and coma 
with a pale and watery condition of the blood. That similar symptoms are apt to 
arise in conjunction with a similar defect of haematosine, has been well known 
since the publication of the remarks of the late Dr. Gooch, and of Dr. Marshall 
Hall, on that peculiar form of cerebral affection. It would seem that, in such 
cases, the functions of the brain are exercised irregularly, languidly, and at length 
not at all; — in consequence of the failing supply of its appropriate stimulus through 
the arteries. 

Inflammatory and other Jiffedions. — Another striking circumstance observable 
in this disease, is a readiness of various organs of the body, and particularly of the 
serous membranes, to inflame. Such intercurrent acute inflammation is a not un- 
common cause of death. The pleura is much more often aflfected in this manner, 
than the peritonaeum or the pericardium. 

Disorder of the stomach and bowels is, certainly, a frequent companion of the 
malady; — nausea, — vomiting, — flatulent distension, — diarrhoea. 

It would appear, however, that these incitlental complications prevail with 
irreiiular frequency in different places. They are probably owing, in some measure, 
to local and peculiar agencies. Thus, vomiting and diarrhoea have been more 
familiar to the Edinburgh observers, than in London to Dr. Bright, or in Paris to 
M. Solon; while the headaches and coma so often witnessed by the British physi- 
cians, have been comparatively uncommon in France. 

With Cardiac Disease. — All the writers on this subject, acknowledge the fre- 
quent association of cardiac disease with tlie renal; and, with respect to this 
concurrence of structural alteration in the heart and in the kidney, several obvious 
and interesting, but hitherto unsettled, points of inquiry present themselves. 
vSome of these we may mention, — as being fit subjects for future investigation. It 
is generally difficult, when we find both organs altered in structure, to trace the 
course of the patient's maladies so accurately, as to determine which change has 
been primary, and which consecutive. It is highly probable, indeed, that, in 
certain cases, the cardiac disease and the renal disease have no relation to each 
other, as cause and effect; but are both consequences of some general cause; — of 
habitual intemperance, for example. 

Is the Renal Disease ever produced l)y the Cardiac? — We might more easily 
arrive at an answer to this question, if the real nature of the change which the kid- 



DROPSY. 165 

ney undergoes were better understood. In tlie acute renal rases, where they prove 
early fatal, the kidney is always found to be gorged with blood; and the accustomed 
.admixture of blood with the urine warrants the belief, that the same condition was 
present in patients who have recovered. From tliis state cf engorgement (which 
is not acute inflammation, since the ordinary events of acute inflammation in that 
organ do not follmv) springs, apparently, the subsequent series of changes. It is 
therefore a plausible conjecture, ihat whatever tends to cause congestion of the kid- 
ney, tends also to aggravate, and may even produce, the peculiar changes in ques- 
tion. That disease of the heart, and especially such disease of the heart as leads to 
dropsy, occasions congestion of the venous system, and in this way gorges the 
viscera with blood, is well known. Under this influence the liver often enlarges. 
So that, in cardiac disease connected with dropsical accumulation, we might a 
priori expect congestion of the kidney, and structural alteration in consequence of 
such congestion. 

A serious objection to this view of the matter is presented by the fact, that dropsy 
often arises from disease of the heart, lasts long, and ultimately proves fatal, with- 
out the occurrence of albuminous urine, and without any appreciable change of 
structure in the kidney. It is plain, also, that passive congestion of the kidney, 
produced by disease of the heart, cannot be the sole cause of the renal change; for 
that change is sometimes well marked, though the heart has been unaffected. 

Does the Reyial Disease ever produce the Cardiac? — That it may do so is, at 
least, very conceivable. The heart, no less than other parts of the body, will 
suffer from the deterioration that has been shown to take place in the blood in these 
cases. A sort of anaemia is produced; and anaemia implies debility of the muscu- 
lar texture of the heart, and tends to dilatation of its cavities; and the weak heart, 
becoming irritable also, grows thicker as it labours. This is the form of cardiac 
disease which has been found, in many cases, to be coincident with renal dropsy. 

Where the heart, as well as the kidney, has undergone organic change, the dis- 
position to dropsical accumulation will evidently be augmented; but what share 
these two organs respectively possess in producing the dropsy, it is very difficult, 
and practically not very important, to determine. 

Pain of the Loins. — Pain or tenderness of the loins is sometimes an accompani- 
ment of the renal disease; this symptom is more often present in the early than 
in the latter stages of the malady. It occurred in one-third of the twenty-eight 
cases narrated by M. Soh)n. Dr. Gregory noticed it in the half of his patients. 

Vesical Irritability. — Irritability of the bladder, or rather a morbid frequency of 
the call to micturition, has been spoken of by Dr. Bright and Dr. Christison as a 
common symptom in renal dropsy. It is a symptom, however, belonging to so 
many other disorders that, taken by itself, it has but little value. 

Causes. — The causes of this disease are obscure. It is clearly ascertained that 
its most obvious symptoms, in their chronic form, have, in very many instances, 
begun soon after the exposure of the body to wet and cold under unfavourable cii- 
cumstances. But it is by no means certain — indeed, the probabilities preponderate 
on the other side — that, in these instances, the renal disease had not previously 
existed in its latent state. The influence of external agencies upon the excreting 
functions of the skin, in exciting definite symptoms, is beyond question. 

It is certain, also, that what is called "acute dropsy" (already described*) arises 
in similir circumstances of exposure, and is attended with a marked disturbance of 
the functions of the kidneys; and chronic renal dropsy has sometimes been noticed 
as occurring in persons who had previously suffered, and had apparently recovered, 
from the acuter form. Are we not warranted in supposing that the recovery was 
imperfect in such cases? — that the kidney had sustained irretrievable injury? — and 
that the disease, although (under treatment, or by lapse of time) it had become 
tranquil or latent, was ready again to give indications of its exisiencc, upon any 
repetition of its exciting cause? 

» See Pages 154 to 156. 



166 DROPSY. 

The possible dependence, in some cases, of the renal disease upon disease of 
the heart, has been already noticed.* 

Again: it is matter of common observation, that intemperate habits have often 
preceded the development of the disease. Yet we conclude, that intemperance 
is miher a predisposing than an essential csiuse; — from the fact that the complaint 
is not unknown among children, and other persons whose manner of life has been 
strictly temperate. A marked example occurred lately to the writer in a young 
girl, fifteen years of age, who had not menstruated. And this leads to another re- 
mark; namely, that dropsy with albuminous urine has been observed not unfre- 
quently to follow a sudden check or suppression of the catamenia. In a few in- 
stances, it has seemed to owe its origin to blows received upon the loins, or to 
extreme fatigue. 

jige at which it occurs. — The disease occurs at all ages; less often, however, 
in extreme youth, than afterwards. This malady is much more common in adults; 
— not, in all probability, because the system is more readily affected by it at one 
period of life than another; but because, as life advances, the circumstances which 
tend to produce or foster it become of more frequent operation; — namely, intem- 
perance, exposure to vicissitudes of temperature, fatigue, and disease of the heart. 
It occurs, probably for the same reason, oftener in men than in women.''] 



SECTION IV.— CARDIAC DROPSY. ^ 

[The mode in*which disease of the heart may occasion general dropsy, has al- 
ready been sufficienlly explained.*' In such cases, indications (more or less dis- 
tinct and certain) of the cardiac affection, are generally observable. We judge that 
the dropsy has this origin by the following circumstances: — I. The presence of 
thoracic symptoms; such as cough and dyspnoea, occurring prior to the dropsy. 
2. The direct signs of cardiac disease, such as distended jugular veins, irregular 
movements of the heart, unnatural impulse, or altered sounds. 3. The history of 
some previous acute disease, affecting especially the left side of the thorax; or, 
particularly, by an account of antecedent arthritic rheumatism. 4. The advanced 
age of the patient; — rendering it probable that some of those organic changes in the 
heart and lar^e blood-vessels are in progress, which are almost natural in the dechne 
of life. 5. The absence of all evidence of renal disease. But we see many persons 
who labour unequivocally under organic disease of the heart, yet who survive even 
for years without becoming dropsical. The interesting question, therefore, at once 
arises, — "Of what kind of heart-diseases is dropsy a consequence and symptom?" 
The answer is, — " Of such disease of the heart, as produces a certain amount of 
permanent obstruction to the passage of the venous blood." The permanent obsta- 
cle must be sufficient, in degree, to distend the veins beyond their natural capacity. 
Hence dropsy is especially associated with dilatation of the right chambers of the 
heart. It would be incorrect to say, that the dropsy is dependent on such dilata- 
tion; for the dilatation itself is at once an effect and a sign of impeded transmission 
of the blood from the right side of the organ. Nor is such dilatation a necessary 
attendant on the general accumulation of water. Tiie impediment may be sufficient 
to gorge the right cavities; while it is yet too slight in amount, or too recent in du- 
ration to have dilated them. 

Conditions on which it Depends. — What, then, are the conditions which imply 
an impediment of the kind v/e are now considering? The two great vital organs 
contained within the tliorax, — namely, the heart and the lungs, form different parts 
of one common mechanism; the object of which is to supply every part of the body 
with blood that has been recently exposed to the air; and these organs, thus closely 
related in respect to function, are, moreover, so reciprocally dependent, that any 

a See Page 1G4. »> " Library of Medicine;" Volume 5; Pages 123 to 130. 

« See Page 151 and 152. 



DROPSY. 167 

Structural change occurring in the one tends to produce disease, sooner or later, in 
the other also. 

It is well worthy of observation, that the order in which the diseases of these 
organs are connected, as cause and effect, is a definite and constant order: — takino- 
place in the direction opposite to that in which the blood circulates. Disease ex- 
isting in any part of the circuit formed by the right chambers of the heart, the 
lungs, and the left chambers, becomes a cause of consecutive disease, first in the 
part immediately behind it. The heart itself, as is well known, is seldom diseased 
throughout, or diseased in a like manner and degree throughout; and its partial 
affections, which are exceedingly common, obey the law just announced, as being 
applicable to the whole circuit of the lesser circulation. Thus, organic disease 
situated at the aortic outlet of the heart, and of such a kind as to hinder the exit of 
the blood from the left ventricle, gives rise to permanent changes in that ventricle; 
— to hypertrophy, either with or (less commonly) without dilatation. The hyper- 
trophy is here a truly compensating and conservative change; and when it is 
exactly proportioned to, and keeps pace with, the impedimetit which has given it 
birth, — so as precisely to countervail and balance that impediment, no delay takes 
place in the stream of arterial blood; and the injury is, as yet, confined to the left 
ventricle. That chamber is remodelled and adapted to its purpose by the vis medi- 
catrix naturx; and no other evil manifests itself than, perhaps, some slight en- 
croachment and pressure upon the neighbouring parts, — in consequence of the 
augmented volume of the heart. 

So long as the mitral valve remains healthy and effective, it offers a barrier o 
protection against the extension of the disease in the direction which is retrograde 
in relation to the course of the blood. But at length, in most instances, the stress 
becomes sensible farther back. The left auricle and the pulmonary veins become 
embarrassed, distended, dilated; and the blood is detained in the lungs. Then 
dyspnoea commences. At first it is occasional only; — whenever the heart is tasked 
with the conveyance of a greater quantity of blood, in a given time, than usual; as 
in brisk movements of the body, or strong emotions of the mind; or when it is op- 
pressed by circumstances that diminish the capacity of the chest; — by a fall meal, 
therefore; by flatulent distension of the stomach and intestines; or by the recum- 
bent posture. Afterwards the dyspnoea becomes more or less constant and dis- 
tressing. 

This gorged and embarrassed condition of the lungs, even when it is permanent, 
and has reached a considerable degree, may exist without materially interfering 
with the functions of the right cavities of the heart; for the pulmonary plethora may 
be relieved by increased secretion from the bronchial mucous membrane. Dyspnosa, 
even when it has thus become habitual, may precede for some time any appearance 
of dropsy. 

At last, however, — the effects of the original evil augmenting and extending, — 
the right ventricle also becomes unable duly to propel its contents into the pulmo- 
nary vessels. It continues morbidly full; is first distended occasionally, then per- 
manently, and at length dilated; and with the dilatation we have a turgid venous 
system; — of which we see a part in the prominent veins of the neck. 

In this manner, then, may be explained the series of symptoms, so commonly 
noticed as lile advances. We find irregularity of the pulse, preternatural impulse 
of the heart, occasional dyspnoea, larger crepitation (habitually audible in the lower 
portions of the lungs), and more or less expectoration (sometimes tinged, some- 
times even loaded with blood). Eventually the ankles begin to swell, and the 
patient becomes by degrees (unless cut off earlier in some other way) decidedly 
and universally dropsical. 

Signs accompanying Cardiac Dropsy. — Many of the direct signs of diseased 
heart may exist, therefore, while there is no dropsy; — intermissions and irregularity 
in its movements, palpitation, or the impulse proper to hypertrophy. But when 
dropsy has supervened, we may expect also the signs which denote the dilatation of 
the right chambers. The heart is hard and felt to beat beyond tjie pra3cordial lunits; 



168 ' DRorsY. 

the pulsations become feeble and unequal, if ihey were not so before; the patient 
is liable to fluttering palpitations, — to extreme and panting dyspnoea on the slightest 
exertion;— even on taking food into the stomach, or adopting the horizontal posture. 
His skin assumes a dusky hue; and his lips and extremities are apt to be livid. la 
these cases, the anasarca first becomes manifest about the ankles. During the 
earlier stages, the cedema disappears in the night, and returns towards evening. It 
is sometimes confined, for a considerable period, to the legs; but by degrees it 
ascends towards the trunk of the body, — the integuments of which become doughy; 
lhe scrotum fills, and water collects in the serous bags of tlie abdomen and thorax. 
In extreme cases, the dropsy is universal,— pervading the cellular tissue of the 
head and face and upper extremities. As the accumulation of serous fluid is com- 
monly gradual, the reticular tissue, — partly perhaps through maceration, but cliiefly 
from continued pressure and stretching, — loses its elasticity; and the oedema is soft, 
and pits readily. Sometimes, the fluid continuing to increase, the cuticle is sepa- 
rated by it; and large vesications take place on the limbs; or some part of the 
cellular tissue sloughs, and a breach of surface is made. The fluid drains oflT, by 
this vent, in great abundance;— to the signal relief of the patient. This beneficial 
accident furnishes a valuable hint to the practical physician. 

Causes; Age. — The most common of them all is advancing life. The morbid 
change appears to commence in the aorta; and consists in a deposit of cartilaginous 
or calcareous matter beneath its innermost membrane. By this alteration, the 
elasticity of the artery is impaired; it acquires a facility of dilatation; and the 
onward passage of the blood, after it issues from the \?Si ventricle, is virtually 
delayed: hence increased efforts, on the part of that hollow muscle, to propel its 
contents; and the gradual backward propagation of organic change. It would per- 
haps be more correct to attribute those alterations of structure to that decay, which 
occurs in virtue of a law that extends to all organized bodies, rather than to disease. 
Earthy concretions in the coats of the arteries are met with (according to Bichat's 
experience) in seven persons out of every ten who die beyond the age of sixty; and 
Dr. Baillie declares ossification to be much more common in old persons, than a 
healthy state of the arteries. 

Inflammation of the Cardiac Membranes, — But the cardiac mischief often ori- 
ginates, at an earlier period of life, in acute or chronic inflammation of the mem- 
branes that invest and line the heart. Chronic endocarditis, marked at its outset by 
slight or vague symptoms, appears to be of common occurrence; for its effects are 
very frequently seen in the dead body. Among the causes of this chronic disease, 
habitual intemperance, — especially in excessive or long-continued indulgence in 
ardent spirits, — holds, we believe, the first rank; but acute inflammation of the 
pericardmm, or of the endocardium, or of both simultaneously, is also a frequent 
source of subsequent changes in the proportions of the several chambers of the 
heart. Such inflammation may arise from ordinary causes; and exist and run its 
course independenfly of any other diseased condition. \<\ by far the majority of 
instances, however, it takes place in connection with acute articular rheumatism. 
The frequency of this complication, in those persons at least who suffer from rheu- 
matism in London, is very remarkable. The heart is found to be more or less 
involved in the disease, in not less than one-third of all the patients admitted into 
our hospitals with acute rheumatism. Of rheumatic carditis the following parti- 
culars have been noticed: — 1. Its proper symptoms are often unheeded by the pa- 
tient, amid the severer pains that aflTect his limbs; and may easily be overlooked by 
the practitioner who does not vigilantly search for them. 2. When the cardiac 
symptoms are well marked, or (being but slighfly marked) have been looked for 
and detected, they generally cease (in a great measure, or entirely) with the cessa- 
tion of the joint-disease they accompany; or those signs which remain (as unnatural 
sounds) are not of a kind to induce evident distress, or to claim the attention of the 
patient. 3. Nevertheless the organ seldom (according to the writer's belief, never) 
reverts to its former stale, or undergoes complete repair; but the structural changes 



DROPSY. 169 

left by the inflammation form the germ of further changes; progressive in their' 
character, and ultimately destructive of life. 

Rheumatic endocarditis is more common than rheumatic pericarditis. Each lends 
gradually to produce such conditions of the heart as occasion dropsy; and it may 
be worth while, in our endeavour to analyze and trace home these conditions, to 
consider for a moment the manner in which the consecutive changes are brought 
about. 

Disease of the Valves. — When, in the course of rheumatic fever, inflammation 
befalls the lining membrane of the heart, it affects chiefly the valves; especially, but 
not exclusively, the valves of the leftside of the heart; and, most constandy of all, the 
sigmoid valves of the aorta. It will at once be seen how these valves, — by being 
thickened, or shrivelled, puckered, or rendered stiff' by adhesion to neighbouring 
parts, or affected with ulceration, or perforation, may have their peculiar functions 
permanently injured; — so that they are apt to become, on the one hand, an obstacle 
to the free passage onwards of the blood; — or incapable, on the other, of effectually 
preventing its backward passage. Hence an imperfect emptying of the chamber 
that precedes the seat of the special alteration; — hence continued striving and hyper- 
trophy; and ultimately, according to the degree and place of these changes, an 
extension of disease towards the right side of the heart. 

Again: when acute pericarditis is set up, the inflamed membrane either adheres 
— partially it may be, but more often at all points — to the heart; or it does not 
adhere. If it does not, the patient dies in the primary attack. If it does, all signs 
of cardiac disease may disappear. But the seed of future mischief has been sown: 
*' hseret lateri lethalis arundo.^^^ The free movements of the heart are fettered by 
the adhering bag; the muscle is urged to stronger or more frequent contractions; 
and this is aided by the eff"ects of the endocarditis; which probably never fails to 
accompany, in some degree, the inflammation of the outer membrane. Hence, 
again, the extension of disease in the direction contrary to that of the blood. 

When these facts are taken into account, they will serve to explain how it is, 
that when we come to examine a patient labouring under manifest disease of the 
heart, we so very often trace, in his history, one or more attacks of acute rheu- 
matism. They who have not been in the habit of putting die question as to this 
point, would be surprised at the number of such cases. When the articular rheu- 
matism was present, the heart-afl^ection was perhaps unnoticed; or, if noticed, the 
patient (as he and his medical attendant are apt to think) got quite well; and when, 
at length, unequivocal symptoms of organic disease of the heart force themselves 
upon our attention, its rheumatic origin is too often unsuspected or forgotten. 

Obstruction to the venous current and dilatation of the right chambers of the 
heart may be propagated, in the manner now described, from the left side of that 
organ. But the obstacle may begin at an earlier link of the chain; — as in the lungs; 
and an incidental question of much interest also presents itself; namely: — " In what 
kinds of pulmonary disease is cardiac dropsy liable to originate?" 

Pneumonia. — Whatever tends to gorge the right cavities of the heart with blood, 
tends also to the production of general dropsy. On this principle it might be ex- 
pected, that dropsy would form a symptom or direct consequence of some of the 
acute disorders of the organs of respiration. When, in pneumonia, a large portion 
of one or both lungs becomes impervious by air and blood, or when pleurisy fills 
one side of the thorax with liquid, — which, by its pressure, shuts out at once air 
and blood from one half the respiratory apparatus, — the egress of the blood from 
the right ventricle, and- therefore from the venous system, must be impeded. And, 
in truth, dropsical effusion is occasionally the result of such disease. That it does 
not occur more frequently, is to be attributed to the free evacuations, and the absti- 
nence, which are early put in force in these complaints; and. which relieve the dis- 
tension before it produces eff'usion. In one remarkable instance of acute laryngiiis, 
which fell under our care, the whole body was anasarcous at the time of the patient'3 

» " The deadly arrow remains fixed in the side." 



170 DROPSY. 

admission into the hospital. His life was saved by tracheotomy; but the dropsical 
effusion had previously disappeared, a few hours after one copious bleeding from 
the arm. This case illustrates the tendency to dropsy arising under impeded trans- 
mission of blood through the lungs: it both exhibits a conformity to the general 
principle, and affords a probable explanation of its infrequent operation. 

Tubercular Disease, — Again: lungs that are hollowed out into large cavities, or 
rendered solid over a wide space by numerous tubercles, are manifesdy incapable 
of admitting into their vessels, from the right side of the heart, the ordinary quan- 
tity of venous blood. In these cases, however, the whole mass of blood is di- 
minished, and kept within the limit which does not imply distension of the veins, 
by the constant agency of various causes; — by the imperfect nutrition of such 
patients, in consequence of abdominal disease; by the sometimes copious expecto- 
ration; by the wasting diarrhoea; and by the profuse perspirations. Accordingly, 
dropsy is an unusual symptom in pulmonary phthisis, or shows itself in the latter 
periods only of the disease, in the form of oedema of the legs; and its occurrence 
then is mainly owing to the debility which affects, in common with the other 
muscular parts of the body, tlie moving organ of the blood. 

Emphysema of the Lungs. — The disease of the lung which most commonly 
and certainly, though often very slowly, leads to dropsy, is dilatation, with or 
without rupture, of its air-cells; — in modern nomenclature, " emjo/ii/sema q/" Me 
lungs.^^ In this morbid condition, many of the smaller blood-vessels of the organ 
become gradually obliterated; — in consequence of the pressure arising from the 
stretching of the membranes, upon or between which they ramify. When the 
dilatation is extensive and advanced, the pulmonary texture is visibly white and 
bloodless. Meanwhile, the nutrition of the body is not impaired. The same 
quantity of blood continues to be returned towards the heart; but it finds not a 
ready entrance, when sent from that organ, into the pulmonary blood-vessels. A 
certain amount of accumulation in the right side of the heart and great veins 
becomes habitual; at length, the capillary vessels feel the congestion; and more or 
less anasarca takes place. 

Debility of the Heart. — The same effects upon the venous circulation may arise, 
when there is no primary organic disease of the heart, from mere debility of its 
muscular tissue; — such as often occurs in anaemia; — in what is vaguely called 
"cachexia;" — in exhaustion from habitual loss of blood; — in any case, in short, in 
which the muscular tone is considerably reduced. The muscle is ill-nourished by 
the thin and watery blood; it cannot tighten upon its contents with sufficient force 
to drive them effectually forwards; it may even dilate somewhat under the centri- 
fugal pressure of the resisting liquid; the attenuation of the blood concurs to 
facilitate transudation of its serosity through the coats of the minute vessels; and 
dropsy ensues. The anasarca thus arising from debility of the heart and poverty 
of blood in young, feeble, or delicate women, is so common, as to require a more 
particular description of its features and circumstances. It seldom goes beyond 
oedema of the legs; but occasionally the trunk and arms are slightly infiltrated, 
and the face is puffy and bloated. It is rarely that the large serous cavities are 
affected. 

These patients are pale; their lips, gums, and tongue are without colour, or but 
faintly red; their muscles flabby and weak. They are '• nervous," easily aj^itated, 
of variable spirits, and often hysterical; — subject to palpitation of the heart and 
shortness of breath whenever they ascend a hill, or a flight of stairs, or make any 
exertion. In very many of them, the systole of the heart is attended with a bel- 
lows sound; and a roaring noise, continuous or intermittent, — like the murmur 
heard in certain shells when applied to the ear, — may be heard in the vessels of 
their neck. Their extremities are readily chilled; their feet are cold at night; and 
they suffer in the winter from chilblains. They complain of pain in one or the 
other hypochondrium, most often in the left; and of headache, which either occu- 
pies now one and now the other temple, or is more generally diffused. 

In most instances they are subject to amenorrhoea, or irregular menstruation. 



DROPSY. 171 

Commonly, the discharge is scanty, pale, postponed, and attended with pain; and 
leucorrhoea is present in the intervals. Sometimes they have tenderness along the 
course of the veins of the lower extremities; — particularly of the saphena and femo- 
ral veins. This symptom is frequently observable when the irregularity dales 
from some sudden check to the actual process of menstruation. Usually the appe- 
tite of these patients is slender and fastidious; and they do not like meat. 

This form of cardiac dropsy is almost always curable. Most of the symptoms 
are referable to a deficiency of red blood; and gradually disappear, as the improving 
complexion indicates that the quality of the blood is restored. 

It is necessary to remark, that tumours of various kinds (aneurisms of the aorta, 
cancero\is growths, &;c.) — occupying the thorax, and causing pressure upon the 
large veins in their neighbourhood — may be the cause of general dropsy. The 
same is true of certain malformations of the chest, and of certain displacements of 
the parts within it. In all such cases, the production of the dropsical accumulation 
may be accounted for upon the same general principles as have been applied to the 
explanation of cardiac dropsy.^] 



SECTION v.— GENERAL TREATMENT OF DROPSY. 

[We have next to consider the principles by which our practice in the treatment 
of dropsies is to be regulated. As, in most cases of dropsy, there are two distinct 
sets of symptoms observable, — namely, those which result from the presence of the 
accumulated water, and those which depend on the bodily conditions that have 
produced the accumulation, — so there will arise, in mostcases of dropsy, two main 
indications of treatment; — the removal of the dropsy itself, and the suspension of 
its physical cause. The latter object implies either the complete remedy of the 
morbid conditions productive of the dropsy, or the establishment of some new con- 
dition which shall prevent or countervail their operation. 

These two main indications may be fulfilled, in diflierent cases, with very dif- 
ferent degrees of facility. If the morbid conditions productive of the dropsy be 
cured, or their tendencies averted, the accumulated liquid will in most cases soon 
disappear of itself. But even in these favourable circumstances, its departure may 
often be accelerated by art. On the other hand, the removal of the accumulated 
water may often be accomplished; while the more important indication, — which 
strikes at the root of the disorder, and would prevent its return, — is capable of 
being effected only slowly, and with difficulty, — imperfectly, or not at all. 

The evacuation of the dropsical fluid is first to be attempted through the medium 
of the blood-vessels. Whatever empties the turgid veins, enables and disposes 
them to refill themselves, by drinking up the superfluous liquids of the body; — to 
be afterwards discharged by some of the natural channels of excretion.*] 

Inflammatory Dropsy. ^k\\ these particular dropsies closely resemble haemor- 
rhage and fluxes. It is to be remembered, that haemorrhage and fluxes are fre- 
quently of an active inflammatory kind; and are to be treated, not by remedies 
calculated to arrest the flow of fluid, but by the remedies of inflammation; — not by 
astringents, but by antiphlogistic measures. On the same principle inflammatory 
dropsy is to be treated, not by remedies calculated to carry off" the fluid, or stop up 
the mouths of the vessels which pour forth the secretion, but by remedies calculated 
to remove inflammation. Dr. Blackall, indeed, says that " a correct guide to 
venesection may be found in the firmness, copiousness, and early appearance of an 
albuminous coagulum in the urine; its limits, in the improvement of the discharge 
of albumen in the urine (that is to say, in the diminution of the coagulum), in the 
state of the blood, and the relief of the other symptoms." But I am satisfied, that 
if we take the state of the urine as our guide, we shall often practise very badly. 

* " Library of Medicine;" Volume 5; Pages 1 11 to 116. 
^ " Library of Medicine;" Volume 5; Page 109. 



172 DROPSY. 

T have found it very common for persons to be cured of dropsy by bleeding, 
although no albumen could be discovered in the urine; while, on the other hand, 
during tlie presence of albumen in the urine, persons have derived little benefit 
from bleeding. I have also seen abundance of albumen in the urine, v^^ith'such 
debility of the frame, as to forbid bleeding altogether. I should therefore advise 
that, in every case of dropsy, the question as to bleeding, should be determined 
simply by observing whether there are inflammatory symptoms or not; — consider- 
ing, not the slate of the urine, but whether the symptoms are those of inflammation 
or not. If in any case of dropsy, we fijid a full, strong, and quick pulse, with 
strength of body, we are then to presume that the case is of an inflammatory nature. 
If there be local pain, and other symptoms of local inflammation anywhere, — 
whether in the head, chest, or abdomen, — that is quite sufficient to determine the 
inflammatory nature of the case. Again: if we cannot learn much from these 
particulars, — if the pulse do not show any phlogistic diathesis; and if the head, 
chest, and abdomen, be particularly free from inflammation, and the disease have 
come on suddenly, — as inflammation often does; — if it be not the work of slow 
disease, like visceral affection; but has come on suddenly, and come on from the 
common cause of inflammation (such as the application of cold and wet, especially 
when the body is over-heated); — then the presumption is that the case is inflam- 
matory; and we shall not do wrong if we bleed, so far as the pulse will justify us; 
for the pulse will often justify this treatment, though it will woi point it out. We 
must frequently have recourse to the pulse; — not to learn what to do, but to learn 
whether it will sanction us in doing what other symptoms indicate to be a proper 
procedure. Whenever dropsy comes on suddenly (from the application of cold 
and wet), and the pulse will justify me, I certainly treat it as an inflammatory com- 
plaint. When the pulse is full, accompanied by a phlogistic diathesis, and signs 
of local inflammation, there can be no doubt about the treatment of the case. 

In this form of the complaint, it is useless to employ diuretics; for the same 
reason that astringents are useless in active haemorrhages from mucous membranes. 
If, however, we employ antiphlogistic measures, the fluid will, in most cases, 
gradually disappear. Sometimes it does not; and then it is well, when we give 
purgatives, to exhibit those which are called '^hydragogue;^^^ which cause very 
watery stools. In general, they will answer every purpose. Purgatives are ex- 
ceedingly beneficial, in cases of inflammatory dropsy; for they not only act as 
anti-inflammatory remedies (like bleeding, in diminishing the bulk of the fluids) by 
causing a rapid secretion of fluid on the mucous surfaces; and thus, by acting upon 
the cause of the disease, tend to subdue the inflammation; but they act as palliatives, 
by causing the absorption of the effused dropsical fluid. It would be in vain to 
give diuretics in inflammatory dropsy; for they would not act during the inflam- 
matory state of the system. Diuretics will not then act upon the kidneys; and 
the more the kidneys are stimulated, the less urine is secreted. But when we are 
giving hydragogue purgatives, we are doing the same as bleeding does; and, at the 
same time, we hasten the absorption of what has been collected; and in proportion 
as the inflammation is lessened, so do the hydragogue purgatives exercise more and 
more power over the kidneys. Among the best are elaterium, and a mixture of 
jalap and cream of tartar. 

Treatment of Passive Dropsy. — If the dropsy be of another description, — 
being iinthout any marks of inflammation, — low diet and bleeding will increase 
the collection tenfold. Here wine and perhaps good nourishment become neces- 
sary; together with steel, sulphate of quinine, and various diuretics. In this case 
the disease hangs on the patient so long, and such great inconvenience is felt from 
the collection of fluid, that, although diuretics will not cure the complaint, yet they 
are necessary for the purpose of lessening the quantity of fluid, which is collected 
in the body. Diuretics cannot go to the cause of the dropsy; they only tend to 
lessen the effect of the dropsy. Among the best are digitalis, calomel, squills, and 
acetate of potass; and it is very useful to give these in combination. When we 

» From uJfltfj, water; and aya, to drive out. 



DROPSY. 173 

cannot increase the dose of digitalis, or squills, we may tliat of the potass; there- 
fore, by giving a great number of remedies, we do belter than by trusting to one. 
We may give them to a full amount, by combining several together. The hydrio- 
date of potass, and all the other salts of this alkali, are strongly diuretic. 

Mercury. — The effect of diuretics is very much increased by the exhibition of 
mercury. In inflammatory dropsy, mercury is highly useful as a remedy against 
inflammation; but, in the opposite kind, it frequently would do harm by increasing 
the debility, especially if there were much organic disease; but given in great 
moderation, so as to produce a slight afl*ection of the mouth, it will enable the 
other diuretics to act much more powerfully on the kidneys. Though we some- 
times succeed in curing dropsy, by putting a patient under a profuse ptyalism, 
when all other things have failed; yet generally that is not the case, unless the 
dropsy is in some degree inflammatory, or unless there is inflammation of some 
organ; but, in all cases, the moderate administration of mercury increases the 
effects of diuretics. 

When the chest is oppressed, and we find the patient in danger of sufl'ocation; 
or when the abdomen is distended, and the patient suffers great pain; or when the 
cellular membrane is distended, so that a patient cannot move about; and we cannot 
wait for the cure of the dropsy itself, or of its cause (whatever this may be); — it 
would be right to have recourse to means calculated to get rid of the fluid as soon 
as possible. In these circumstances, violent purgatives (such as elaterium) in full 
doses, answer belter than diuretics; and for this reason; — they cause a greater dis- 
charge; and they frequently go to the cause of the dropsy; and remove some 
obstruction, some congestion, or some inflammation. But, of course, diuretics 
may be given with the purgatives, to increase the effect. It is found useful to give 
diluents at the same time; for diuretics are frequenfly so very acrid, that they 
irritate the kidneys, much more than is necessary for secretion; and their operation 
is much facilitated by the patient's drinking largely of diluents. The same is 
observed with respect to purgatives. They seem to operate a great deal better, if 
plenty of diluents be taken at the same time. 

Mechanical Means. — Sometimes patients are so oppressed with the fluid, that 
they cannot wait any longer. We find that our. remedies does not remove it; and 
then we are obliged to have recourse to certain mechanical means for accomplishing 
this object. These are paracentesis* of the chest, or of the abdomen, and (in cases 
of anasarca'') the making of minute punctures in the skin, with a needle.*' Some 

^ From TrapaxEVTEw, to pierce through. 

^ From ava, through; and <ra^f , fiesh. 

<= The introduciioii of the needles is effected either by smartly pricking the skin, and press- 
ing onwards, while the operator rotates the needle, or by a blow of a small mallet. Since 
the adoption of acupuncture by scientific practitioners, the following mode is preferred:— the 
spot being- selected, usually the seat of pain, or (when any circumstance forbids this) the 
adjacent parts, — the operator, having stretched the skin with the fore and middle fingers of 
the left hand, pierces it perpendicularly with a gentle pressure; and the body of the needle 
is advanced by means of a semi-rotatory motion, in opposite directions, till it has penetrated 
to the required depth. This is repeated till the desired number is introduced. Their with- 
drawal is sometimes effected by means of a forceps; but it will be better to withdraw iheni 
by the same motion with which they were introduced, as the skin is painfully elevated by 
their direct and forcible retraction; possibly, also, by the latter mode, the point of the needle 
might be broken off, if it were not well tempered. The withdrawal of the needle is not fol- 
lowed by hemorrhage; but sometimes a single drop of blood oozes from the puncture. In 
penetrating, the needle often meets with variable degrees of resistance;— according to the 
nature of the parts through which»it passes. The Japanese and Chinese allow the needles 
to remain only while the "patient makes thirty respirations. M. Cloquet states, that he de- 
rived the most marked benefit in cases Avhere he causerl them to be kept in several days: 
[his accords with my own experience. It is true, the pain may cease instantaneously on the 
introdnciion of the first needle; but we ob>erve this by far more frequently after the needles 
have been in some lime. Indeed, so satisfied am I on this point, that 1 prefer a single needle 
remaining for some time in the part, to several introduceci and withdrawn speedily. But 
there is yet no general rule as to the time which the needles ought to be allowed to remair. 
Dr. Bache — who has employed acupuncture successfully in AnieVica, in casesof rhoumatisni 
—stales, that the more chroriic (or long-standing) the disease, the greater will be the length of 



174 . DROPST. 

persons scarify; but I am quite sure that every purpose may be answered with a 
line needle. By making minute punctures in ihe skin, an immense quantity of 
water may be drawn away. There is no occasion to introduce the needle deeply; 
we have simply to put it through the skin, by rotating it between tlie finger and 
thumb; and when it is withdrawn, a bead of clear serum will appear; and the ooz- 
ing wdl perhaps continue for some time. I have known it continue for days even 
after death. Twenty or thirty punctures may be made; and I never saw harm 
arise from the practice, when it was put in force above the knee. But although 
these punctures made with a needle are very minute, and the aperture is merely 
through the skin, i)aiients have lost their lives through them. Gangrene has taken 
place even through this slight operation; but, in every ease of this description that 
has come to my knowledge, the apertures had been made beloiv the knee. It is 
an established rule in scarifying, to make the scarifications as high as possible 
towards the trunk of the body, — near to the most powerful parts of the body; and 
the same rule should be observed with respect to acupunctures, I have used them 
with great success all over the trunk, and upon the tliighs, as low as the knees; and 
I have used them with equal success in all parts of the upper extremities; and I 
never met with any inconvenience. Before I was aware of the danger I frequently 
used them below the knee; and never once did any accident at all dangerous occur 
to me. Gentlemen, however, have related to me cases which came to their own 
knowledge, where the operation below the knee was dangerous; — where it was 
followed by sloughing of the skin; and, indeed, by sloughing of many muscles. 
One patient lost the gastrocnemii;^ and, at the end of two or three weeks, his life. 
These mechanical means are now and then necessary; but less frequently, if the 
disease be treated according as it is inflammatory or not. If we carefully determine 
the presence or absence of inflammation, we shall cure the complaint in a large 
number of cases. At St. Thomas's Hospital, when I have admillied a patient with 
the word '^ dropsy^^ on his letter, I have frequendy been asked — "how 1 could 
admit such a case as that; since it was well known that dropsy could not be cured; 
and that Doctor Fordyce never admitted such cases." One of the greatest improve- 
ments in medicine, is tliat of distinguishing inflammatory diseases from those which 
are not so; and the establishment of the fact, that a great number of diseases are 
nothing more than so many inflammations. One half of the cases of dropsy which 
I see, are of an inflammatory nature; and yield to bleeding, and the other common 
remedies of inflammation. 

time the needles should remain in the tissues. Practitioners who are best acquainted with the 
mode of performing the operaiion, object to forcing ihe needle in by sudden and direct 
plunging; because ihe tissues on iis route are thus wounded; whereas, when the needle is 
gently related, they mainiain that the fibres are only separated. In general, the pain of in- 
troduction is so slight, as lo be entirely disregarded. As a proof of this it may be mentioned, 
that when M. Cloquet drew the ailention of the profession to acupuncture, in Paris, it was 
by no means uncommon to see the students bare the calves of their legs, and insert common 
pins into the substance of the muscles; to convince the incredulous of the innocuity of the 
operation. Sometimes, however, the progress of the needle is marked by sudden and severe 
pain. M. Cloquet describes the pain as bearing some analogy to an electric shock. M. 
Daniu has made the same observation. (When the needle is of an oxidable metal, a gal- 
vanic current issues from it, and is recognised by the galvanic inxAWpVier of Schvjeigger. But 
this circumstance does not appear to have any influence on the efficacy ol acupuncture; 
which is equally successful when the needles are of gold, silver, or platina.) After the 
needle has been a short time introduced, it produces a sensation of pricking, heat, and in 
some instances cold and num.bness; it is surrounded also by an areola, more or less vivid. 
Beclard saw one case, in which the introduction of a needle into the leg, to sooihe acute 
pain, was followed by fainting and delirium. From the impression which it made on. his 
mind, he felt disponed to reject the operation altogether. Fainting, however, must be of rare 
occurrence. M. Cloquet did not observe it ofiener than once in thirty limes, in the thousands 
of cases in which it was employed at St. Louis. In upwards of fifty cases in which Dr. 
Bache employed the needlesj he did not observe a disposition to swooning in more than one 
case; in which, moreover, syncope did not take place; and in no case was any untoward 
consequence observed. Care should be taken to have the. needles perfectly polished before 
using then); as the pain of introducing one that is quite smooth, will be comparatively slight. 
For this purpose, they should be passed into the emery-bag, both before and after use. 
* From yatmii, the stomach,; and xvjjjma, the leg. 



175 



CHAPTER V. 

DEFICIENT SECRETIONS. 

Some diseases are exactly the reverse of hsemorrhao-e, the profluvia, and dropsy; 
-—being distinguished by a deficiency of secretion. In the height of inflammation, 
the ordinary secretion of the part may become scanty. Although it is increased 
at first, it will subsequenlly decrease; — usually remaining, however, beyond the 
natural quantify. Sometimes, in inflammation, the secretion is suspended. The 
secretions of the part itself, as well as the rest of the body, may be diminished 
under active inflammation; — "of the partf for the condition of the secreting 
vessels in this state is incompatible with the discharge of their functions; — "of the 
rest of the body^''^ from the disturbed state of the circulating fluids. This circum- 
stance may occur, however, independently of inflammation. As in violent dis- 
charges, so we sometimes have, without inflammation, a perfect deficiency of 
secretion. This happens, in a most remarkable way, in the case of the kidney. 
Old men will sometimes cease to make water, not from any retention of urine, 
but from a suppression of it; — the kidney ceasing, or nearly ceasing, to secrete. 
In " ischuria renalis," as it is called, we have an instance of a case exactly opposite 
to that which occurs in the profluvia. 'J'he treatment of this particular disease 
will be given hereafter; I am now only speaking of these affections in general. 
We sometimes observe, on opening bodies, a similar state of the serous membranes. 
Sometimes the pericardium, and sometimes the pleura, is perfectly dry; — almost 
as dry as a piece of dried bladder. This is mentioned in many works on Morbid 
Anatomy. I do not know that this state induces any symptoms during life. Ac- 
cording to Reynaud and Stokes, this condition of the pleural surfaces, gives rise 
to the peculiary^zc/ion-sounds in breathing, which mark the approach of pleurisy; 
but the state which is found after death, is precisely opposite to that w^hich occurs 
in the aflTections of which I have just been speaking. 

jiatagonisni of the Secretions. — [It is difficult for the student to understand the 
increase and decrease in the quantity of the various secretions, unless he possess 
some acquaintance with thelaws of relation which exist between them. 

"I. If one surface be more vascular and irritable than another in its neigh- 
bourhood, counter-irritation excited in the latter, will not diminish the morbid 
action in the former. An illustration of this principle is afforded in the example 
of conjunctival inflammation. If a blister be applied to the temple, for the relief 
of this state, it does not diminish the severity of the action; since the mucous 
membrane of the eye is more irritable thaii the neighbouring skin. 

"2. An increased secretion of any given surface or structure, cannot be dimin- 
ished by instituting an artificial discharge in some other part of the same tissue; 
because difl"ereiit portions of the same structure are related to each other by sym- 
path.y, and not by antagonism. Hence a copious secretion from the nose, will 
aff<)rd no relief to the conjunctiva under inflammation attended with discharge; nor 
will a disease of the mucous tract of the urinary organs be benefited by diarrhoea. 

" 3. Structures dissimilar in their oflices antagonize each other; and the cuta- 
neous secretion, therefore, may influence that of the kidneys. This is well known 
to occur; and augmentation of the one, is followed by a proportional diminution 
of the other. In extensive anasarca, the functions of the kidneys are almost en- 
tirely suspended; and suppressed cutaneous exhalation, is oftentimes succeeded by 
discharges from the intestinal and pulmonary mucous surfaces. 

*' 4. When the functions of one organ exercise a positive control of those of 
another, it is observed that their respective secretions have some resemblance, with 



176 CHANGES OP STRUCTURE. 

respect to their effect upon the economy. The skin and kidneys combine to ex- 
crete ivater from the blood. Or the vicarious organ must be labouring under 
morbid predisposition; as when disease of the bronchi or intestine is excited by 
exposure to cold, and a general impression upon the surface of the body."* 

These principles of correlation between the organs of the body, have been 
gathered from the physiological writings of Mliller. They are, however, now 
generally recognised in the science of medicine. — T, Williams.^ 



CHAPTER VI. 

CHANGES OF STRUCTURE. 

Inflammation sometimes produces changes of structure; and as I have spoken 
of those circumstances which merely affect secretion, or the escape of different 
fluids,'' I now proceed to those wliich affect the substance of the body itself. Changes 
of structure, though frequently produced by inflammation, and frequently connected 
with inflammation, are sometimes (like haemorrhages, dropsies, and the proflnvia) 
not connected with it. They are, in the first place, changes of consistence, and 
changes of size; in the next place, transformations, — in which the substance is 
changed in its nature; and thirdly, new formations, — in which something new 
appears, totally different from what we see in the body naturally. Two, or even 
all three of these changes, may occur together. The first of which I shall speak, 
and which are more frequently the effect of inflammation than not, are changes of 
consistence, and changes of size. With respect to changes of consistence, I need 
not say that they can only be two; — hardening on the one hand, and softening on 
the other. I shall first speak of induration. 



SECTION I.— INDURATION. 

Turgescence. — It is to be remembered, in the first place, that induration may be 
only apparent. An organ may feel much harder than natural, — may be really 
harder; and yet we are justified in saying, that the hardness is only apparent. I 
will explain this. If there be extreme congestion in a part that can expand, it will 
become larger, and feel much harder than natural. If there be an obstruction to the 
flow of blood from the liver, though the proper structure of the liver itself will only 
be of its natural hardness, yet, in consequence of the obstruction, it will feel exceed- 
ingly hard; but, on liberating the blood, or making an incision, and letting the 
blood escape, it Vv'ill come down to its natural consistence. This affection may be 
induced by an obstruction during life; and I believe that the. same thing may be 
induced after death, by a violent injection of fluid. We must therefore consider, 
when we see a part indurated, whether it is organic induration, or merely a state of 
great turgescence, or repletion, in consequence of an excess of fluid. 

Organic Induration. — When a part is really hardened, it is generally pale. Of 
course, if the hardness be meiely dependent upon the collection of blood in the part, 
it will be of a deeper colour than usual; but if the part be organically hardened, — 
if it have undergone a hardening process, it is generally paler. As the part is more 
compact, we must suppose that, in general, the diameter of the blood-vessels will 
be less; and, therefore, there will not be such a proportion of blood as there was 

"Mailer's "Physiology;" Second Edition; Volume 1; Page 5i8. 
'' See Chapters" 2 to 5; Pages 136 to 176. 



CHANGES OP STRUCTURE. 177 

before. Sometimes the hardened part acquires a new colour. It may be gray, 
yellow, brown, or even black; but, for the most part, a portion of the body which 
has become indurated, is paler than usual. It does not follow, because a part has 
become indurated, that the size should be altered. A part may be hardened; and it 
may be larger or smaller than before; or it may retain its natural size. We have 
(every day) instances of induration, in the case of a fistula along the side of the 
rectum, and in " fistula in perinaeo." The parts we find here may be all exceed- 
ingly hard. The heart is not unfrequently in this condition; for though this organ 
is more frequently afiected in size, we not unfrequently find the heart hard. Even 
the general cellular membrane is frequently seen hardened; and especially in young 
children. 

Cause of Induration. — This process of hardening is, for the most part, slow; 
and is generally the effect of chronic inflammation. Sometimes ii does not occur 
till the inflammation is entirely over; — till ihe part has become pale, and there is no 
reason to suppose that inflammation exists; and then that process will take place, by 
which the part becomes hardened. 

[It is important to establish that distinction between induration and hypertrophy, 
which is indicated by the essential difference in the actions upon which they respect- 
ively depend. The former necessarily owes its origin to inflammation; the latter 
is the result of an increase in the natural assimilative powers of the part. To con- 
sider intimately the process of induration, it must be remembered that the slowness 
with which the product of the chronic inflammation is efl'used, allows sufficient 
time for the absorption of the fluid portions; — thus leaving the cells of the tissue to 
be occupied by the hardened fibrin exclusively. 

This view of its production immediately suggests, that the mode in which counter- 
irritation frequently either softens or removes the induration of parts, consists in 
exciting a more active inflammation; which, by its rapidly eff^used product, liquefies 
the hardened material, and thus renders it absorbable. In induration, then, the 
albuminous and fibrinous portions of the blood accumulate, unassimilated, in the 
primitive cells and between the particles of the tissue. The material, therefore, 
upon which the hardening of structures depends, is always the same, however dis- 
similar the composition of the latter. That the process of inflammation, however, 
is intimately modified by the organization of the structure in which it occurs, appears 
obvious from the fact, that mucous membranes never undergo the hardening process. 
Nor could such a change be a priori expected; for it is well known, that inflamma- 
tion in them is seldom marked by the effusion of albumino-fibrin; and this further 
accounts for the fact, that mucous surfaces are never agglutinated by common inflam- 
mation. From these observations it at once appears, that if the liquor sanguinis, in 
this simple and chronic action of hardening, were altered by disease in the blood, it 
may give rise, by assuming modified forms, to various malignant and non-malignant 
aflfections; — the deposition of tubercles, carcinoma, melanosis, and so forth, may 
be the result. These, however, will be separately considered. In reference to this 
state. Dr. Carswell* remarks: — "Induration diff'ers from the solidification in acute 
inflammation in this; — that there is, at the same time, increased cohesion of the 
anatomical elements of the aflfected part. Tissues, instead of being more easily 
separated (as in the former state), are more firmly united, or so often confounded 
together as to have lost their distinctive characters; and soft,' spongy, or cellular 
organs, frequently acquire a very great degree of density and tenacity. It is obviously 
the consequence of the organization of the coagulable lymph efl'used, in the second 
stages of acute inflammation, either into the interstitial cellular structure of the organs, 
or into the tissues themselves, in the state of softening induced by \he first stages. 
It is always accompanied by the gray discoloration of chronic inflammation, and 
by a greater or less degree of opacity of the membranous tissues." For a valuably 

a " Pathological Anatomy.— Illustrations of the Elementary Forms of Disease. By Robert 
Carswell, M. D." &c. 

VOL. I. 12 



178 CHANGES OF STRUCTURE. 

practical account of inflammatory changes, we direct the reader to this splendid 
work of Dr. Carsvvell. — Thomas Williams.'] 

Treatment. — When there is no inflammation, the afl?ection is best removed by 
irritating the part. If the hardening be evidently attended by inflammation, anti- 
phlogistic remedies are the best tliat can be adopted. Bleeding, both local and 
general, together with mercury, iodine, fomentations, poultices, friction, and pres- 
sure, are particularly proper. But sometimes there is no inflammation to be 
discovered; and then stimulation of the part answers much better than any thing 
else. It is also of great use to exite a discharge from the part itself, or close to it. 
It will frequently cause an absorption of the excessive matter which has been 
deposited. Occasionally, when there is no inflammation to be discovered, the 
treatment of induration becomes so irritating, that inflammation is set up; so that 
inflammation, although it may at first have laid the foundation of the disease, and 
produced it, yet afterwards has ceased; and then comes on again, as a third stage. 



SECTION II.— SOFTENING. 

The opposite to this change of parts, is softening; called by the French *' ramol- 
lissement;^^ which means nothing more than ''^ softening.''^ Formerly this change 
was very vaguely described. Even induration was commonly described as a termina- 
tion of inflammation, by the name of ''scirrhus;^^ — scirrhus being confounded with 
simple induration. The process of softening is remarkably seen in central parts of 
the nervous system; and also in the alimentary canal. The mucous membrane of the 
stomach and intestines, is frequently reduced to a mere pulp, which may be brushed 
off" with a slight touch of the finger; and sometimes it appears to be removed even 
before death. In the case of the brain, we (every day) see that organ reduced, in 
certain portions, to a mere soft paste. It occurs, also, in the skin; — sometimes in 
the epidermis, sometimes in the cutis itself, and sometimes in the nails. We must 
all have seen the nails so softened, as to appear more like wet card than any thing 
else. This softening will aff'ect the cellular membrane; and then it will allow the 
serous membrane without the intestines (for example), or the mucous membrane 
within, to be peeled ofl". If we can peel off" the peritonaeum from a portion of the 
stomach and intestines, it must be from the subjacent cellular membrane having 
become so softened, that the serous membrane is no longer attached. So, if we 
can peel off" portions of the mucous membrane, it must be from the sub-mucous 
cellular membrane having become so softened, that it is no longer properly attached. 
The cellular membrane will sometimes remain solid, while all the other parts are 
excessively softened. This is seen in the case of the brain, for example, and of 
the spinal marrow. They will become soft; while the pia mater (which corresponds 
with cellular membrane) immediately upon the brain, and immediately upon the 
spinal marrow, will be perfectly firm. A serous membranej such as the peritonaeum, 
will sometimes soften; as also will arteries, and even cartilage, and bone itself. 
Bones may show such a disposition to become softened, that one species of disease 
has acquired the particular name of ^^mollities ossium;^^ and in rickets, — another 
disease of the bones, — they are much below their natural consistence. The muscles, 
too, will sometimes become soft. After a person has been long exposed to the 
operation of lead, in painting, I have seen the muscles become much softer than 
natural; and so pale, as to look like any thing but muscles. The heart itself, like 
other muscles, will frequently become soft. Sometimes the finger may be pushed 
through its parietes, in consequence of the excessive softening which occurs. But 
every structure in the body may become softened. When parts are softened, they 
frequendy retain their natural colour; but sometimes they are paler than they should 
be; sometimes they are redder; and sometimes they become brown and dark. 
There are great varieties with regard to colour; both when a part is indurated, and 
when it is softened. The colour may be unaltered; or it may be paler than natural 
(which is generally the case), or it may be deeper than usual. 



CHANGES OP STRUCTURE. 179 

As with induration, so with softening, a part may sometimes acquire an augmented • 
volume; or it may become smaller; and sometimes its bulk remains unaltered. 
You would not suppose that a part could be very rapidly softened; and yet it is 
certain that a part may be softened in a very short time; — at least, for myself, 
together with many French writers, and perhaps others, I feel satisfied that that is 
the case. It is mentioned by the French, that a few days, if not a shorter time, are 
sufficient to produce a pulpiness of an organ, which before was apparently in a 
state of health. I think 1 have seen sufficient to make me believe that, in an acute 
disease, an organ (previously sound) may lose its natural firmness, and become a 
mere pulp, in a very short space of time. This result is unquestionably due to the 
solvent power of the inflammatory product upon the component tissue of the organ; 
combined with the pressure which, by distending the cells, it exerts upon their 
walls; — thus impeding and suspending their nutrition. 

Induration is generally the effect of chronic inflammation; and softening, in some 
circumstances, arises from the same source. But I have seen a person in tolerable 
health suddenly, without any evident reason, fall into a state of the greatest debility; 
— with most complete prostration of strength; with no pulse; and, in two or three 
days, some organ or other has been found reduced to a pulp. I had great doubts, 
when I first noticed this, of the accuracy of my observation; but on reading the 
French writers, I found that they detailed cases exactly similar; and that they came 
to the conclusion which I felt inclined to entertain, though not without hesitation. 
When very rapid, I do not believe it is always the result of inflammation, or is 
even inflammatory; and when a slow process, I am sure it is not always inflam- 
matory; for the parts are often exceedingly pale. In rickets (or mollities ossium)^ 
what inflammation is there of the bones? 

[This change, which consists in the softening of structures, has been more 
accurately examined in the brain than in any other organ; and, since the process is 
essentially the same in every structure, the brain may be allowed as the type of 
softening in other parts. Dr. Hodgkin* instances the brain of a child affected with 
hypertrophy, to illustrate the dependence of ramollissementupon excessive growth; 
for the texture of the brain, under this rapid nutrition, has not acquired the firm- 
ness which interstitial deposit may give. 

It is, however, pathologically important to distinguish between the one, — which 
is only an excessive process of growth; and the other, — which unquestionably is 
distinct from, and injurious to, the process of nutrition when associated with inflam- 
mation. Dr. Symonds,*" in reference to this point, coincides with the above opinion; 
and declares that softening, as a disease of nutrition, is (compared with that which 
results from inflammation) of infrequent occurrence. — " When softening is due to 
inflammation, the fluid effused, in most cases, not only breaks down the structure 
by infiltration, but also by \is pressure impedes the nutritive deposition. But when 
softening presents itself as a true perversion of nutrition, we find the tissue in one 
of two states; — either those molecules which impart the usual degree of firmness 
are deficient; or, when the tissue is less composite, the ultimate molecules are 
softer than natural." — It is now generally admitted, by morbid anatomists, that the 
colour of the softening is regulated by the previous amount of blood in the part; — 
the transition of the part, however, from one colour to the other, after the com- 
mencement of inflammation, will depend upon changes in the eff'used matter. 
When redness of a part is at first intense, the colour of the resultant softening is 
permanent, until suppuration occurs; when it successively assumes a chocolate- 
brown, green, or gray colour. If the lungs or brain be the seat of these successive 
changes, each state receives distinctive appellations. In the lungs they are known, 
in the language of Andral, as the "ramollissement rouge" and "grise;" in that of 
Laennec, as " hepatisation grise," and in the brain they are recognised under the 
epithets, "red" and " yellow softening." Abercrombie"" has described a white or 

">■ " Cyclopasdia of Surgery;" Page 200. '' " Library of Medicine;" Volume 1; Page lU. 
c u Pathological Researches on the Brain and Spinal Cord." Part I. Section II. 



180 CHANGES OP STRUCTURE. 

colourless softening, in which the cerebral matter is curdy and glistening. This 
change he states to depend upon inflammation; and instances the corpus callosum, 
the septum lucidum, and fornix, as its frequent seat. — Thomas WiUiams.~\ 

Cadaveric Softening. — I have mentioned,^ that every case of apparent induration 
is not to be considered real; for it may depend upon great congestion. From the 
presence of fluid, a part may acquire increased bulk and firmness. But sofiening 
cannot be merely apparent. If a part be soft, there can be no deception in.it. It 
is necessary, however, to guard against an error on this point. Softening may 
occur after death; and merely because, on a post-mortem examination, we find a 
part excessively softened, it is not to be concluded that it was in that state during 
life. Parts will become softened from decomposition; — they will melt down to a 
reddish pulp. I mentioned, when speaking of redness, that a red appearance is 
sometimes mistaken for inflammation;'' whereas it may be only the effect of a red 
fluid which transudes, and encircles and dyes the part. Parts will become softened 
from decomposition. The brain, without any morbid state, very speedily becomes 
soft. Every body knows, that if he wishes to dissect a brain well, he must have 
it fresh; — that if the person has been dead any time, or the brain has been exposed 
to the air, it becomes too soft for accurate dissection. But the fluids within the 
body will themselves sometimes dissolve parts. There can be no doubt that the 
gastric juice will produce a softening of the interior of the stomach; and even do 
more than that. It wfll soften the whole coats of the organ, escape into the cavity 
of the peritonaeum, and soften whatever it comes near. This was discovered by 
John Hunter; and I think we have suflScient proof of the accuracy of his observa- 
tion. The appearances thus arising from the gastric juice, have sometimes led 
persons, who were ignorant of the fact, to imagine that a patient had been poi- 
soned. 

Effects of Softening. — I need not say that, when softening occurs during life, 
it must produce some effect. A large number of cases of paralysis, depend upon 
a softening of the brain, or of the spinal marrow. Some case of fatuity, likewise, 
depend upon a softened state of the anterior portion of the brain. Sometimes 
extreme debility supervenes, when any essential organ (such as the liver, the lungs, 
or the heart) becomes softened. Except in bones, and parts at or near the surface, 
the existence of this softened state cannot, of course, be well known during life. 
We only infer it as probable. 

Treatment. — Induration, I have stated," may in certain cases be removed by the 
remedies of inflammation; while, in others, stimulants will frequently cure it; 
especially if aided by mercury. But it is not known whether a softened state of a 
part can be recovered from. Indeed it is extremely difficult, if not impossible, to 
restore the consistence of an organ, after it has been reduced to the state of pulp. 
If the part show signs of inflammation, the only treatment is that appropriate for 
inflammation. It is difficult to know that the part is softened; it is only seen to be 
inflamed. In cases of paralysis, we cannot tell that the partis softenecl; but when 
symptoms of violent pain at one part of the head and great heat occur, and the 
patient gradually becomes paralytic, there is a probability that the part is softened; 
but still no proof of it is given. If signs of inflammation be observed, they must 
be treated; — without regard to softening or induration. If prostration of strength 
come on, it must be our endeavour to remove it; — not knowing whether the parts 
are softened or not. In the case of the heart, extreme feebleness of its stroke, 
when examined at the chest, is frequently found. 



SECTION III.— HYPERTROPHY. 

The foregoing are changes with respect to consistence; we have others with 
respect to size. If a part really obtain an addition of substance, not dependent on 

» See Page 176. " See Page 80. ^ See Page 178. 



CHANGES OF STRUCTURE. ISl 

transformation, or a new formation, it is said to be hypertropMed. Tliis is a new 
word; but it is a very convenient one. The part suffers an excess of nourishment; 
it is therefore hypertrophied, — over-nourished. 

[An important principle, regulating the formation of all organized textures, has 
been brought to liofht by the microscopic labours of Schwann and Schleiden, in 
Germany. They found, that in the production of any given form of tissue, — such 
as fibre or tube, — natuie does not at once unite the organic molecules in tliat form; 
but first creates, by a definite process, *' round vesicles or cells," and subsequently 
transforms these into the various elements of the organic textures. By the adap- 
tation of these views it can be shown, that nutrition exemplifies the fundamental 
principle of organic assimilation; — each elementary particle attracting similar par- 
ticles from the blood, in order to maintain the integral organ; and, by the changes 
thus impressed upon them, they are caused to participate in the vital principle of 
the organ itself. Under the head of "induration," however, it has been already 
remarked,* that organs may increase in size, independently of inflammation. In 
this state, the albumen and fibrin of the blood accumulate, unassimilated, between 
the particles of the tissue. In proper hypertrophy, however, the assimilative 
action continues, and at an augmented rate. The uterus, in the pregnant state, 
increases in bulk by the addition of real contractile particles, duly assimilated to the 
original tissue. But inflammation is not an increase of the plastic, or nutritive 
process; although its products are susceptible of organization. In hvpertrophy and 
inflammation, " nucleated cells" are equally generated in the effused material. 
These cells may undergo no further transformation: and, with the fluid in which 
they are contained, may constitute pus; or they may proceed to assume the form 
of fibres. But the tissue which thus results is always the same, whatever may be 
the structure of the organ in which the inflammation is seated. In parts which 
are undergoing hypertrophy, however, though the nutritive matter effused assumes 
at first the form of nucleated cells, each tissue exerts a different assimilating influ- 
ence upon it; and causes the transformation of the cells into structuie of its own 
kind, whether fibrous or cellular. — T. WiUiams.~] 

Nature of Hi^pertrephy. — Hypertrophy may aflect one elementary tissue of an 
organ only; or it may effect the whole of an organ togrether, — every tissue of which 
it is composed. It will sometimes affect the cellular membrane; and then this 
becomes thicker and perhaps denser than it should be. A part may be over- 
nourished, without increasing its size. The excess may be such as merely to 
harden it; so that, in one sense, induration may be an hypertrophy. But, very 
generally, when a part is over-nourished, it acquires a considerable excess of bulk. 
If the cellular membrane be over-nourished, and at the same time indurated, dead- 
wliite lines, or semi-translncent streaks, are seen along it. Frequently, only por- 
tions of it fall into this state of excessive nourishment. There may be produced 
tumours which, when cut, resemble a turnip in consistence, and in which white 
and grayish fibres are seen. This is the character of scirrhus; and there is a doubt 
among those who cultivate morbid anatomy, as to whether this ought to be called 
a new formation; or is merely an excessive nourishment — hypertrophy and indu- 
ration — of the cellular membrane. But however this may be, when the cellular 
membrane is thus affected, it presents dead-white, or semi-translucent lines; and it 
may form a tumour in one particular spot. Sometimes the cellular membrane, in 
this state, on being cut, will resemble lard, or imperfect cartilage. 

Tissues mid Orirans liable to Hypertrophy. — Mucous membranes are frequently 
hypertrophied. The villi of the intestines are sometimes very much enlarged; the 
mut-ous follicles are likewise enlarged; and the whole are increased in size. The 
skin frequently suffers this change; — becomes excessively indurated and thickened. 
The brain will sometimes he hypertrophied; though I never saw more tfian one 
instance of this affection. I have seen many instances of partial induration, and 
cases where all the brain was very firm; but there was nothing except a hardening 

• See Pa?e 177. 



182 CHANGES OP STRUCTURE. 

of the organ. In this instance, however, the brain had become larger than it should 
be. It caused the skull to be very much beyond the usual dimensions; and looked, 
on opening the skull, as if it had been ready to burst it asunder. The convolutions 
were all very large. This is a state described by many authors; and, for the most 
part, fatal disease of the brain is at length produced. This patient — a lad, who 
was exceedingly precocious — had a head larger than a man's. His character cor- 
responded with that of an adult; and he suddenly became apoplectic and hemi- 
plegic, and then died. Nothing was to be found but an excessive size of the organ; 
— the brain, in other respects, being healthy. 

The spinal marrow has been seen hypertrophied. Nerves will fall into this state 
after amputation. The nervous ends will become very large; and frequently there 
is a morbid sensibility. Muscles are sometimes seen hypertrophied; but the organ 
most frequently thus affected is the heart. The most common disease of the heart, 
is excessive nourishment of some portion; and that portion is, by far most frequently, 
the left ventricle. Blood-vessels, as well as the heart, will become hypertrophied; 
vessels are sometimes only accessorily hypertrophied; vascular tumours may like- 
wise occur. On examining these tumours, we find nothing but a congeries of 
blood-vessels. Some tumours of this description have been called " fungus haema- 
todes;" but such an appellation leads to a confusion of terms. By ^'•fungus hasma' 
todes^^ we more particularly understand a combination of this state with a deposition 
of encephaloid (brain-like) substance. 

Changes in Size accompanying Hypertrophy. — When a part is over-nourished, 
there is usually (I said*) an increase of bulk. But an excess of nourishment may 
go only to condensation; and then a change of size does not occur, but only a 
change of consistence; and sometimes an organ which is partially over-nourished, 
may be smaller than usual. It will sometimes happen, when an organ is composed 
of more tissues than one, that one tissue will entirely waste; and the wasting of the 
one, may more than counterbalance the over-nourishment of another. With respect 
to the cavity of an organ so hypertrophied, it may sometimes be seen diminished, 
sometimes increased, and sometimes unaltered. That occurs in the case of the 
heart. Sometimes, if the heart be hypertrophied, the cavities enlarge; but some- 
times the deposition of matter takes place outwards, and the heart really is enlarged, 
but the cavity remains much the same. Occasionally, however, the deposition 
takes place inwards; and the cavity becomes greatly reduced. When a part is thus 
hypertrophied, the consistence sometimes remains the same; sometimes it is in- 
creased; and sometimes it is diminished. There is just the same variation in colour. 
Sometimes the colour remains natural; sometimes it is paler; and sometimes it is 
heightened. 

Causes. — I believe that hypertrophy of a part is generally, more or less, of an 
inflammatory nature. Certainly, that is the case with the heart. Hypertrophy 
of the heart is, in most instances, entirely of an inflammatory nature; and, indeed, 
it may be supposed that an excess of nourishment must be the result of an excessive 
action in the part itself; — it must be supposed, therefore, that all the natural pro- 
cesses of the heart are going on with tenfold vigour. If a certain operation be 
necessary to the continuance of nourishment, and it is much increased, an excess 
of nourishment will be afforded. It is impossible, in a great number of cases, to 
consider hypertrophy as any thing more than a sort of inflammatory state. Ex- 
cessive exercise of a part, however, will sometimes cause it to be over-nourished. 
We know that muscles will increase by exercise. A great excess of action in a 
part, will sometimes cause it to acquire a bulk much beyond its natural dimensions. 
Still this is excessive excitement. It is chronic inflammation which causes hy- 
pertrophy; acute inflammation rarely does, — except so far as it lays the foundation 
for hypertrophy. Andral mentions, that hypertrophy may sometimes arise from 
a defect of absorption; — that the absorbents do not carry away the materials that 
they ought. An accumulation of nourishment takes place, without undue nourish- 

» See Page 181. 



CHANGES OP STRUCTURE. 1S3 

ment being deposited. This, however, is but a mere hypothesis. He calls it a 
want of de-assintiilation; — the want of removal of those particles which are already 
deposited, and have served their purpose.* 

State of General Health in Hypertrophy. — When a part falls into this condition 
of hypertrophy, it is necessarily in a state of excessive activity, — though perhaps 
without strength; and, indeed, no mark of inflammation may be discernible. Per- 
sons of the most sickly character, are frequently subject to this affection; as in. 
those unhealthy parts of the world where bronchocele exists; — where the thyroid 
gland falls into a state of hypertrophy. Individuals in those situations are, for the 
most part, m a state of delicate health; — sallow, — shrivelled. So, in rickets, the 
ends of the bones enlarge very much; — they are hypertrophied; but the case is one 
of debility. In scrofula, we frequently see parts become enlarged. The ends of the 
fingers, in a case of decided scrofula, are oftentimes much enlarged; the mesenteric 
glands, and also the upper lip, are much larger than they should be; and yet such per- 
sons are not instances of strength, and of increased vigour. Indeed, in the most 
unhealthy districts, (the valleys of the Alps, for example,) hypertrophy — not only 
of the thyroid gland, but also of the liver, the tongue, the bones, and the hand — 
frequently happens; and yet the persons are pale and emaciated, and no sign of 
inflammation appears. Hypertrophy may induce very serious effects in the case 
of the brain. I believe that sooner or later apoplexy, paralysis, or epilepsy, will 
ensue. In the case of the heart, very great suffering is induced. There is pal- 
pitation from the slightest causes; there is, generally, a strong violent pulse; and, 
at last, there is dropsy. 

Treatment. — The usual remedies for hypertrophy, are the general remedies 
for inflammation; — rest and low diet, with moderate and repeated bleeding. But 
occasionally these measures ar.e not justifiable; and the strength must then be 
supported. Of course, when this affection occurs in a cachectic habit of body, (as 
rickets, or scrofula, or the state of cretinism in the Alps,) any thing that depresses 
the powers of the body may do harm; and good air and good food are the best 
remedies. 



SECTION IV.—ATROPHY. 

The opposite of hypertrophy is atrophy, — wasting. Sometimes the part which 
wastes does not become smaller, but becomes thinner than usual. Its bulk may 
be the same; but its texture may become lighter, — more spongy than usual. Atro- 
phy sometimes affects the whole of an organ; sometimes only a portion, or a tissue; 
and sometimes the part will become thinner and thinner, till at last it is perforated. 
Parts that waste away are generally softer, and frequently paler than natural. 
Atrophy of parts is commonly induced by inflammation, or by violent irritation. 
The excessive nutrition of neighbouring organs, will frequently cause one to waste; 
— the excessive action going on in one, causing the actions of the other to decline. 
A wasting away of the testicles, frequently supervenes on inflammation which has 
followed the mumps. Andral mentions that, after suppuration near the liver, he 
saw the gall-bladder waste away entirely. 

* Dr. Carswell, in his " Illustrations of the Elementary Forms of Disease," resolves the 
causes of hi^pertrophy into three: — 

" 1. The frequent and increased action of an organ in the exercise of its function. 

"2. The existence of a mechanical obstacle to the accomplishment of the function of an 
organ. 

" 3. The long continued influence of a morbid stimulus." 

The firsi is exemplified in the hypertrophic growth of the voluntary muscles, from fre- 
quent and excessive action. Examples of the second are presented to us in the enlargement 
of the walls of the hollow viscera, from obstruction to the ready escape of their contents; — 
the heart, stomach, and bladder may be enumerated. Long and chronic inflammation, and 
irritation of a part, would induce the third. Elephantiasis, and other similar afleclions of 
the integuments, are the best illustrations.— T. Williams. 



184 TRANSFORMATIONS OP STRUCTURE. 

Causes. — Atrophy is frequently an effect of bad air, bad food, depression of 
mind, or deficient exercise. As we must consider hypertrophy in ijeneral to be 
excessive function, so in atrophy there is diminished action, a d'e/zcze^c?/ of function.* 

Treatment. — As it is usually the very opposite state of things from hypertrophy, 
very opposite remedies are usually required. So far from the part being allowed 
to be at rest, it must be well used, if possible; and must also be stimulated as far 
as may be. 



CHAPTER VII. 
TRANSFORMATIONS OF STRUCTURE. 

I NOW proceed to consider those changes, in which one structure is converted 
into another structure, natural to the body. These are called " transformations." 
Though of a diseased character, they are like those which naturally occur, during 
the growth and decline of an individual in health; or else they are the structures of 
which the particular part is actually found to be naturally composed, in some orders 
of the animal series. The cellular membrane is the frame-work of the other struc- 
tures of the body; and, in the natural condition of the body (that is, in its natural 
progress), we observe that when a part is no longer wanted, it degenerates into 
cellular membrane. An instance of this is presented to us, in the thymus gland 
of the foetus. Now such a change will occur merely as a diseased process. A 
part may be resolved nearly into cellular membrane; and that is an instance of 
transformation. Cartilage will sometimes, by disease, become bone; but it is per- 
fectly natural to the progress of the body, that cartilage should become bone in the 
foetus; for cartilage precedes the formation of bone, although recent physiologists 
state, that there are distinctive marks by which the primitive cartilage may be dis- 
tinguished from that which subsequently forms the basis of the bones. For the 
most part, then, the morbid changes which are transformations, are nothing more 
than alterations, precisely the same as those which happen naturally in the progress 
of the human body; or they are alterations of a part to a structure, natural to some 
other animals. Although they are morbid processes, they observe exactly the same 
law as those wliich are natural. One structure is not changed into another, unless 
that same structure is observed to be naturally changed into that other, at some 
period of the progress of the body; or urdess that other is the natural structure of 
the part, in some other of the series of animals. Cartilage, I have said, will 
become bone through disease; and the same is observed as a natural process at 
certain ages; whereas it is never known that, by any disease, a mucous will become 
a serous membrane. As such a change is unknown in physiology, so it is unknown 
in pathology. 

Mucus membranes may be converted into skin, and skin may be converted into 
mucous membranes; muscles will also degenerate into fibrous membranes. Now 

a Dr. Carswell views this organic change as owing its origin to causes which are the 
converse of those inducing hypertrophy: — 

1. Atrophy from a diminished supply of blood. 

2. Atrophy from the diminished exercise of the function of innervation. 

3. Atrophy from the diminished exercise of the functions of an organ. 

The first kind is exemplified in the diminution of bulk which takes place in the brain, 
after ossification of the carotid and vertebral arteries of one side. Atrophy of the testicle 
results from the obliteration of the spermatic artery; of the spleen from the closure of the 
splenic artery; and so on.— The second is illustrated in cases of paralysis. — The third va- 
riety is shown in the effects of artificial anus; — the intestine beneath or beyond being 
reduced to a transparent membrane. Or when one of the bronchial lubes is obliterated, the 
ImigbeyondsitTophisQs.— T. Williams. 



TRANSFORMATIONS OF STRUCTURE. 185 

the very same part which is mucous membrane in one animal, is skin in another; 
and what are muscles in some animals, are merely fibro-li^amentous substances in 
another. These same changes, however, will occasionally take place out of their 
natural course, through disease; and they are then called "transformations." 
Cartilage, on the other hand, is never known, in physiology, lo become mucous 
raembrane. What is cartilage in one animal, is never mucous membrane in another; 
and in the transformations which take place in the progress of the human body 
naturally, cartilage never becomes raucous membrane. So in disease, cartilage is 
never known to be converted into a mucous membrane. 

Cellular Transformations. — Almost all the structures of the body will waste 
into cellular membrane. It is perhaps hardly right to say they are transformations 
into it; because cellular tissue is the frame-work of all the other structures. In- 
deed, it has been said, that if all the various other substances were absorbed, and 
nothing but the cellular substance remained, (provided it could be kept firm,) it 
would maintain the entire form of the body. Parts often appear lo be transformed 
into fat; but Andral considers that this is merely an instance of inordinate secre- 
tion of fat, with or without atrophy of the tissues. 

Membranous Transformations. — We have frequendy a transformation to serous 
membrane. When the extremity of a bone has been dislocated, it will be found, after 
a considerable lapse of time, that a serous membrane is formed around it. If acoa- 
gulum of blood be effused into the brain, or any other firm substance (even a bullet) 
be deposited there, it will become surrounded by a serous membrane (a "capsule," 
as it is called): which secretes serous fluid. Occasionally, when there is a loss of 
substance which nature cannot entirely repair, the space is enveloped by a serous 
membrane. Even when a portion of substance is deficient, not by external vio- 
lence, but by a natural defect, its place is frequently supplied by a serous membrane. 
In a defect of portions of brain, we find in their room a bag, containing liquid; 
which bag is, to all intents and purposes, a serous membrane. What are called 
"apoplectic cells" in the brain, are nothing more than cavities formed by a coagulum 
of blood which has been effused; and which coagulum has had a serous membrane 
formed around it. The coagulum will be absorbed, while the serous membrane 
may remain, and continue to secrete fluid.* 

Such cysts may be formed in almost any part of the body. A serous membrane 
is a closed sac, with a smooth internal secreting surface; and is found in the body 
naturally. Precisely such sacs are formed by disease; and are of all sizes; — from 
that of a pin's head, to a very considerable bulk. We find these cysts sometimes 
placed in juxta-position, either attached or unattached to each other; and sometimes 
they are closely united to the surrounding parts. They may be single, or they 
may be numerous, — solitary, or crowded. Generally there is no red vessel to be 
traced beneath the external surface; and the utmost vascularity is an arborization 
upon this. The part which surrounds these cysts is found in different states. 
Usually it is perfectly healthy, sometimes it is wasted, and sometimes it is in other 

* It is remarked by Miiller, and Heule, that the adventitious membranes, which are pro- 
duced in the lungs to line vomical cavities, and in the brain to circumscribe a clot of blood 
or a collection of matter, although presenting a smooth surface internally, are notwithstand- 
ing wholl}' unUke serous membranes in organization. Delpech and Mr. B. Phillips and 
others state, that these artificial membranes consist of nothing more than a condensation of 
the surrounding tissue, from infiltration of its cells. Bichat, however, declares that all 
cysts are analogous in structure to serous membranes; but this statement is found, by all sub- 
sequent writers, lo be incorrect. But, further, these cysts may undergo a variety of changes, 
without any conformity with the law expounded in the context by Dr. Elliolson. The facti- 
tious lining of morbidly produced bursas, and all diseased cavities, irrespectively of their 
contents, may indiscriminately be transformed into an osseous or cartilaginous .substance; 
or hair may even grow in the most unnatural situations, and from the most diflerent struc- 
tures. These, in addition to other physiological reasons, would induce me to question the 
accuracy of the law of transformations, sought to be established by the author. It is certain, 
.that many transformations of which no type or analogue can be found, either in inferior 
animals, or in the earlier stages of man's development, frequently occur from diseased 
action,— T. WilliaiM. 



186 TRANSFORMATIONS OP STRUCTURE. 

States of disease; as, for example, in a state of induration. Occasionally we find 
these cysts surrounded by pus, or some other secretion. They are frequently sur- 
rounded by celkilar substance, which gives them an additional coat; sometimes they 
become indurated, — even to cartilage or bone; and sometimes they become more or 
less fibrous. The cellular membrane becomes very firm round the fibrinous cup 
of an abscess, and gives it an additional support; and so it is with respect to these 
serous cysts. The cellular membrane around them is frequendy condensed. 

Interior of Adventitious Cysts. — The internal part of these cysts, presents very 
different appearances. Occasionally, and indeed for the most part, it is smooth, — -ex- 
actly as in a natural serous membrane; but it varies, just as natural serous membranes 
do when diseased. When natural serous membranes are diseased, they are frequently 
rough, granulated, or flocculent within; and so the interior of these adventitious 
membranes presents a great variety of appearances; — being occasionally roughs 
with minute granules; and sometimes with large caruncles, as it were. The gra- 
nules which adhere to the interior of these cysts, are frequenUy of an osseous cha- 
racter; or contain, at leasts more or fewer particles of bone. Occasionally we ob- 
serve false membranes lining the interior of cysts; that is to say, fibrin has been 
poured out; — giving them exactly the appearance presented by inflamed serous 
membranes, and of which I spoke formerly.* There are frequently partitions in 
these cavities, — dividing them into compartments. Frequently there are prolonga- 
tions from the interior, runnmg through the cavity of the cyst, and not completely 
dividing it; but causing it to have a number of compartments, communicating more 
or less with each other. 

Contents of Cysts. — The contents of these new serous membranes, as well as 
their internal surface, are very various. Occasionally they contain merely a serous 
fluid; — occasionally they contain blood. They will contain something like mucus; 
—various saline matters, fatty matters, tubercular matter, and some things which 
are peculiar to cysts. There is a far greater variety in the contents of these serous 
cysts, than in those of the natural serous membranes of the body, when the latter 
happen to be diseased. Different substances may be found in different portions of 
the same cyst. We may also find some cysts growing from the inside of others, 
— hanging in them by peduncles; and sometimes, instead of hanging in this man- 
ner, they are attached to the interior by a flat surface of considerable extent. 

Hydatid Formations. — It has been imagined, that all the new formations of the 
body are originally nothing more than cysts; and these cysts have been called 
*' hydatids.'"' The term " hydatid''^ should be confined to a certain animal; but it 
is used vaguely to embrace, not only real animals, but also these serous cysts; 
which are nothing more than morbidly formed serous membranes. It has been 
imagined, that all the new formations of the body were originally hydatids; — that 
is to say, either parasitic animals, or such wew cysts as I have mentioned. One 
compartment of these cysts, it is true, will sometimes be filled with scirrhous mat- 
ter, another with melanotic, and another with encephaloid; and we continually see 
minute serous cysts by the side of scirrhus, melanosis, &c.; whence it has been 
supposed, that these are merely different stages and forms of the same disease. But 
I do not see any proof of it; for when a part has once fallen into a state of disease, all 
kinds of disease will frequently spring up around and in it. Where we cannot 
detect any new serous membrane, but where we see the solid substance of scirrhus 
(for example), it has been supposed, that it was originally nothing more than a 
serous cyst, filled with indurated substance; — that the transverse bands are nothing 
more than new serous cysts, which grew on the inside, and hung by peduncles; 
and which became filled with an indurated substance, until the whole formed one 
mass; — that the fibrous bands we see in scirrhus, are nothing more than different 
serous cysts, all compacted in this way. On this subject, the works of Dr. Baron;"^ 

» See Pages 108 and 109. •> From iJwg, yJaToc, water. 

c " Inquiry, illuslrating the Nature of Tuberculated Accretions," &c.(1819); " Illustrations, 
of the Inquiry," &c. (1822); and "Delineations of the Origin and Progress of Various 
Changes of Structure," &c. (1828). 



TRANSFORMATIONS OP STRUCTURE. 187 

and a paper by Dr. Hodgkin, in the " Medico-Chirurgical Transactions,"^ may be 
consulted. Their views are ingenious; but whether altogether true, I will not pre- 
tend to say. Dr. Hodgkin followed Dr. Baron; and, as far as I can comprehend 
his paper, has only developed Dr. Baron's views. 

Minute sacs, as observed in various parts of the body, are usually nothing more 
than new serous cysts. They are continually met with in the choroid plexus of 
the brain; and they are seen of all sizes; — from the most minute, till they attain a 
very considerable magnitude. 

Mucous Transformations. — With respect to the transformation to mucous mem- 
branes, when a natural mucous membrane is destroyed, it is very common for 
nature to supply a new one. This is, of course, not always a disease; — -any more 
than inflammation is always a disease. When a fistula takes place by the side of 
the rectum, or in the perinaeum, it will acquire alining membrane of a mucous cha- 
racter. Even in an old purulent cavity, a lining of this character is sometimes 
seen. When an abscess takes place in the lungs, and does not heal, but 
remains for a considerable length of time, the internal secreting surface acquires the 
character of a mucous membrane. 

When a new mucous membrane is formed in the lungs, a cavity (constituting a 
vomica) will sometimes exist for years; and both the fistula and the cavity will be 
lined by something like mucous membrane. In all instances of this newly formed 
mucous membrane, — formed through disease, although by a restorative process, — it 
will be found to be one of the most simple character. A new mucous membrane so 
perfect as that ofthe intestines, however, is seldom seen; — it will never exhibit such 
villi. In its utmost state of advancement, it will be only like the mucous membrane 
of the urethra. The urethra presents one ofthe most simple specimens of a mucous 
membrane; while the mucous membrane of the intestines presents an example of a 
perfect description. 

Cutaneous Transformations. — If a mucous membrane be exposed to the 
atmosphere, it acquires all the characters of skin. As already stated, skin and 
mucous membrane may be always classed together;" but if a mucous rhembrane be 
completely exposed to the air, so as to be dried, it becomes exactly like skin. We 
often have an opportunity of seeing this, in the instance of prolapsus ofthe womb. 
When the womb falls through the vagina beyond the external opening, and there 
remains (not being replaced by art), the vagina becomes dry, shrivelled, and pale, 
— like skin; and if it were allowed to remain there permanently, it would be diffi- 
cult to tell the difference between it and skin. When the skin is destroyed, it 
may be reinstated by fresh skin. 

Fibrous Transformations. — Conversion to fibrous membrane is very common; 
and it is the cellular membrane particularly, which undergoes this process. The 
cellular membrane will become indurated, so as to form cords; or so as to form a 
continuous membrane of a fibrous character; and frequently we have it indurated 
and accumulated into a mass. In all these cases, fibres may be seen; and in the 
midst of these fibrous bands may be observed cellular membrane, not yet perfectly 
changed. Tumours consisting of fibrous membrane, or of cellular membrane yet 
imperfectly converted into fibrous, may occur; they may be homogeneous, and may- 
consist of lobes; or, again, gf granules. Sometimes they will become vascular, — 
differing exactly as we see various natural fibrous membranes differ. They are 
more or less firm, according to the change which has taken place; — varying from 
the softness of pulp, to the hardness of bone. The structure surrounding one of 
these tumours, is often perfectly healthy; but sometimes it will be actively inflamed, 
and sometimes it will waste away. These tumours will occasionally take place 
after accidental inflammation; and sometimes they will occur without any obvious 
reason whatever. We sometimes see, that after the cellular has (in this way) been 
converted into a fibrous membrane, it becomes still harder; and forms cartilage, and 
even bone. 

» Volume 15; Page 265. " See Page lOG. 



188 TRANSFORMATIONS OP STRUCTURE. 

Cartilaginous Transformations. — The transformation to cartilage, is also a 
very common morbid process; and takes place exactly in the same circumstances 
as the conversion to fibrous membrane. Very often it succeeds it, and is present 
with it. Wfiat becomes fibrous membrane at first, will often become cartilage after- 
wards. Cartilage, if of diseased origin, is very often formed of cellular membrane 
in the substance of organs; and frequently between the diflferent tissues; so that it 
is common to see it under a serous membrane. Wlien the pleura or the pericardium 
is observed cartilaginous or ossified, it is the cellular membrane immediately under- 
neath the serous membrane, that is converted into bone. When cartilage is formed 
in this way, it is sometimes in mere little points, and sometimes in patches. This 
is a very common occurrence in arteries. Spots in the interior of an artery, of a 
different colour from the rest, excessively firm, — of a cartilaginous character, are 
sometimes seen; and these are formed under the lining membrane of the artery. 
Cartilage is frequently formed like a fibrous tumour, — m lumps or hard knobs. It 
is very common, after chronic inflammation of a serous membrane,— -when the 
whole is thickened together, — to find a knob of cartilage here and there. Serous 
cysts frequently have knobs of cartilage in different parts; and frequently they are 
cartilaginous to a great extent. These knobs are found in the substance of different 
organs; but 1 believe they are for the most part cellular membrane, extending most 
frequently from the surface into the substance, and there increasing in size. 

Cartilage, of new formation, is sometimes seen loose in the cavity. It is very 
common to see it in a joint; and it is not uncommon to see it in the veins of the 
pelvis. I believe it is formed under the synovial membrane, in the one case; and 
under the lining membrane, or inner coat of the vein, in the other. It protrudes, 
till at length it has a peduncle; which peduncle becomes thinner and thinner, till 
the whole is detached; and then we have a loose cartilage in the joint, or in the 
veins. I sent to the University* a specimen of the veins of the pelvis, in which 
were a great many cartilages, which could be moved about from one portion of the 
vein to another, like peas. Transformations to fibrous membrane and to cartilage, 
SO frequently run into each other, that fibro-cartilaginous transformations result. 

Osseous Transformations. — Induration, however, frequently proceeds farther 
than this. The natural change of cartilage info bone, is continually observed to 
take place in disease. After cartilaginous transformation has existed for a long time, 
we frequently find bone produced. It is said that the cellular membrane, fibrous 
membrane, and cartilage, are (strictly and positively) the only parts of the body 
that are ever converted into bone; but whether that is the case or not, they are the 
parts which by far the most frequently are so converted. The loose cartilages 
which I mentioned, as frequently existing in the veins of the pelvis, frequently 
become bone; so that we have hard bony substances loose in these veins; and these 
go by the name of " phlebolites,'"* — vein-stones. 

When bone is deposited, the deposition may take place in the form of minute 
granules; so that the part is rough; — a condition in which the valves of the heart 
are frequently found. Or it may be deposited in the form of scales; — a character 
in which we frequendy see it in the interior of arteries. When the radial artery is 
slit up, we frequendy find bone deposited in minute scales, which may be removed 
from the interior; and sometimes it forms continuous plates. I have seen a kidney 
converted into a bony cyst, in which there was a continuous deposition of bone. 
This is a proper term; because the bone is deposited in a continuous manner, like 
membrane; but it would be wrong to say ^'■membranous.^^ Sometimes it is de- 
posited irregularly, — in an amorphous'' manner. 

It is sometimes deposited abundandy, — forming very considerable masses. We 
occasionally, in encysted tumours, find a piece of bone larger than a walnut; or 
perhaps as big as two walnuts. I have seen at least two or three instances of it. 
Bone thus deposited is sometimes homogeneous. If it be cut, it presents no fibres, 

a University-College, London. 

^ From <j)Xg7rf, <^\zZo^, a vein; and Xj9o?, a stone. 

c From « (privative) without; and fAo^<pti,fQTm. 



NEW FORMATIONS. 189 

and is without any reticulated portion. Sometimes it grows harder than natural 
bone. Sometimes it has rays or cross fibres, like diploe,* with an external com- 
pact substance. We see an instance of nature's highest efforts and powers in form- 
ing new bone, in necrosis; where a deposition, to a considerable extent, lakes place 
under the periosteum; and which deposit will become a perfect bone, surround- 
ing the old one. Diseased formations of bone are found to consist of phosphate and 
carbonate of lime, and of some animal matter; — just like healthy bone; but the 
proportion of phosphate and carbonate of lime is exceedingly various; so that we 
rarely find two cases of bone formed by disease, in which the proportion of the 
two is the same. 

These are the chief observations which it was necessary to make on transforma- 
tions. When structures are so converted, we say it is a transformation; and that 
it is into an analogous structure. That is to say, the structure which is produced, 
is analogous to a natural structure; — to a structure seen somewhere or other in the 
body during health. But besides these, we have new formations; — noX formations 
newly made (that is not the meaning of the term); hni forrnations of a neiv cha- 
racter; — something which is new to the body, and which is altogether of a diseased 
character. These are called ^'■non-analogous or heterologous formations." 



CHAPTER VIII. 

NEW FORMATIONS. 

The chief of these formations, of a solid kind, are tubercles,^ — such as are seen 
in scrofulous cases; melanosis,'^ which is a formation of black substance; and 
sometimes a yellow substance, called cirrhosis.'^ Besides these, there are produced 
certain salme substances, unknown to the healthy body. For example: when 
speaking of calculi, we shall find a substance called " ican/Aic oxide," and another 
called " cystic oxide;" — substances unknown to the healthy body. Some of the 
liquid products of inflammation (pus, for example) are unknown to the healthy 
body. The secretion of serum and of lymph, in inflammation, may be compared 
to analogous transformations. They are liquids subsisting in a healthy body; 
although their appearance in the part is unhealthy; — at least, their quantity is 
unhealthy. But we have a substance produced in inflammation, that is unlike the 
natural fluids of the body; — is ?i new formation, and of a liquid character; — namely, 
pus. There is an analogy running through all these things. In inflammation we 
have the liquid products of the part increased. For example: from a mucous 
membrane we have secreted more mucus than natural, and of an unhealthy quality; 
and from a serous membrane we have serum produced in abundance; — so that these 
may be compared to those changes of structure, in which there is merely an alter- 
ation of size and consistence, and in which the part becomes hardened or enlarged. 
Again: I mentioned that there are some diseases in which there is a deficiency of 
secretion;^ — as, for instance, "ischuria renalis," and drjmess of the skin; and these 
may be compared to softening and atrophy of substance, where there is a deficiency 
of matter. Then again we have, in inflammation, liquids secreted which are 
foreign to the part. For example: we frequently have lymph secreted: and 
though that is a fluid natural to the body, yet it is not natural to the part; and 
these secretions may be compared to those changes of structure, in which one part 

* From JjwXoa;, to double. 

b From " tuberculum," the diminutive of "tuber," a swelling. 

^ From fxsKag, fx&xavog, black. ^ From Ki^^of, yellow. e See Chapter 5; Page 175. 



190 NEW FORMATIONS. 

of the body assumes the character of another part; such as the transformation to 
cartilage or bone. Then, in inflammation, we have pus produced, — a new liquid; 
and (as I shall presently mention) in some diseases, a semi-fluid substance, like 
jelly; which substance is called "colloid,"* — from being like jelly. Sugar is 
sometimes formed in the urine; as well as the cystic and xanlhic oxides, just 
alluded to. Cirrhosis, melanosis, tubercle, and encephaloid, are new solid forma- 
tions. All these are called " non-analogous" or heterologous;" — being heterodox 
matters. Now some of these formations may be organized; — they are organizable, 
if such a word may be used. Scirrhus, for example, is of this description; fungus 
haematodes (as it is called), or encephaloid tumours, may also be organized; but 
tubercular substance cannot be organized. Scrofulous tubercles may become bone; 
but more frequently ihey are softened down, and pus is seen; but they are not 
substances capable of being organized, and forming part of the body. 



SECTION I.— TUBERCLES. 

I shall begin the consideration of new formations with tubercles. The word 
*« tuber cW'' has been employed in a vague sense. It is used by one person in one 
sense, and by another person in another; but there is now a great tendency to 
limit it to a scrofulous deposit. All small tumours in the substance of organs and 
serous membranes, or indeed upon the skin, have been called, and are still called 
*' tubercles;" but the French have adopted the custom of restricting the word to 
tubercles of a scrofulous character; and it is in that sense that I now wish to speak 
of it." 

Seat of Tuberculous Matter. — [In whatever organ the formation of tuberculous 
matter takes place, the mucous system^ if constituting a part of that organ, is, in 
general, either the exclusive seat of this morbid product, or is far more aflfected 
with it than any of the other systems or tissues of the same organ. Thus, the 
mucous system of the respiratory, digestive, biliary, urinary, and generative organs, 
is much more frequently the seat of tuberculous matter, than any other system or 
tissue which enters into the composition of these organs. The deposition of tuber- 
culous matter on serous surfaces, is often observed; as in the cellular tissue gene- 
rally, and on the free surface of serous membranes in particular. In those organs, 
into the composition of which the serous and mucous tissues enter, the tuberculous 
matter may be seen in both at the same time; as in the bronchi and air-cells, and 
in the interlobular cellular tissue; but in such cases it will be found to predominate 
in the former. And in those organs where there is no mucous tissue, — such as 
the brain, muscles, &:c.; — we find the tuberculous matter deposited in the cellular 
tissue which unites their fibres or lamellae. It very rarely occurs that tuberculous 
matter can be detected in the bloody while contained in its proper vessels. But it 
is frequently met with in this fluid in the cells of the spleen; the spongy structure 
of which admits of the accumulation of blood in such quantity, that the tuberculous 
matter can be seen forming in this fluid at some distance from the wall of the cells 
in which it is contained. 

Repeated, careful, and minute anatomical researches, have led us to regard these, 
the mucous and serous surfaces and the blood, as the exclusive seat of tuberculous 
matter. In no instance is this morbid product deposited in the molecular structure 
of organs. It always makes its appearance on free surfaces, as a product of secre- 
tion. We must again repeat, however, that although it may form on serous sur- 
faces, its seat of election is the/ree surface of mucous membranes. There, as into 
the great emunctory of the system, it appears to be separated from the blood, and 
becomes visible to us, under a variety of forms afterwards to be described. As a 

> From xoXXa, glue. 

b Tubercles, in all their varieties, form the subject of a paper (to which the reader is re- 
ferred) in the thirty-eighth volume of the " Edinburgh Medical and SurgicalJournal." 



NEW FORMATIONS 191 

morbid constituent of the blood, we can take no cognizance of the existence of 
tuberculous matter, otherwise than through the medium of the secretions, or until 
this fluid has ceased to circuUue. Then it is seen to separate from the other con- 
stituents (the serum, fibrin, and colouring matter) of the blood; and is distinguished 
from them by the peculiarity of its physical characters/] 

Form and Consistence of Tubercles. — A scrofulous tubercle is of a yellowish 
white colour; and is usually round. It varies from the size of a millet-seed to that 
of a nut; and it is sometimes even still larger. It is firm, but friable; for although 
it is tolerably hard, yet if taken between the finger and thumb, it breaks down; — . 
unless it have been converted into bone; and then, indeed, it is no longer a tubercle. 
Its character is curdy or cheesy; and it softens down into a substance, which is 
non-analogous to the rest of the body. It softens down into a sero-purulent fluid; 
but in this fluid we still have the friable tubercular substance, forming flakes within 
it. When the matter is let out altogether, a curdy substance floating in it is seen. 
When a tubercle softens down, the liquid (of course) has a tendency to escape, like 
the matter of an abscess. There is formed an abscess, which either increases or 
remains stationary for a time; and at length, when it is discharged, there is an 
attempt on the part of nature to heal up the part; — to produce cicatrization. These 
tubercles not being an organized substance, and not being organizable, must increase 
by juxtaposition; — exactly as stones would do, or any thing else inanimate.'' 

Formation of Tubercle. — It is supposed by some that a tubercle is liquid at 
first, and becomes harder afterwards. I should suppose that every thing in the 
body, when first secreted, must be liquid. One cannot conceive that vessels will 
pour forth solids. They all appear destined to hold liquids, however short a time 
the matter may remain fluid after its escape. It may, perhaps, become hardened 
immediately. Neither do I suppose that any thing can be absorbed but liquids. 
It is the opinion of Cruveilhier, that tubercles are liquid at first; and Andral like- 
wise entertains the same opinion. Although they become of a yellowish white 
colour, yet they are at first grayish, and semi-transparent; and the semi-trans- 
parency gives a farther reason for supposing, that they are originally formed liquid. 
It is clear that they do undergo changes; — first having a transparency, and then 
becoming yellow; and we may suppose that there are more minute changes still; 
but changes which occur at too early a period, to render it possible for us to discern 
them. 

Softening of Tubercle. — They soften down, it is said, by a deposition and 
secretion around them, penetrating and breaking them up. But I am not myself 
satisfied that this is a true account; because we often find them softened in the very 
centre, without any liquid which could have got into them. We find them firm 
externally, and liquid within, I should therefore suppose, that the softening of the 
tubercles was really a chemical change; and their not being organized forms an 
additional argument in favour of this opinion. If there be a deposition of external 
liquid matter, which goes into them, certainly the external part ought to be softened 
down as soon, at least, as the interior; but they generally soften at the centre. 
However, it is not invariably that they are softened down at the centre; for they 
will sometimes soften in other parts, especially upon the surface. When they are 
softened down, an abscess is formed, and the tubercular matter escapes. It is very 
common for fresh tubercular matter to be deposited within the cavity, after the dis- 
charge of the contents of the same character. 

Composition of l^ubercle.— When tubercles are not softened down, — when they 
are firm, they are found to consist chiefly of animal matter; with some muriate of 
soda, phosphate of lime, carbonate of lime, and traces of oxide of iron. This, how- 

» Article " Tubercle," by Dr. Carswell, in the "Cyclopaedia of Practical Medicine;" Vol- 
ume 4; Page 253. 

b Dr. Carswell ("Cyclopaedia of Practical Medicine") defines tuberculous matter to be 
" a pale yellow, or yellowish gray, opaque, unorganized substance; the form, consistence, 
and composition of which vary with the nature of the part in which it is formed; and the 
period at which it is examined." 



192 NEW FORMATIONS. 

ever, matters little. It is right to ascertain these points as far as possible, in the 
hope that it may lead to some important discovery hereafter; but siiil we do not 
yel understand their nature better, by understanding of what they consist. Some 
have an exceedingly firm cretaceous earthy matter. Of course, the same sub- 
stances are found in all of them; but in proportion as they are firm, the phosphate 
and carbonate of lime abound, compared with the other materials. Dr. Carswell 
has made some beautiful drawings, representing tubercles in all their various stages; 
as well as numerous specimens of transformations and new formations; — such as 
ossification of the trachea, an ossified cyst, ossification of the valves of the heart, 
and an ovarian tumour containing hone; for teeth, and even hair, have sometimes 
been found in tumours of this description.* 

Organs liable to Tuberculous Deposit. — These tubercles are seen almost every- 
where; — we find them in almost every part of the body; but they are more fre- 
quently met with in free cellular membrane, or in the cellular membrane which is 
a component part of different organs. Besides these situations they are found in 
the liver, in the brain, in the kidneys, in the testicles, and in the lymphatic glands. 
They are also found in the air-cells of the lungs, and in the parietes of these air- 
cells; and they are found also in the lymphatic vessels themselves. 

[We have never found tuberculous matter in cartilage, fibrous tissue, serous, 
synovial, or mucous membranes, tendon, or muscle. When tuberculous matter 
has been found in the serous, synovial, and mucous membranes, the morbid con- 
dition of these membranes, which always accompanies the presence of tuberculous 
matter in them, has not been properly appreciated; for in such cases these mem- 
branes, particularly the mucous and synovial, are completely disorganized by in- 
flammation; and converted into a reddish brown pulp. It is in this substance that 
the tuberculous matter is deposited; as may be ascertained by examining the 
mucous membrane of the intestines, and the synovial membrane of the knee joint, 
when in this state of disease.''] 

The Organs most usually affected at Different Ages. — In adults tubercles are 
by far most frequently found in the lungs; and, next to the lungs, in the small in- 
testines. In three hundred and fifty adults with tubercles in various other parts of 
the body than the lungs, Louis (the celebrated French pathologist) found only one 
whose lungs were free from them. When tubercles exist in adults, therefore, they 
are most frequently found in the lungs; and next to them come the small intestines. 
Speaking still of the adult, after the small intestines comes the mesentery, in point 
of frequency of this affection; — so that all other parts stand at a very great distance 
from the lungs, with regard to the frequency of tubercles in them. The intestines 
and mesenteiic glands stand at a certain distance from the lungs, in point of liability 
to this disease; but all other parts stand even at a greater distance from them. So 
great is the tendency to them in the lungs, that Louis has made the calculation I 
have just stated. The liver is a part in which scrofulous tubercles are less fre- 
quently found than in any other; but they are by no means uncommon in the 
spleen, particularly in infants. In infants, it is very common for other organs than 
the lungs to contain tubercles, while the lungs remain free; which is just the re- 
verse of what is observed in adults. In infants we more frequently find many 
organs aflfected at once than in the adult; in whom nothing is more common than 
to find them only in the lungs. In infants, too, the proportionate frequency of 
tubercles in dilferent organs, is not the same as in adults. The frequency does not 
pursue the order of lungs, intestines, and mesentery; but follows quite a different 
rule. For example: they are far more frequent in the spleen, in the mesenteric 
glands (or, as they are called, the mesenteric ganglia), and in the bronchial ganglia. 
They more frequendy affect those three parts, than the lungs; and they are much 
more frequently found in the nervous centres (the brain and the spinal marrow) of 

» We must refer our readers to the splendid series of pathological plates which Dr. 
Carswell has published; entitled — " lUuslraiions of the Elementary Forms of Disease." 

I' Ariicle "Tubercle," by Dr. Carswell; in the "Cyclopgedia of Practical Medicinej" 
Volume 43 Page 359. 



NEW FORMATIONS. 193 

infants, than of adults. They are very rare, however, in the foetus during its first 
months; but about the fourth year they become far more frequent; though they are 
not then very numerous. From the fourth to the fifth year, they are found to be 
very frequent; and attack many organs at once. So frequent are they in children 
at this period of life (at least in Paris), that Lombard says three-fourths of them 
perish from tubercular disease; or, at any rate, there is a tubercular deposit found 
somewhere or other, after death. After this age they becom.e less frequent, till the 
period of puberty; though they are still more numerous than before the fourth year. 
From the fourth to the fifth year, as we have said, they are very frequent; then 
they decline for a time; but still they are more frequent than before the fourth year. 
It is found that children are more free from tubercles during the second year, than 
at any other period before the fifth. Tubercles are said to occur in men chiefly 
from the age of twenty-one to twenty-eight, and in women especially before the 
age of twenty. In men they appear later than they do in females. 

Not confined to Man. — They are not confined to the human subject: they con- 
tinually arise in brutes. I believe that, both in this country and at Paris, monkeys 
generally die of tubercular disease; and tubercles are found in a large number of 
their organs. They occur also in horses, pigs, cows, rabbits, hares, sheep, and 
birds. It is said that a great number of the parrots which die at Paris, have tuber- 
cles. Parrots, like monkeys, come from a warm climate; and become aflTected by 
the coldness and vicissitudes, of such latitudes as Paris and our own. It is said, — 
but I do not pretend to know much of such matters, — that they are not found in 
dogs. 

Predisposing Causes, — The predisposing cause of tubercles, certainly appears 
to be a want of proper food, and a want of proper external temperature. If an ani- 
mal be kept in the dark, and likewise in a damp situation, — so that it is exposed to 
cold and damp, and particularly if it be fed on not very nutritious food, — we may, 
in many instances, produce tubercles at pleasure. I believe that the great and 
almost the only cause of tubercles, in the human subject, is the want of good food, 
and of a proper external temperature. Exposure to cold and moisture, and parti- 
cularly (perhaps) alternations of temperature, will produce tubercles. When the 
disposition to them is once produced, it becomes hereditary; and children with 
every comfort around them, — well fed and well clothed, — are known to become, at 
a certain age, the victims of tubercular disease. The disposition, when once esta- 
blished, certainly becomes hereditary; but, without any hereditary predisposition, 
thousands and tens of thousands die of tubercular disease, from exposure to cold 
united with moisture, and the want of good food; and (in all probability), in a great 
measure, from vicissitudes of temperature. However, the influences of these 
causes may be much diminished by good food; — by keeping up a good fire within, 
we suffer much less from an external low temperature. It is food which is required 
for this purpose; not mere stimulants, such as spirits or wine. These will not 
answer the purpose. It must be good nourishment; which maintains a slow but 
constant fire (if I may so speak) within; and does not give merely a temporary 
excitement, which always increases the injurious eflfects of a subsequent low tem- 
perature. This subject, however, will be particularly spoken of when I come to 
the treatment of phthisis; which is the great tubercular disease of this country. 

Encysted Tubercle. — This tubercular deposit acquires an enveloping membrane, 
and frequently two. Sometimes no lining membrane is discernible; sometimes the 
deposit takes place in a diffused manner, and it is then said to be " infiltrated;" 
but, in the lungs, the tubercular deposit is more frequently seen surrounded by a 
membrane, than otherwise. We may sometimes observe a capsule; in the interior 
of which we often find a softer membrane; which may be easily peeled off', while 
the external one is frequently pretty tough.*" When it is formed, tubercular de- 

^ The term " encysted'^ whether applied to pulmonary tubercle, or to tubercle in any other 
organ, is (according to Dr. Carsweil) almost always incorrect. " In the lungs," he says, 
"encysted tubercle is a deception; — the distended walls of the air-cells having, in all proba- 
bility, been in almost every case taken for cysts. In like manner, the exiremities of the 
VOL. I. — 13 



194 NEW FORMATIONS. 

posit may remain for years without injury; but if the deposition be very great, it 
forms a source of irritation. If a great quantity be deposited in different parts, — 
and often, indeed, where the deposit is trifling, — the surrounding substance falls 
into a state of irritation; the tubercular substance softens; and that process takes 
place which I have already mentioned.* 

Mppearance of the Ulcerating Cavity. — The cavity, when the matter is dis- 
charged, is for the most part irregular. It is not of a definite shape, but irregular. 
Its parietes generally grow harder and harder; and frequently the tubercular sub- 
stance is not entirely discharged, but adheres pretty firmly to the sides. These 
cavities frequently have sinuses communicating with the external surface, or with 
the large bronchial tubes. When the tubercle has been near the surface, (which is 
very common in the case of the absorbent glands,) the ulcer has generally a flabby 
edge, which is turned inwards; — the very reverse of what takes place when an ulcer 
is cancerous; and it often heals up perfectly well. Even in the case of the lungs, 
we shall see that occasionally such cavities do certainly heal. 

Character of the Pain. — These tubercles are attended by no pain, so far as the 
deposition itself is concerned; but the irritation around is frequently a cause of pain; 
and if a tubercle be near the surface of the lungs, the pleura generally falls into a 
state of inflammation. There is more or less pleuritis; and the person suffers pain 
in the side. When a tubercle is producing much inflammation around, of course 
there must be the usual signs of inflammation. In the case of the glands of the 
neck, there is considerable pain when active inflammation is excited. 

Scrofulous Diathesis. — The disposition to form these tubercles, is called *' a 
scrofulous habit of body;" and the person is said to labour under scrofula (or struma) 
when labouring i;inder such deposits as these. The marks of a constitution so dis- 
posed are, generally, a fair and fine skin, fine soft hair, a dilated pupil, and a large 
upper lip; and it is observed, that when the internal parts labour under scrofula, — 
not the external parts, but the internal viscera, — the extremities of the fingers and 
thumbs, and even of the toes, become enlarged. It is a remarkable circumstance; but 
it happens in a great number of cases of phthisis, and certainly in scrofula of many 
other parts, — such as the liver, and the mesenteric and lymphatic glands, — that the 
ends of the fingers become enlarged. I presume that a faint scrofulous inflamma- 
tion attacks the last joint. Many persons, however, are scrofulous, who have 
neither a fair skin nor soft hair; but, on the contrary, a dark complexion. But still 
they look pale, and have dilated pupils and a tumid lip; and perhaps are pock- 
marked. Those more particularly disposed to it, however, certainly have a fair 
skin, a pulse disposed to be quick, and elongated fingers. When the disease, how- 
ever, becomes established, — when tubercular matter is deposited, the ends of the 
fingers enlarge; so that the nail is prominent. It is like an acorn, — exceedingly 
convex; and the last joint altogether becomes broad. 

This disease, as I said,'' may undoubtedly be hereditary; and is so in a very large 
number of cases. It is a disease that attacks persons of all ages; but particularly 
in the early parts of life; while the disease of which I am now going to speak, is 
rarely seen in the young, — rarely seen before the middle period of life; and generally 
not until after the middle period is past. 

biliary ducts, when dilated, and filled with tuberculous matter, have been described as en- 
cysted tubercles; and we have already said that the dilated air-cells, particularly in the cow, 
— which may vary from the size of a pea to that of a cherry, — have frequently been regarded 
as hydatids. We do, however, meet with encysted tuberculous matter; but not until it has 
undergone important changes, which precede its ultimate removal from the organ in which 
it was formed." (" Cyclopsedia of Practical Medicine;" Article " Tubercle;" Volume 4; 
Page 253.) 
a See Page 191. " See Page 193. 



NEW FORMATIONS. 195 



SECTION II.— CARCINOMA. 



i 



Definition. — [Those growths may be termed " cancerous," which destroy the 
natural structure of all tissues; which are constitutional from their very commence- 
ment, or become so in the natural' process of their development; and which, when 
once they have infected the constitution, if extirpated, invariably return, and con- 
duct the persons who are affected by them to inevitable destruction. The forms of 
disease which may be classed under this head, are extremely various; though, in 
some cases, they pass into each other by imperceptible gradations. This fact, and 
the circumstance that, after extirpation of the disease, one form may take the place 
of another, serve to exhibit the physiological connection between growths, the 
extremes of which often do not show even the most remote similarity of structure. 
After extirpation of common cancer of the mammary gland, " fungus meduUaris" 
may form, either in the breast or in some internal organ. " Carcinoma simplex" 
and " alveolare" are sometimes met with together in the mammary gland; and 
*' carcinoma reticulare" and " melanodes" in the orbit. " Carcinoma fasciculatum," 
altogether fibrous in structure, and destitute of even the most remote resemblance 
either to " fungus meduUaris" or to- common cancer, exactly resembles them in 
physiological characters. 

Alinute Structure of Carcinoma. — The most invariable anatomical character of 
the carcinomatous degeneration, is loss of the proper tissue of the affected part; 
which always disappears during the progress of cancer. Vessels, muscles, nerves, 
glands, bones, and all other tissues, how different soever from each other, become 
alike involved in the same cancerous degeneration. The first appearance of can- 
cerous degeneration, however, does not consist in the mere transformation of the 
previously healthy tissues; but the elementary forms of carcinoma become developed 
between their interstices, and thus displace the natural structure. That this is the 
case, is shown by the way in which the elementary forms of carcinoma are pro- 
duced. It can easily be proved, that the germinal cells of carcinoma are formed, 
not from any previously existing fibres, but from a real seminium morhi; which 
developes itself between the tissues of the affected organ. This is best displayed 
in the alterations which the muscular coat of the stomach undergoes from "carcino- 
ma alveolare." The germinal cells of carcinoma, are deposited between the bundles 
of muscular fibre; which, in the early stages of the disease, are easily distinguish- 
able: at even a later period the muscular layer of the stomach, though enormously 
swollen, may still be recognised; until, at length, the production of the germinal 
cells, equally in all the coats of the stomach, obliterates every trace of their different 
layers, and of the natural structure of the organ. 

The parts in the neighbourhood of a cancer, usually become firmly connected 
with it at an early period: hence carcinoma is less movable than other growths. 
Carcinoma of the stomach adheres to the pancreas, or the liver, that of the female 
breast to the skin, or the pectoral muscles. In the female breast, the condition of 
the nipple and its early retractioff are characteristic; though neither that, nor the 
connection of the scirrhous growth of the pectoral muscles, is invariably met with. 
Indeed, the author* has often observed carcinomatous growths, in which neither of 
these occurrences had taken place. The retraction of the nipple, in cancer of the 
mammary gland, depends on its proximity to the disease. The swelling of the 
axillary glands, in carcinoma of the breast, and the existence of similar swellings 
in other neighbouring parts, are both important. The dilatation of the veins, how- 
ever, cannot be depended on as a sign of malignancy. 

Presence of Septa. — In cancer of the stomach, the condition of the muscular 
coat affords a sure anatomical sign of carcinoma, whatever may be its form. In 
most cases of carcinomatous disease of the walls of the stomach, the muscular 
coat not merely becomes exceedingly swollen, but its section presents a partitioned 

» Muller. 



196 NEW FORMATIONS. 

appearance; which is partly the result of the bundles of muscular fibre having been 
divided, but in part also is caused by the division of membranous and fibrous septa 
and capsules. In the intervals of the bundles of muscular fibre there become deve- 
loped, in some parts, the cellular globules of ^'carcinoma simplex," and the cells of 
*' carcinoma alveolare:" in other situations, fibrous septa run in different directions. 
Often, on closely inspecting the surfaces of these sections, membrano-fibrous septa 
are seen running between the interstices of the muscular bundles, and crossing each 
other irregularly. These compartments are filled with gelatiniform cells, which 
enclose smaller cellules; so that the interior of the capsules themselves seems to be 
subdivided. On a few occasions, the author* saw similar capsules apparently filled 
with fibrous masses. The septate appearance of the muscular coat, shows itself at 
the very commencement of cancerous degeneration: in *' carcinoma alveolare" it 
may subsequently disappear, when all distinction of tissues in the different layers 
of the stomach has been completely confounded; — having given place to the cells 
filled with a gelatiniform substance. Engravings of this appearance of the muscular 
coat of the stomach, are to be met with in most illustrated works on pathological 
anatomy; in which the structure of cancer of the stomach, as far as it is visible to 
the naked eye, is represented.* 

This septate character is not peculiar to the muscular coat of the cancerous 
stomach; it is also observed in other muscular parts, when affected by carcinoma. 
In Pockel's museum, at Brunswick, the author* noticed this appearance in a speci- 
men of scirrhus of the rectum; and in another of scirrhus of the oesophagus, com- 
plicated with scirrhus of the stomach. It occurs also in the urinary bladder.*" 

This appearance is not characteristic of any peculiar form of cancer, having 
been observed in most of its varieties; — in '* cancer alveolaris," in " carcinoma 
simplex," and medullary sarcoma of the stomach. 

There are no other general characters of carcinoma. Eccentric development is 
not peculiar to it; neither does softening always begin at the centre of the growth; 
nor is it always characterized, in its early stages, either by a lack of vessels, or by 
any peculiar distribution of them. The vessels in it bear the same relations as in 
other parts. Sometimes they are scanty; at other times exceedingly numerous. 

It is not Heterologous. — The positive characters of carcinoma do not display 
any thing heterologous or foreign to healthy organization.'^ Some of the elements 
of cancer occur in the healthy organism of the adult, while others are such as exist 
in the primitive fcBtal state of tissues; as cells, varicose fibres, and cylindrical 
fibres. Varicose fibres are produced by the elongation of cells, and their linear 
arrangement; and perfect fibres are, in their turn, formed from such as are in the 
varicose state; whence it follows, that the diflferences of the extremes depend 
merely on the point at which the development of the tissues is arrested. A struc- 
ture, the development of which is arrested while the cells are in their primary 
stale, will be very unlike one in which the cells are elongated, and in progress of 

« Miiller. 

b See Cruveilhier, "Anatomie Pathologique," Livp 13, Planche 6; Carswell, *' Patholo- 
gical Anatomy," " Carcinoma," Plate 1, Figures 1 and 2, and Plate 3, Figure 1; Seymour, 
" Medico-Chirurgical Transactions," Volume 14, Plate 1; Baillie, "A Series of Engravings," 
&c.. Fasciculus 3, Plate 7, Figure 1. 

c In Baillie's " Morbid Anatomy" (Fasciculus 3, Plate 4, Figure 2), is an engraving of 
ihe septate structure of carcinoma of the cesophagus; and another of carcinoma of the rec- 
tum (Fasiculus4, Plate 4, Figure 1). 

J The greater number of modern pathologists, regard these various structures as non- 
analogous, or heterologous formations. So great an authority as Miiller, however, con- 
tends, — on the grounds of chemical analysis, and microscopic investigation, — that they are 
essentially analogous formations. Schleiden has also subsequently shown an intimate 
similarity between the ultimate cells of cancerous structures, and the primitive formations 
of embryo-life. But the question of importance (in reference to thisreputed analogy) which 
presents itself to me, is not whether the elementary components may not be the same, but 
whether the same elements appear in similar combinations in natural structures. The 
negative of this is on the side of probability. Cancer, therefore, in all its varied phases, is 
a tissue which has no counterpart in the normal structures of the living body. — T. Williams. 



NEW rORMATIONS. 



197 



transformation into fibres; while those growths which tend rapidly to assume a 
fibrous texture, will also present a different appearance. 

Principally formed of JUbumen. — An albuminous substance forms the basis of 
all carcinomatous growths; for, if freed from skin and cellular tissue, they may be 
boiled for eighteen or twenty-four hours, without yielding more than a very small 
quantity of gelatine; often, indeed, without the slightest trace of it being dis- 
covered. What little of it is dissolved occasionally, contains caseine and salivary 
matter.* 

[The following table, extracted from Dr. Walshe's admirable article on cancer, 
in the " Cyclopaedia of Practical Surgery," exhibits, in a clear and comprehensive 
manner, the species and varieties of cancer, together with their synonymes.] 



>> 

i 


t 


01 


i 

s 


Species. ,^» Varieties. 


Synonymes of the Species. 


'Z 


5 


^ 


a 
















Common Vascu- 3 


Spongy or Ossivorous Tumour. Rt;YSCH. 

Palletta. 
Struma Fungosa (Testis). Callisen. 
Spongoid Inflammation. Burns. 
Milt like Tumour. Munro. 












Medullary Sarcoma. Aeernethy. 












coma'? J 


Cerebriform Disease or Cancer. Laennec. 












Solanoid. Recamier. Zang. 


Pulpy Testicle. Baillie. 










Encephaloid.< 


Nephroid. Idem. 


Carcinus Sponsiosus. Good. 


<n 


m 








Napiform. Idem. 


Carcinoma Spongiosum. Young. 




c 




ce 




Carcinoma Fasciculatum vel Hyali- 


Fungoid Disease. A. Cooper. Hodgkin. 




i 




s 




num. MuLLER. 


Medullary Fungus. Madnoir. Chelius. 


s 






c 




Funsus Hsemalodes. Hey. 


Acute Fungous Tumour. C Bell, 


5 


o 


? 


■g 




Heematode Cancer. Aoctobes 


Medullary Cancer. Travers 


c2 


b 


aj 


cS 




Gallici. 


Cephaloma. Hooper. Carswell. 


D 


i 


m 


'i< 






Carcinoma Medullare. Mulleb. 


3 


1 


^ 


o 

s 

a 


■ I 


Soft Cancer. Auctobes Vabu. 


f Pancreatic Sarcoma? Abeb- 


Carcinomatous Sarcoma. Aeernethy. 


> 


® 




Hi 


NETHY. 


Carcinoma Scirrhosum. Young. 


< 


s 






Napiforra. \r>^„,^^„„ 
Scirrhus. <! Chondroid. \ ^ecamier. 


Scirrhous Cancer. Travebs. 










Scirrhoma. Carswell. 










Lardaceous Tissue. AucT. Gall. 


Carcinoma Simplex vel Fibrosum. Mul- 










Carcinoma Reiiculare. Mul- 


leb. 










L LEB. 


Stone Cancer. Auctobes Varh. 


i Pultaceous 1 


Areolar Gelatiniform Cancer. Cruveil 










Colloid. J pe^a?ly Tlveolar [ Ch^vkilhieb. 


HIER. 

Carcinoma Alveolare. Mulleb. 










I f Cancer. 1 


Gum-Cancer. Hodgkin 



a. Scirrhus, or Carcinoma Simplex. 

Formation. — It appears that there are two changes in scirrhus; — there is a 
transformation and a new formation. It would appear that the cellular mem- 
brane of the affected parts becomes exceedingly indurated, and is changed into a 
hard fibrous membrane; but in the midst of this there certainly is a new deposit, 
of a particular description. 

Structure. — When scirrhus takes place, we see a firm, exceedingly hard, une- 
qual, irregular mass. It is of a light grayish colour at first; and, if cut into tliin 
slices, is semi-transparent. If a section be examined, a large number of fibres tra- 
versing morbid structure in difi'erent directions may be seen, between which fibres 
tliere is a substance less white than the rest. The deposition constituting tubercles 
is organic: it is not a new organization, but a new deposition. In scirrhus there is a 
transformed structure, at any rale; and besides that, there is an inorganic substance, 
deposited between the fibrous portions. These fibrous portions, running in difi'erent 
directions, form septa, — divisions; and are opaque and paler tlian the others; that is 
to say, of a more dead white. In fact, the section of a scirrhous tumour is exactly 
like that of a turnip. In a turnip, we observe fibrous septa, running in diflerent 

> " The Nature and Struclural Characteri.'^tics of Cancer;" by J. Mailer, M.D. Tran^-. 
lated by C. West, M.D. 1840. Pages 28 to 32. 



198 ^ NEW FORMATIONS. 

directions; and a softer less white substance between them. The septa, in 
scirrhiis, run in every direction; and sometimes are seen to form regidar cells. 
The proportion of less hard substance between the fibres, is exceedingly various; 
and the mode in which the fibres are distributed, is likewise exceedingly various; 
so that sometimes we have a mammary tumour, sometimes a pancreatic tumour, 
and sometimes a tubercle; — that is to say, a tumour something like a mamma, or 
something like a pancreas, or something like the tumour of scrofula; — a tubercle, in 
the common acceptation of the word, may occur. 

Microscopical Characters. — [The diseased masses are generally irregular in 
form; not lobulated; hard, and resisting the knife; and presenting, when divided, 
a grayish appearance, which has but very little similarity to cartilage. Whitish 
bands are not invariably present. Scirrhus of the mammary gland occasionally 
shows, here and there, whitish filaments; some of which are hollow, and contain 
a colourless, whitish, or yellowish matter. Probably this appearance of white 
filaments, is the result of thickening of the walls of the lactiferous tubes and lym- 
phatics; and this idea is confirmed by the absence of these filaments from scirrhus 
of non-glandular parts. The mass of scirrhus is composed of two substances; the 
one fibrous, the other gray and granular. The fibrous substance is rarely apparent 
immediately on making a section of these growths; but is «!een on scraping away 
the gray matter, for which it serves as a sort of basis. On removing the gray 
matter, either by scraping it away or by maceration, the fibrous substratum is seen 
to be composed of a very irregular network of firm bundles of fibres. The gray 
matter is found to consist of microscopic, formative globules, but slightly adherent 
' to each other, and varying from 0.00048 to 0.00108 or 0.00130 of an English inch 

in diameter. They are insoluble in acetic acid, and also in water, at any tempe- 
rature. In many of these cells, only a few points, which look like small granules, 
can be seen; while in others may be distinguished a larger body, which looks like 
a nucleus, or like a smaller vesicle, contained within a formative globule. Though 
crowded closely together, the formative globules lie between the meshes of a 
fibrous structure, with which they have no connection, and from which they can 
be easily removed; while, notwithstanding the thinness of their walls, they can be 
isolated from each other with the greatest facility. It is difficult to make out 
whether the single or double vesicular corpuscule, which is often distincdy seen 
within the formative globule, corresponds ^o the nucleus of a cell, or whether it is 
a young cell encased within the old one. If it be a nucleus, then the small spot 

I upon it would be analogous to the nucleolus, which Schwann usually found on the 
\. nucleus of the cells in the foetus. If, on the other hand, the pale (apparently 

II vesicular) corpuscules be in reality young cellules, then the corpuscules on their 
I surface would correspond to the parietal nucleus from which other cells are deve- 
loped. The paleness and transparency of the vesicular corpuscule which may be 
contained within the formative globule, does not by any means prove it not to be a 
nucleus; for, in the foetal tissues, the nuclei are sometimes remarkably pale, and 
even present a vesicular appearance. Probably, however, the vesicular bodies do 
correspond to young cells; and the analogy of this structure to that of " cancer 
alveolaris" is greatly in favour of this supposition. In a case of " carcinoma 
mammae," which occurred in a woman aged fifty, the same structure which was 
observed in the breast, and which there appeared to contain j'^oung cellules, showed 
itself also in small tumours of the ribs. Since many structures in the embryo are 
originally developed from cells, there exists a general resemblance between the 
cellular texture of carcinoma, and the primitive state of those tissues. But this is 
merely a general analogy; for the structure of carcinoma does not resemble one 
tissue more than another. Professor Valentin,'' indeed, has observed bodies with 
central nuclei, — which he considered to be cartilage corpuscules somewhat altered, 
— in the sanies from a carcinomatous sore of the face, as well as in the substance 
of the diseased mass itself. It is uncertain, however, whether these bodies were 

a Repertorium far Anatomic und Physiologie, 1837. 2 Abath. p. 263, 292. 



NEW FORMATIONS. 199 

real cartilage corpnscules, or whether they might not have been cells of the kind 
just mentioned. In addition to the formative globules of carcinoma, oil-globules 
are always seen, in considerable number, diffused through scirrhous growths.^] 

Softening of ScirrJius. — The less hard substance, at last, undergoes the same 
process as a true scrofulous tubercle. It softens down into an ichorous fluid, — into 
something like jelly or gum; and the process here begins usually, — perhaps always, 
but at any rate usually, — in the centre; as is generally the case in scrofulous 
tubercles; — the centre having been originally the hardest part.^ The skin above 
becomes puckered, or retracted; and its colour also becomes changed. It assumes 
a leaden, or livid hue. At first, the whole tumour is movable; though it will not 
allow the whole of the fingers to be placed under it; — it will not allow the edge to 
be turned up. But, after a time, it forms adhesions to the neighbouring parts, and 
becomes immovable. 

Ulceration. — Ulceration takes place in a scirrhous mass, exactly as in the case 
of a scrofulous tubercle; and when the ulceration begins, that state of things is 
called " cancer;" — scirrhus being the first stage (the stage of induration); and cancer 
the second staore (the stage of softening and ulceration). In this form of ulcer, the 
edges are everted and elevated; — we see the edges much raised, irregular, and 
turned out. The surrounding cellular membrane undergoes the process of suppu- 
ration. Now and then we see a sort of fungus sprouting up from the ulcer; — a 
hard gristly fungus. The centre of such an ulcer is deep; the discharge is generally 
very fcetid; and great irritation is produced. Sometimes, instead of a simple sup- 
puration around, we have sloughing, and now and then nature succeeds in throwing 
off the whole mass; — the scirrhous tumour has not formed adhesions to the sur- 
rounding parts; but suppurates, or rather sloughs out. The lymphatic glands, to 
which the absorbents of such a tumour run, generally become contaminated. They 
generally become indurated, — scirrhous; and undergo the very same process as the 
original part. 

Character of the Discharge. — [The liquid ichor, or sanies, which forms the 
discharge from cancerous sores, is thin, acrid, and generally of a dirty green colour; 
but liable to variation in tint from admixture, in various proportions, with effused 
blood, or from impregnation with melanotic fluid; as in a case related by Rouzet. 
It possesses a peculiar, and almost characteristic foetor. It is said by some to 
effervesce with acids, and turn syrup of violets green; but Ploucquet found, on the 
contrary, that it exhibited the reactions of an acid. In warm countries, especially^ 
generation of worms not unfrequently occurs in this matter.'' There is nothing, 
however, peculiar to the cancerous discharge in such development; yet the fact 
seems to have led to the singular theory respecting the production of cancer by an 
insect. Valentin states his having discovered nuclear globules, and cartilage-cor- 
puscules in the " pus of a cancer;" but, according to Miiller, such discharge is not 
peculiar to this affection; — occurring, on the contrary, from all suppurating surfaces. 
To the similitude of pus granules, and nuclear epithelium cells, we have already 
adverted. The surface of the ulcer may participate in the kind of formation dis- 
played by the whole mass: thus, Miiller has seen the white net-work of reticular 
carcinoma spreading into the minute asperities on the surface of fungating growths. 
In encephaloid, consisting of caudate corpuscles, the tailed appearance is found in 
course of development in tlie most superficial part of new vegetations. The same 
observer once saw a thick layer of polyhedral chole-steatomatous non-nuclear cells, 
forming a mass like tallow, on the surface of a cancerous ulcer in the mamma. 

Sometimes Cicatrize. — Singularly as the fact clashes with the general laws of 

» Miiller, on " Cancer;" Pages 41 to 44. 

^ The process of softening may commence in any part of a carcinomatous tumour;— as 
well at the periphery as the centre. The notion ofthe constancy of central softening, has 
been shown to be incorrect by careful observation. The change may originate in a single 
spot, or simultaneously in several. — " Cyclopadia of Practical Surgery;" — Article ''Cancer;'* 
Voluvie 1; Paie 617. 

<: Vacherj " Dissertation sur le Cancer des Mammelles;" Page 61. 



200 NEW FORMATIONS. 

carcinomatous growths, it is no less true, that these products are not wholly inca- 
pable of cicatrization. Scirrhous ulcers occasionally assume a healthy vermiHon 
tmt, become covered with normal s^ranulations, and actually cicatrize over a greater 
or less extent of surface. Abernethy relates a case of encephaloid tumour of the 
groin, in which, after the removal of a "portion of the tumour," the ulcer gradu- 
ally " lost its inflamed aspect, granulations formed, and a cicatrix took place." 
M. Berard witnessed a similar occurrence; and cerebriform cancer of the limbs 
and meninges, has been known to cicatrize in the same manner, after inopportune 
incision. According to Bayle, the majority of scirrhous formations in which this 
change is observed, are of a particular structure and character. Pouteau considered 
them the most intractable of all. Certain it is, that the amendment is delusive and 
temporary: the process ceases; and the disease advances with renewed activity. 
It must be understood, that we here refer solely to cicatrization occurring over 
actual cancerous substance. 

The reappearance of carcinoma in the situation of its previous development, 
after the spontaneous separation, or artificial removal of a tumour, is unfortunately 
a most common occurrence. This local reproduction is effected in different ways: 
— -1. The process of cicatrization may not distinctly commence, or may be inter- 
rupted at an early stage; and fungating growths may spring from some part of the 
wound. 2. A perfect cicatrix forms; and, after a variable lapse of time, a tumour 
grows in the subjacent tissues; presses on the inodular structure; destroys it; 
appears externally; and, on examination, presents the characters of carcinoma. 3. 
Reproduction may be accomplished in the tissue of the cicatrix itself, by the de- 
velopment of tuberiform, or infiltrated carcinoma. 

To whichever species the original growth may belong, the secondary formation 
is ordinarily encephaloid; whence, probably, the observation that consecutive, run 
their courses more rapidly than primary, tumours."] 

Parts liable to Scirrhus. — This is a disease which in general primarily affects 
those parts which are not necessary to life. It affects glands the functions of which 
have been interrupted, or have never been performed; it affects the breasts, — par- 
ticularly when a woman is past child-bearing; and it particularly affects the breasts 
of women who have never had any children. It also, where there is any predis- 
position, particularly affects parts which have suffered mechanical injury. Many 
women have had cancer in the breast after a blow; though, in all probability, they 
would not otherwise have suffered. It particularly affects the breast, the uterus, 
the ovaria, the testes, and the thyroid gland; none of which parts are necessary to 
life; — the breast, uterus, ovaria, and testes, being all for the sake of the next genera- 
tion, and not for the sake of ourselves; — except, indeed, as a gratification. The 
thyroid gland is, of course, a part unnecessary to life. 

Farts secondarily affected. — When, however, cancer has existed in these parts, 
it affects others secondarily; and then we find the lungs, liver, omentum, mesen- 
tery, spleen, pancreas, brain, the medulla of the bones, and the skin, become the 
subjects of the affection. Now and then it may affect these parts primarily; but 
as a general rule, — and one can only speak generally. — it affects the parts which 
I have last mentioned only secondarily. When it affects the skin primarily, — 
which it now and then does, — a kind of wart is the first thing which appears; and 
it becomes cancerous. If it affect the skin only secondarily, then (I believe) more 
generally we have a tubercle, in the common sense of the word; — a little hard 
lump. When the breast has been affected with cancer, the skin in the neighbour- 
hood will become the subject of tubera; — little hard scirrhous lumps. We cer- 
tainly often see cancer affect the cardia, the pylorus, and the rectum primarily; yet 
although it sometimes does so, it is by no means so frequent an occurrence, as the 
affection of those particular organs which are not necessary to life, and the functions 
of which may cease without the body at large sufiering. When it affects the 
alimentary canal, it attacks particularly certain portions, which form divisions of it. 

^ " Cyclopaedia of Practical Surgery;" Article " Cancer;" Volume 1; Pages 617 and 618. 



NEW FORMATIONS. 201 

For example: it affects the lips, which are the first part; next to them it will affect 
the fauces, and the cardia; — the lips forming the commencement of the moulh, the 
fauces of the throat, and the cardia of the stomach. Then it affects the pylorus, 
* — the commencement of the intestines; and then, again, it affects the rectum; 
which is the termination of the canal. It is a curious fact, that it is generally the 
apertures of cavities that are affected. We shall see, when we come to consider 
diseases of the heart, that it is the openings which suffer, far more than any other 
portion of that organ. 

Effects on the adjoining Parts. — In certain situations, cancerous deposits may 
acquire considerable volume, without apparently influencing the substance of the 
part in which they are formed; but, in other situations, the presence of carcinoma 
leads to certain changes in the surrounding tissues. They may be stated briefly, 
thus: — I. Condensation. 2. Obstruction of function, from mechanical pressure. 
3. Discoloration of the surrounding parts. 4. Hypertrophy, or atrophy. When 
carcinoma is so situated as to obstruct the functions of some of the liollow viscera, 
hypertrophy of the muscular apparatus behind the obstruction is the result; as in 
disease of the cardia or rectum. But in scirrhus of the mamma, there is frequently 
hypertrophy of the glandular structure; so that it scarcely, if at all, exceeds its 
healthy fellow in size; while, in other cases, its general bulk may be increased, or 
parts of it may be tumefied, and others atrophied. 5. Absorption of the neigh- 
bouring parts. 6. Serous infiltration. 7. Inflammation, either elimjnatory in its 
effects, or not. 8. Fibrous transformation. 9. Extension of the disease to con- 
tiguous textures, by infiltration. 

Such are the changes produced on the adjacent tissues during the progress of 
carcinoma; but the carcinomatous tissue itself, being (like normal textures) the 
seat of nutrition, is (like them) susceptible of its disordered actions. Of these, the 
principal is congestion; — arising either from irritation of the arteries, or obstruction 
of the veins. The first consequence, as may be supposed, is a change in the colour 
of the diseased mass; which may either assume a florid hue, or a purple, brown, 
or black tint, — according to the cause of the obstruction; but — owing to the deli- 
cacy of the vessels in the adventitious growth, the trifling support received from 
the substance in which they ramify, and their imperfect communication with each 
other — extravasation of blood almost always follows; — frequently causing a sudden 
increase of the non-ulcerated tumour. The subsequent changes of the effused blood, 
are strikingly similar to those observed in cerebral haemorrhage. The liquid por- 
tion is gradually absorbed, with the haematosine; the discoloured fibrin remains 
behind, in a sort of cavity lined with a smooth and delicate membrane; while the 
circumjacent cancerous matter acquires a yellow tint. At a more advanced period, 
the clot disappears; the lining of the cavity is more distinctly serous in its character; 
and its contents are of a serous, or glutinous nature. Such is, doubtless, the origin 
of the greater part of the cysts found in the interior of carcinoma.*] 

Attendant Symptoms. — The disease is attended, in general, — almost from the 
very earliest stage, — with severe pain;'' — sharp, lancinating, and of the most dread- 
ful kind. The pain certainly does not depend upon inflammation; for it will occur 
where no inflammation can be discovered. 

[^Haemorrhage. — Haemorrhage, v/hich does not ordinarily occur before ulceration 
has set in, is sometimes one of the earliest effects of the disease. Thus, the dis- 
charge of a few drops of blood from the nipple, in scirrhus of the breast, — a tole- 
rably frequent occurrence, — has, in some rare instances, been the first morbid 
phenomenon observed. Profuse menorrhagia, in not a few cases, precedes all other 

* " Cyclopaedia of Practical Surgery," Article " Cancer," by Dr. Walshe; Volume 1; Page 

b Scirrhous formations, in their early stage, are not endowed with any marked sensibility. 
It has been remarked, however, by numerous observers, that pain is very commonly expe- 
rienced about half an hour after these tumours have been examined. When pain is exciied 
immediately after or during pressure, this, according to some writers, is owing to ihe pre- 
sence of inflammatory action in the tissue surrounding the cancerous substance. — '* Cyclo" 
padia of Practical Surgery;" Article ^^ Cancer;" Volume 1; Page G34. 



202 NEW FORMATIONS. 

symptoms of uterine cancer; and in a case of pharyngeal carcinoma, which we 
observed some years past, the patient persisted in affirming, that severe haemorrhage 
from the throat was the first circumstance that drew his attention to the part. In 
a similar manner, haemoptysis is frequently the first occurrence announcing tuber- 
culous disorganization of the lungs. But we would not be understood to mean, 
that effusion of blood is really the very first abnormal effect of the heterologous 
formation: others have probably led the way; but, from their trivial character, 
escaped the attention of individuals who are not in the habit of carefully watching 
the variations of their health. Admitting this to be the fact, the practical value of 
haemorrhage, as a symptom, is by no means lessened. 

Derangement of Function. — Derangements of function form an important item 
in the symptomatology of carcinoma; and, of course, vary with the organ in which, 
or in the immediate vicinity of which, the morbid matter is developed. They may 
be included under the heads of " irritative" and "mechanical." As illustrations 
of the former, we may adduce the vaginal discharge produced by non-ulcerated 
scirrhus of the uterus; and the occurrence of hydrothorax and pleuritis, in subjects 
affected with mammary cancer. In exemplification of the latter, may be mentioned 
the occurrence of amaurosis, from pressure on the optic nerve; the interruption to 
vision, occasioned by tumours driving the eye from its normal site; obstinate con- 
stipation, from pressure of enlarged pelvic glands; derangement of local circulation 
and serous accumulation, either in the shut cavities or in the cellular membrane, 
produced by partial closure of adjacent circulating tubes, — arterial, venous, or lym- 
phatic.*] 

Sloughing Stage of Cancer. — When the stage of ulceration has arrived — in 
which there is inflammation, sloughing, and suppuration, — the irritation is so great, 
that the whole constitution suffers materially; and the skin acquires a peculiar sal- 
low tint; — a sort of pallid yellowish straw-colour. The state of the body is 
decidedly cachectic; that is, the whole body is in an unhealthy state. Andral 
ascribes this sallow appearance to a change which the blood undergoes; — the con- 
stituents of the vital fluid being absolutely altered. There is a sallow look; by 
which any experienced person will suspect, that the individual is labouring under 
some malignant disease. This has been called " cancerous cachexia;" — ^^cachexia''^ 
meaning a bad habit of the whole body. 

[To this catalogue of evils may be added, as of not very uncommon occurrence, 
a morbid change of the bones, exhibiting itself in some one of the following forms: 
— I. Atrophy of the spongy and compact structures, from defective nutrition. 2. 
Excess of inorganic matter in their composition. 3. Defective supply of saline 
materials; in consequence of which, the bony tissue appears as if it had been 
macerated in a mineral acid (" carnification.") 4. Carcinoma of their substance. 
The first of these forms is singularly rare. Recamier, however, appears to have 
met with an example of it. Of the third we have not met with an authentic in- 
stance; and insert it rather hesitatingly. In the first three cases, the morbid state 
is a manifestation of the cachexia^ m the fourth, it is an evidence of the diathesis 
having reached the bones. In the first, second, and fourth cases; — especially the 
last, — fractures occur with extraordinary facility. In cases of cancerous deposition 
in the bones, the fracture may either arise from complete transformation of a portion 
of the cylinder into cancerous matter, or from the pressure of a central growtli; — 
causing the absorption of the compact tissue. When the fracture is of the former 
description, crepitation will either be wholly absent or ill-marked; in the latter case, 
this sign is producible in the ordinary way. When a cancerous patient suffers 
persistently, or pretty constantly, from pain in a particular spot in the course of a 
bone, the occurrence of such fracture is to be apprehended; but such local pain is 
not a constant forerunner of the accident, nor is it necessarily followed by it. The 
pain has been mistaken by patients for rheumatism; and this error has, not unfre- 

* " Cyclopaedia of Practical Surgeryj" Article " Cancer," by Dr. Walshe; Volume 1; Page 
635. 



NEW FORMATIONS. j303 

quently, been shared by the medical attendant.* In not a few cases, the occurrence 
of fracture has manifestly hastened the fatal issue of the disease."] 

Termination of Scirrhus. — I mentioned*" that the diseased part sometimes 
sloughs out; and the person recovers. That, however, is so rare a circumstance, 
that even if the surgeon remove the disease, the reUef is but too often temporary; 
for, in the greater number of cases, the disease reappears; — either in the same 
neighbourhood, or in an opposite part. It would appear that it depends, in a great 
number of cases, upon some constitutional tendency; and all that art can do is to 
remove those parts which have fallen into a diseased state; but, as the tendency 
remains in the constitution, persons generally show the disease again, sooner or 
later, in some other situation, or around the spot of the operation. 

Hereditary Predisposition.-— This disease, like scrofula, may be hereditary; — 
I mean, of course, the disposition to it; and it is not known (at least, as far as I am 
aware) what circumstances give a predisposition to it. Those which give a pre- 
disposition to scrofula, are evident enough; but I am not aware of any circum- 
stances, which are known to give a predisposition to scirrhus and cancer. I have 
known many persons die of cancerous disease, one of whose parents had previously 
died of the same affection. There are several drawings by Cruveilhier, illustrating 
the various stages of this airection."^ 
• 

b, Encephaloid Disease. 

Its Nature. — The next disease of which I shall speak, is one which differs from 
scirrhus and cancer, in affecting the young rather than the old. It is what is 
called " fungus haematodes," or " encephaloid disease." It has been called "ence- 
phaloid," because the deposition is not hard, like scirrhus; but, to a certain extent, 
resembles the brain. It has also been called "fungus haematodes;" because, when 
it arrives at the stage of ulceration, a fungus, of a bloody character, sprouts out; 
and, on cutting into it, we see large distinct cells filled with effused blood. It is, 
therefore, like brain in some parts, and is bloody in others. The deposited matter 
is like brain; but in the cells in which the deposition takes place, haemorrhage con- 
tinually occurs; so that blood is effused there, and a coagulum forms. There is a 
great disposition to haemorrhage in this disease; but the deposit itself is an opaque, 
whitish, homogeneous substance; and maybe compared, in colour and consistency, 
to cerebral pulp. There is an excellent representation of the affection, by Dr. 
Carswell; taken from cases in which it was situated in the brain and liver. I have 
opened many brains and livers, containing tumours about the size of a walnut; 
which, on being cut into, presented a homogeneous brain-looking pulp. There is 
often nothing like the firm fibres of scirrhus; — no distinct white bands ramifying in 
the tumour; but a mass such as I have just described. When exposed to the air, 
it softens down, — ^just as the brain will do; and it may be washed away, — leaving 
a filamentous texture. If a tumour of this description be taken, and exposed to a 
stream of water, the pulp may be washed away; leaving an exceedingly fine fila- 
mentous structure, which has contained the opaque brain-looking substance; but 
then this structure, unlike scirrhus, is exceedingly fine and delicate. The consist- 
ency of encephaloid substance varies; — from that of a soft custard, down to the 
firmest part of the brain when perfectly fresh. One portion of this is sometimes 
pinkish; and sometimes portions will be as red as a clot of blood; but if the blood 
have been effused in great quantity, regular clots of blood appear. Various portions 
differing in colour, size, and consistency, are often found; and some of them are 

* Salter, in the " Medico-Chirurgical Transactions;" Volume 15; Page 186. Samuel 
Cooper, in the same; Volume 17; Page 51. 

b " Cyclopaedia of Practical Surgery;" Article " Cancer," by Dr. Walshe; Volume 1; Pages 
63Gand637 

e See Page 199. 

d " Anatomic Pathologique du Corps Hnmain; ou Descriptions, avec Figures Colorizes 
et Lithographi^es, des diverses Alterations Morbides dont le Corps Humain est susceptible." 



204 NEW FORMATIONS. 

even cartilaginous; — that is to say, there is a double formation, — a double disease; 
and scirrhus is united with it. Now and then, bony particles are observed. Some- 
times we see portions of it in a regular cyst. Instead of fine filaments, containing 
this brain-like matter, absolute cysts are seen; and sometimes portions resembling 
the white of boiled eggs, — coagulated albumen. 

Softening. — This deposit, as it grows, softens down; and, like scirrhus and a 
scrofulous tubercle, it generally softens first in the centre. When it softens down, 
cavities are formed; or (perhaps we might say) cavities become discernible. These 
cavities chiefly contain blood; and, on washing this away, filaments or shreds float- 
ing in the cavity are distinguishable. If a portion of it be near the surface, the skin 
grows discoloured, the tumour adheres to the subjacent parts, and increases in size; 
or if the tumour be situated within, the serous membrane above it grows thin, till 
it gives way. The tumour, therefore, may ulcerate through the surface; or a serous 
membrane within may give way. 

Ulcerating Stage.— ^\\eu the tumour ulcerates, a fungus generally shoots forth, 
—but it is not firm, — like the fungus of scirrhus; but (on the contrary) is soft, 
easily torn, and bleeds very much. It is irregular, and of a dark red colour. When 
the fungus is very small, it exactly resembles the red soft polypi which grow from 
a mucous membrane; It grows very rapidly, and pours forth a fcetid sanious fluid; 
and people sometimes die, not from the irritation of the tumour, but from haemor- 
rhage. I had a patient who died from haemorrhage, occasioned by one of these 
fungi in the bladder. There was, in the interior of the bladder, a fungus as large 
as a walnut, which never gave him any pain, or produced any irritation to the con- 
stitution; but which bled in spite of every thing which could be done. He dis- 
charged, not only bloody urine, but pure blood; and at last sunk under it. The 
haemorrhage from a fungus of this description, is often very copious. Now and 
then portions will slough. 

Varieties. — [Microscopical investigations have led to the establishment of the 
three following varieties, with respect to its intimate constitution: — 

" Carcinoma medullare," abounding in roundish formative globules, which make 
up the greater part of the medullary mass, though intersected by a delicate fibrous 
network. The specimens which Gluge examined, seem to have been of this kind. 
The globules differed in size; — the smallest being larger than pus-globules, and having 
a diameter of ylj of a millimetre.* They were irregular, though approaching the 
spherical form: their border was transparent; but dark points and round lines were 
distinguished on their uneven surface. He likewise observed crystals, of various 
kinds, in "fungus meduUaris." The author regards the formative globules of this 
variety of morbid structure, as very similar to those of common cancer, and to those 
which constitute the gray mass of '* carcinoma reticulare:" a few points, or very 
minute granules, were often all that could be detected in their interior; but fre- 
quently, on making use of a high magnifying power, a nucleus may be seen; — ^just 
as in other forms of carcinoma. The size of these globules is about the same as 
in common cancer, though they are subject to great varieties in this respect. 

2. *' Carcinoma medullare," with an exceedingly soft cerebriform base; composed 
of pale, elliptical bodies, without caudate appendages. The author* is acquainted 
with but one specimen, which he can refer to this class: it was a case of cerebri- 
form fungus meduUaris of the foot, and of the interior of the tarsal bones. With 
the exception of the vessels which were distributed to the diseased mass, its sub- 
stance was almost entirely formed of uniform ellipsoidal corpuscules; which cohered 
but very slighdy with each other. These corpuscules had a very pale hue, when 
looked at under the microscope; they were one-and-a-half or twice as large as the 
red particles of the blood, and equalled them in breadth. The author,* in no in- 
stance, observed a fibril proceeding from these bodies; nor did he ever see a single 

* The millimetre is equal to thirty-nine hundredths of an inch, English measure. 
b Mailer. 



NEW FORMATIONS. 205 

nucleus, or a young cellule in their interior. A few very minute points were all 
that could be detected, by the highest magnifying powers. 

3. " Carcinoma medullare," with caudate or spindle-shaped corpuscules. Some- 
times, on tearing a piece of this kind of fungus meduUaris, the torn surface will 
present a resemblance to a fibrous structure. This appearance is owing to several 
of the caudate corpuscules being arranged in one direction; as was observed in a case 
related by Valentin. The author* has seen a similar structure in several specimens 
of "fungus meduUaris;" — sometimes interspersed in the midst of round, formative 
globules; at other times forming the greater part of the growth. According to the 
direction in which the caudate corpuscules are disposed, a radiated appearance is 
sometimes produced; at other times, the structure seems more tufted; while, in 
other instances, the direction of the corpuscules is so various, that the tumour does 
not display the slightest trace of fibrous texture. It is, indeed, not always easy 
(even when the caudate bodies are so disposed as to occasion a fibrous appearance) 
to tear the growth into tufts of fibres; although irregular portions of it may be broken 
off very readily. Frequently, however, the caudate corpuscules are arranged with 
great regularity. Their interior either contains a granular substance witliout any 
evident nucleus, or a nucleus with one or more nucleoli may be more or less dis- 
tinctly seen. These corpuscules are prolonged at one or both sides, and in some 
rare instances at more than two sides, into fibrils of different length. They are cells, 
the development of which has been arrested, in the stage of transition from cells 
to fibres.^] 

Farts liable to be Sffecied. — This is a disease which affects every part of the 
body. It will affect the testicle; and then it is called, by some, "soft cancer of the 
testicle;" or it may affect the breast, the eye, the uterus, ovaria, spleen, pancreas, 
liver, urinary bladder, brain, mesentery, and bones. It is very common in the eye 
of chddren. It is continually seen in the extremities; and the absorbent glands 
become contaminated, as they do in the case of common cancer. When the glands 
are affected, on being divided, they disclose nearly the same appearances as the 
original tumour; but there is this difference, it is said, — that they never send forth 
a fungus. 

There are frequently in the neighbourhood smaller tubera, — circumscribed, but 
without a capsule; varying from the size of a pea to that of a walnut; of a pale 
grayish colour; and firmer than the original tumour; but they are the same disease. 

Secondary Encephaloid. — This is a disease which commonly affects other organs 
secondarily; so that when persons liave it in the breast, it is very common to find 
them gradually become the subjects of cough, and pulmonic disease; and, on open- 
ing them, we find similar tumours within. It is said that the organs which are 
affected secondarily, are never affected primarily. It is very common for many 
organs to become affected at once; and so great is the disposition to this disease, 
when there is any disposition at all, that Mr. Travers says he has never known a 
person survive four years, in whom he had operated for the extirpation of the disease. 

General Symptoms. — The constitution becomes impaired. There is a cachectic 
look, even earlier than in scirrhus. Usually the person becomes emaciated, but 
now and then there is hardly any irritation at all; and sometimes a person may die 
of this disease in the stomach, without having suffered any pain at all; and frequenuy 
without any person having suspected the nature, or even the seat, of the disease. 
With respect to the easel mentioned" of the disease in the urinary bladder, the man, 
although he died from the hcKmorrhage occasioned by it, never suffered the least 
pain. Even when the mass is very considerable, there is generally little or no 
pain; and sometimes there is litde or no irritation of the constitution. The case 
differs very materially from scirrhus, therefore, in another respect. Scirrhus, I 
mentioned,* is almost always attended with violent deep lancinating pain; whereas, 

* Muller. b Muller on Cancer; Pages G3 to Go. 

^ ^ '^'^' d See Pa°re 201. 



206 NEW FORMATIONS. 

in encephaloid disease, there is very little pain, and sometimes there is very little 
irritation. 

Dubious Nature of the Tumour. — A tumour of this description is exceedingly 
soft. Its external appearance is remarkably smooth and equal; and it gives the idea 
of fluctuation; so that I have knovi^n surgeons of great experience deceived in cases 
of this nature. They have imagined it was a collection of fluid, and plunged a 
lancet into it. I have seen this mistake occur over and over again; — from its extreme 
resemblance, with respect to the touch, to a tumour containing fluid. Frequently, 
for a length of time, the part will not be at all discoloured. It is soft and elastic; 
and it is these two circumstances that give the idea of fluctuation. The tumour, 
when taken out, is generally more or less round; and (as I stated before) it differs 
from scirrhus, in occurrmg at an early period of life. A kidney, taken from a child 
six years of age, has been seen, in which several portions of disease were of this 
nature. It seemed to be a mixture of various diseases; — some portions were scro- 
fula; some were of scirrhous hardness; and in other parts there was certainly fungus 
haematodes. 

Causes. — I do not know what gives the disposition to this disease. I am not 
aware of any external circumstances, which cause persons to be more liable to it; 
nor do I know whether it is hereditary. It is very probable that the disposition to 
it is hereditary, — exactly like the disposition to scirrhus; but it is carefully to be 
remembered, that this is not a painful disease, like scirrhus; and that it is a disease 
which afl*ects the opposite period of life, to that in which scirrhus particularly pre- 
vails. Some consider it to be a mixture of scrofula and cancer. 

c. Carcinoma Alveolare. 

[This form of carcinoma was described in Germany, by Otto, as a peculiar species 
of scirrhus of the stomach; and in France, by Laennec and Cruveilhier, under the 
names of "cancer gelatiniforme," and "areolaire." 

The description which Otto has given, represents the main features of this de- 
generation (which always appears under one form) so exactly, that it may be 
detailed as aff'ording a good illustration of the general anatomical characters of the 
disease. 

Anatomical Characters. — The scirrhus occupied more than two-thirds of the 
whole stomach, and extended from the pylorus over a width of more than seven 
inches of its anterior and posterior wall. The walls of the stomach were so thick- 
ened, at the diseased parts, that tliey did not collapse. In several places, they were 
two inches and a half in thickness. The surface of the scirrhous part was uneven 
and tuberculated. Otto says that its substance differed so much from that of ordi- 
nary scirrhus, that, perhaps, it ought not to be referred at all to that class of diseases. 
The basis of its structure was composed of innumerable white fibres and laminae, 
crossing each other in all directions, and having their interspaces occupied by cells, 
which varied in size from that of a grain of sand to that of a very large pea. Some 
of the cells were closed, but many of them communicated with each other: they 
all contained a very viscous, clear, perfecdy transparent jelly. Externally, the 
diseased growth was covered by peritonaeum, through which the half-projecting 
sacculi and cells were seen. The inner surface of the stomach was almost entirely 
deprived of its lining, wherever the disease extended; and most of the cells, both 
large and small, opened into the cavity of the stomach; into which, when firmly 
pressed, they poured their contents. The inner coats of the stomach were entirely 
destroyed by the disease. The muscular coat extended, for a short distance, into 
the morbid structure; but small cells, filled with jelly-like matter, were everywhere 
deposited between the muscular fibres. 

The cases of "carcinoma alveolare" of the stomach which the author* has ex- 
amined, correspond so exactly with this description, that he can but confirm it in 

a Mttller. 



NEW rORMATIONS. 207 

all points. At the commencement of the degeneration, the mucous and the mus- 
cular coals of the stomach swell; and sections of the latter present that striated 
appearance, observed in all forms of carcinoma of the stomach. The cellular 
structure containing the jelly-like matter, develops itself between the bundles of 
muscular fibre; but the like process takes place, at the same time, in the mucous 
membrane. In the early stages of the disease, the cells can be distinguished only 
by means of the microscope. 

Occasionally, this cellular structure not only becomes developed in the stomach 
but also forms isolated nodules in different parts of the surface of the peritonaeum. 
In M. Pockels's museum at Brunswick, the author^ observed such masses of cells; 
which had formed on the abdominal peritonaeum, in a case of "carcinoma alveolare" 
of the stomach. The smallest clusters of cells were scarcely larger than the head 
of a pin.^ 

Symptoms. — The symptoms of this form of cancer, which occurs most fre- 
quently in the stomach, are (according to Cruveilhier) more obscure than those of 
any other variety of carcinomatous disease. It is certainly less prone than other 
forms of cancer to give rise to sympt'oms of general reaction, and is more slow in 
producing the *' cachexia cancerosa." Pockels observed neither pain nor vomit- 
ing; but the peculiar colour of the face which characterizes organic diseases of the 
stomach was not absent. Though most frequently met with in the stom.ach, 
"cancer alveolaris" is not by any means confined to this organ; for Cruveilhier 
has seen it in the small intestines, the rectum, the caecum, the uterus, the ovary, 
and the bones; and the author* has also met with it in the intestines, in the female 
breast, in the great omentum, and especially in the peritonasum. 

Varieties. — Cruveilhier distinguished between " cancer areolaire gelatiniforme," 
and "cancer areolaire pultace:" the cells of the former contain a transparent jelly, 
those of the latter a turbid pultaceous matter. He has observed the latter form in 
the uterus and in the bones.*' The case which he relates of " cancer alveolaire 
pultace" of the skull, is very remarkable; and the representation he gives of it is 
very interesting.* The diseased bones were the frontal, the ethmoid, the inferior 
turbinated, and the vomer. The morbid growth extended both outwards and in- 
wards; and had attacked the mucous membrane of the nose, and the dura mater. 
A somewhat similar structure was once observed by the author,* in a breast which 
M. Dieffenbach had removed. In this instance, the very firm puriform matter was 
contained within cells which had numerous communications with each other, and 
were lined by a membrane evidently vascular. Some lobules of this- tumour were 
completely permeated by these cells; while other parts of the same growth pre- 
sented no trace of this structure, but only the ordinary network of " carcinoma 
reticulare." 

Characters of the Jelly. — The jelly-like matter contained in the cells, preserves 
its transparency even if kept in alcohol; and if expressed from the cells, and boiled, 
does not yield a trace of gelatine. After boiling, for eighteen hours, a portion of 
"cancer alveolaris" which had been macerated in alcohol, nothing was dissolved 
but a small portion of a substance somewhat allied to salivary matter, not preci- 
pitated by any re-agent, — not even by tannin; and of the existence of which eva- 
poration afforded the only evidence. 

In the remarkable case of " cancer pultace" of the skull, above-mentioned, M. 
Boutin Limousineau, assistant to M. Gay-Lussac, analyzed the yellow matter from 
the cells; and found that it contained caseine. The matter had, in this case, the 
colour of tallow. 

» Muller. 

^ Engravings of " carcinoma alveolare" of the stomach may be found in Otto's " Seltene 
Beobaichiungen zur Anatomie, Physiologie, und Pathologic;" Plate 1, Figure 4; CruveiN 
hier's "Anatomie Rathologique," Book 10, Plate 4; and Carswell's "Pathological Anatomy," 
Fasciculus 3, Plate 1, Figure 8. 

^ " Anatomie Pathologique;" Livre 24, Table 2, Figure 1; and Livre 27, Table 2. 

<* " Anatomie Pathologique;" Livre 21; Table 1. 



208 NEW FORMATIONS. 

Microscopical Characters.— From microscopic examination of *« carcinoma 
alveolare" of the stomach, the author'' obtained the following results. If the smaller 
cells are looked at under the microscope, they are found to contain (encased within 
ihem) many still smaller cellules; which, in their turn, include others of yet more 
diminutive size. In the smaller cells, the darkish yellow parietal nucleus is dis- 
tinctly evident. Many cells, likewise, contain (free within their cavity) mere 
nuclei; as cytoblasts,'' from which new cells are to be afterwards developed. The 
walls of the largest cells are distinctly fibrous, and their fibres run from one cell to 
another. Twice the author* observed rod-shaped crystals, in the jelly-like matter 
of preparations which had been kept in spirit; and on another occasion, he saw 
spindle-shaped corpuscules in the jelly from a " cancer alveolaris" of the breast. 

Mode of Development. — The history of the development of " carcinoma alveo- 
lare," corresponds exactly to that of the primitive formation of cartilage, and of the 
*' chorda dorsalis," as described by Schwann. The young cells are produced from 
cytoblasts, or nuclei developed in the interior of the parent cell; and, although the 
parent cell continues to increase in size, these young cellules (by degrees) fill up 
its cavity. At length, the walls of the young cells come in contact with each other, 
and they form, together with the parent cell (within which they are encased), one 
compound cell. Thus, the process of development goes on, till the larger cells on 
the internal wall of the stomach burst, and pour their jelly-like contents into its 
cavity. The fibres forming the walls of the largest cells constitute a nidus, within 
which younger generations of cells are developed. In order, however, to observe 
the manner in which the cells are encased one within the other, and the relation 
they bear to their nuclei, it is necessary to examine them in an earlier stage, and 
before their walls have begun to be split up into fibres. 

The main point distinguishing "carcinoma alveolare" from "carcinoma reti- 
culare" and "carcinoma simplex" seems to be, that, in the former, the cells con- 
tinue to grow, and their walls become adherent to each other; while this progressive 
development, and mutual cohesion, do not take place in the delicate cellular globules 
of the two latter forms of cancer.*"] 

Summary. — [The following proposition directly flows from numerous facts 
stated in the preceding pages: — A cancerous tumour, in all circumstances, — even 
should it remain single and stationary for years, — is but the local evidence of a 
general vitiation of the system. "But," it may be inquired, " is not this a contra- 
diction? — How is it possible that, if the organism at large be in a state of disease, 
a single spot shall alone manifest its presence?" We confess our inability to explain 
away this difficulty; but neither the fact of its existence, nor its inexplicability, 
shakes the solidity of the opinion advocated. All pathologists who have carefully 
investigated the history of the tuberculous affection, admit that local agencies, of 
whatever kind they may be, can never cause the production of a particle of tubercle, 
— that constitutional derangement must lead the way. Now here we have pre- 
cisely the same difficulty to contend with; — a knot of tubercles may exist for years 
in the summit of a lung, and every other organ remain free to the last from the 
disease. Why this is so, we know not. These are the mysteries of pathology; 
and they are mysteries which, in the existing state of the science, it would be idle 
to attempt to penetrate. 

From all that has been said, we may deduce the following definition of cancer. 
Cancer is a disease anatomically characterized by the presence of scirrhus, ence- 
phaloid, or colloid; originating in a general vitiation of the economy; and possessing 
the properties of assimilation, of reproduction, and of destroying life by a peculiar 
cachexia.*^] 

[We shall conclude the consideration of carcinoma, with the following tabular 
view of the distinctive characters of the three species into which it is divisible; 

* Mo Her. *• From nvTot, a cavity; and /5xa(rT0f a germ. 

' Moller on Cancer; Pages 50 to 54. 

d " Cyclopaedia of Practical Surgery," Article " Cancer," by Dr. Walshe; Volume 1; 
Page 650. 



NEW FORMATIONS. 



209 



taken from Dr. Walshe's article on " Cancer," to which frequent reference has 
been already made; and we may safely recommend an attentive perusal of that 
clear and comprehensive article, to the reader who seeks for a more extensive 
acquaintance with the subject than was consistent with the nature of the present 
work.] 

COLLOID 

Has the appearance of par- 
ticles of jelly, inlaid in a 
regular alveolar bed. 

The contained matter is 
strikingly transparent. 

Greenish yellow is its pre- 
dominant hue. 

(Its vessels have not, as yet, 
been sufficiently examin- 
ed.) 

The jellylike matter is ex- 
ceedingly soft; a colloid 
mass is, however, firm and 
resisting. 

The pultaceous variety has 
been detected in the veins. 



ENCEPHALOID 

Reserabfes lobulated cerebral 
matter. 

Is commonly opaque from its 

earliest formation.- 
Is of dead white colour. 

Contains a multitude of mi- 
nute vessels. 

Is less hard and dense than 
scirrhus. 



SCIRRHUS 

Resembles rinds of bacon, 
traversed by cellulo-fibrous 
septa. 

Has a semi-transparent glos- 
siness. 

Has a clear whitish or bluish 
yellow tint. 

Is comparatively ill supplied 
with vessels. 



Is exceeding 
dense. 



ly firm and 



Is frequently found in the 
veins issuing from the dis- 
eased mass. 

The predominant microsco- 
pical elements are glo- 
bules, not always distinctly 
cellular, and caudate cor- 
puscula. 

Occasionally attains an enor- 
mous bulk. 

Has been observed in almost 
every tissue of the body. 

Very commonly co-exists in 
several parts or organs of 
the same subject. 

Is remarkable for its occa- 
sional vast rapidity of 
growth. 

Is frequently the seat of in- 
terstitial haemorrhage, and 
deposition of black or bis- 
tre-coloured matter. 

When softened into a pulp, 
appears as a dead white or 
pink opaque matter, of 
creamy consistence. 

Subcutaneous tumours are 
slow to contract adhesions 
with the skin. 

Ulcerated encephaloid is fre- 
quently the seat of hae- 
morrhage, followed by ra- 
pid fungous development. 



The progress of the disease 
after ulceration is com- 
monly very rapid. 

Is the most common form 
under which secondary 
cancer exhibits itself. 

Is the species of cancer 
most frequently observed 
in young subjects. 



Has not been distinctly de- 
tected in that situation. 

The main microscopical con- 
stituents, are juxtaposed 
nuclear cells; caudate cor- 
puscula do not exist in it. 

Rarely acquires larger di- 
mensions than an orange. 

Its seat, as ascertained by 
observation, is somewhat 
more limited. 

Is not unusually solitary. 



Ordinarily grows slowly. 



Is comparatively rarely the 
seat of these changes. 



Resembles, when softened, 
a yellowish brown semi, 
transparent gelatinous 
matter. 

Scirrhus thus situated usual- 
ly becomes adherent. 

Scirrhous ulcers much less 
frequently give rise to hee- 
morrhage; and fungous 
growths (provided they 
retain the scirrhous cha- 
racter) are now more slow- 
ly and less abundantly de- 
veloped. 

There is not such a remark- 
able change in the rate of 
progress of the disease after 
ulceration has set in. 



Is much less common before 
puberty. 



Is composed of cells 
state of emboitement. 



Observes a mean in this re- 
spect. 

Has so far only been seen in 
a limited number of parts. 

Has rarely been met with in 
more than one organ. 

Grows with a medium degree 
of rapidity. 



of the kind. 



Has hitherto been observed 
in adults only.» 



VOL. I. — 14 



' CyclopaBdia of Practical Surgery;" Volume I; Page 647. 



210 NEW FORMATIONS. 



SECTION III.— MELANOSIS. 



Nature of this Product. — The next new formation of which I have to speak, is 
called " melanosis," or " melanodes;" in which is deposited a mass of black sub- 
stance; which, if cut, gives an unctuous smooth section; either uniformly dark 
coloured, or presenting certain shades; so as to be mixed up with patches, or streakvS 
of paler coloured substance. Sometimes it is deposited in lobules, or a mass; and 
sometimes in plates. If a mass of this description be macerated, the black portion 
is separated; and this readily mixes with water, and stains the hand, linen, and paper; 
— just like Indian ink. It has neither taste nor smell. I never tasted it myself; but 
this is said to be the case; and it is worthy of notice, for considerations which I 
shall presently mention. It resembles in every respect the " pigmentum nigrum" 
of the eye, or the dye of the cutde-fish; and the colouring matter of the hair, of the 
skin of negroes, of some parts of the brain, the bronchial glands (or ganglia of the 
lungs) of old people, and the placenta of some carnivora, may be similar. When 
it is washed out by water, the structure which is left after the separation of the 
black substance, is circumscribed, and more or less firm. When I say '•'-circum- 
scribed^^^ I am supposing that a piece of an organ is taken; that the part is healthy 
which is washed, and thus the black portion removed; after which there will 
remain a circumscribed substance, more or less firm, different from the rest of the 
organ in which the black matter lay. Although the character of this disease is 
blackness, we do not always have a decidedly black colour. There are shades of 
brown, and even of a yellow hue, as well as the black. The masses, or deposi- 
tiqps, are not only of all sizes, but also of all shades. 

^ncdogous to Tubercle and Carcinoma. — Sometimes a black mass of this de- 
scription is thought to soften down; but that must be a rare occurrence. It has 
t)een seen that scirrhus softens down; and that tubercle softens down; but this 
mass very rarely, if ever, softens. It is, of course, a totally inorganic substance. 
It is like a tubercle in this respect, — that it never becomes organized; but it is 
unlike a tubercle in rarely, if ever, softening. A dark-coloured fungus will some- 
times arise, from the part in which this black deposit has taken place; and so far 
ii resembles " fungus haematodes." The neighbouring glands will become affected; 
— I mean the glands which are connected with the absorbents of the part. Some- 
times we have melanoid tubera, or tubercles (using the word '•^ tuber cules^^ in its 
common acceptation), — melanoid deposition in remote organs; so that the disease 
appears (like fungus hasmatodes or scirrhus) either in a primary or a secondary 
form; — beginning in one part, and being found afterwards (though not, of course, 
in so advanced a stage) in distant organs. There appears to be an analogy between 
this disease and "fungus haematodes," as to the organs which are primarily and 
secondarily affected. There is the same order observed with regard to both cir- 
cumstances. An absorbent gland, or a ganglion affected with this disease, might 
be sometimes taken for a mass of melanotic substance. The absorbent glands 
frequently have this substance deposited in them; and become blackened; and, of 
course, it is a gland blackened with a secretion of melanotic matter, and not a real 
mass of new matter, which is there. If we do not consider that the part which is 
examined is one in which an absorbent gland actually lies, it might sometimes be 
mistaken for a mass of this peculiar melanotic matter. 

Melanods distinguished from Carcinoma. — [Melanotic deposition not unfre- 
quently occurs in carcinoma, more especially the encephaloid variety; and, on this 
account, Miiller and other writers have considered it to be merely a variety of car- 
cinoma. Dr. Walshe, in his Essay on Cancer,'' has pointed out the following 
reasons for dissenting from this opinion: — 1. Pure melanic pigment — no matter in 
what abundance accumulated — produces no other effects than those dependent on 
the mechanical obstruction caused by the mass it constitutes. 2. When melanotic 

^ '' Cyclopaedia of Practical Surgeryj" Volume 1; Page G14. 



NEW FORMATIONS. 211 

tumours produce the local and general symptoms of cancerous growths, they are 
found to be composed either of encephaloid or scirrhus (more especially the former), 
impregnated with black matter. 3. Neither the local nor general symptoms of 
carcinoma are modified in cases where melanic matter is found to pervade it. 4. 
Melanic matter is incapable of forming a tissue; — being an unorganized fluid, into 
which vessels have never been observed to penetrate.] 

Varieties of Melanosis. — [Laennec, to whom we are indebted for the first de- 
scription of this disease (the discovery of which is claimed by Dupuytren), described 
the four following forms of this affection: — 1. Masses enclosed in cysts. 2. Masses 
without cysts. 3. Infiltration in the tissue of organs. 4. Deposition on the sur- 
face of organs. This classification, with some slight modification, was adopted by 
most writers; but the results of more recent researches on melanosis, and other 
morbid states and products which present the same distinctive physical characters 
as the former, suggest the propriety of a more comprehensive arrangement. The 
following tabular view, which Dr. Carswell has given, presents the leading fea- 
tures and varieties of this disease, in a very clear manner.] 

Classification of Melanotic Formations. 
I. True Melanosis. 



Origin. 




A modification of secretion. 


Locality. 


1. 


Tissues, systems, and organs. 

a. In the substance and on the surface of organs 

h. In the cavities of hollow organs. 




2. 


New formations. 


Form. 


1. 


Punctiform. 




2. 


Tuberiform. 




3. 


Stratiform. 




4. 


Liquiform. 


Seat. 


1. 


Molecular structure of organs. 




2. 


The blood. 

II. Spurious Melanosis. 


Origin. 


A. 


Introduction of carbonaceous matter. 




B'. 


Action of chemical agents. 




C. 


Stagnation of the blood. 



Locality. Of first kind: the lungs. 

Of second kind: the digestive organs; the surface of serous and 
raucous membranes: the cavities of hollow organs; new forma- 
tions. • 
Of third kind: the blood. 
Form. Of first kind: uniform. 

Of second kind: — 1. Punctiform. 2. Ramiform. 3. Stratiform. 

4. Liquiform. 
Of third kind: — 1. Punctiform. 2. Ramiform. 
Seat. 1. The blood, contained in its proper vessels, or effused. 

2. Pulmonary tissue; cellular and membranous.* 

Occurs in the Lower Jlnimals. — It has been seen, like the other deposits, in 
brutes; and particularly in the horse. Of all brutes, I understand, it is most fre- 
quently found in the horse; and it is said to occur most frequently in cream- 
coloured and spotted gray horses; and oflener in horses in the south of Europe 
than here. I do not speak from observation of my own; for I have not dissected 

=^ Dr. Carswell, on "Melanosis:" in the "Cyclopedia of Practical Medicine;" Volume 
3; Page 80. 



212 NEW FORMATIONS. 

many brutes. So large are the masses which sometimes occur in horses, that they 
have occasionally been found, in the abdomen, to weigh thirty pounds. It is like- 
wise seen in dogs, cats, rabbits, mice, and rats; — so curious have some people been, 
in the investigation of melanosis. 

Jittacks all Parts of the Body. — It not only attacks so many creatures, but it is 
said to attack all parts of the body; — chiefly, however, the lungs and the liver. Dr. 
Halliday mentions an instance of most intense melanosis in the human subject; 
where it existed, almost universally, in the subcutaneous and inter-muscular cellular 
membrane, — in the cellular membrane under the skin, and among the muscles; in 
the peritonseum, the pericardium, the pleura, the ovaria, the sternum, and the bones 
of liie cranium; — so extensive sometimes is this deposition. 

Age at inhich it Occurs. — This is a disease which does not occur early in life, 
like fungus hcematodes; but rather resembles scirrhus in this respect; — seldom oc- 
curring till the individual has passed the middle age. 

Encysted or Diffused. — Sometimes, though rarely, this substance (I do not use 
the word " matter;^'' because that conveys the idea of pus) is enclosed in a cyst. 
Most other deposits have a cyst; but it is only sometimes that this is found to be 
so enveloped. Occasionally, instead of being collected into a mass, it is completely 
diffused; — not merely in small scales and plates, but generally (\\&\\sei\ along a 
membrane, mucous or serous; and when this is the case, it really is deposited, not 
upon the membrane itself, but rather in the cellular membrane immediately under- 
neath it. I apprehend so because it is the cellular membrane that is liable to be- 
come cartilage and bone, and which is particularly liable to other diseases. 

O71 False Membranes. — This disease, too, is not unfrequently seen in new mem- 
branes of the body; false membranes. When a serous membrane has been inflamed, 
or has had lymph deposited and afterwards organized, then the false membrane be- 
comes cellular membrane, as mentioned before;* and these new false membranes 
are sometimes seen to contain a melanoid deposit. 

On Seroics Surfaces. — It is said, however, to be sometimes found on the surface 
of a serous membrane. It is right I should mention that I have not seen it; but it 
is said to have been found, not underneath the membrane, but lying on the surface. 
The parts around, probably, do not undergo any change except softening. Around 
this black deposit, the real natural parts of the body are found softened; but in 
general that is all, unless this disease coexists with another; and it is a very com- 
mon thing for it to coexist with scirrhus, with " fungus haematodes," and even 
with tubercles. Where, however, it exists alone, — where it is conjoined with no 
other disease, it seems to occasion nothing more than a mere softening of the sur- 
rounding parts. 

In a Fluid Form. — Occasionally, this same substance would appear to exist in 
a fluid form. Occasionally we have a cyst filled with a liquid perfectly black; in 
which no diflference has been observed from the mass I have now described, except 
that the one is liquid and the other solid. When this melanoid matter has been 
found in a fluid state, there is every reason to believe that it was formed originally 
fluid, and not softened down; because the usual course of the disease is for the 
mass to remain solid, however long it may last. When we see black fluid con- 
tained in a cyst, therefore, we must conclude (in general) that this substance had 
been originally formed with a disposition to remain fluid. 

Serous Membranes. — We frequently see, upon a serous membrane, spots of 
melanosis; that is to say, perfectly black spots, which appear to be quite analogous 
to this affection. Indeed, one can hardly open many bodies, without seeing these 
spots upon certain serous membranes; particularly the peritonaeum (towards the 
pelvis), the uterus, the bladder, and the rectum. These appear to do no harm, — 
they are perfectly innocent deposits; and sometimes we see very extensive depo- 
sits, superficially diffused; and in persons who are known not to have suflTered at 
all fiom that circumstance. 

• See Paore 108. 



NEW FORMATIONS. 213 

Mucous Membranes and Skin. — It is frequently seen in mucous mennbranes, 
after they have been injured. After a mucous membrane has ulcerated, and has 
healed (which is very common in the intestines), the cicatrix is frequendy black- 
ened, more or less, with a deposit of this description. The deposition, as I men- 
tioned before,^ is sometimes not exactly black, but merely grayish; — sometimes 
brownish, or even yellow; and this we see in the skin after an eruption, and after 
ulcerations of various kinds. After an eruption, the skin will sometimes remain 
black, but more frequently brovynish; and, after an ulcer, it is very common for the 
legs to remain of a dark colour, — sometimes black, but more ftequenUy of a brown- 
ish yellow. These, I presume, may be considered various shades of a similar 
deposit. The same is seen in the brain, after paralysis from effusion of blood into 
its substance. A deposition of this sort is sometimes seen in the mucous mem- 
brane of the intestines, after chronic diarrhosa. Occasionally, in the intestines, 
small points of black deposit are seen; as if a very fine powder had been sprinkled, 
in the finest possible way, upon the surface of the intestines. I do not know that 
it indicates any thing particular, but, every now and then, we see such points, ex- 
tensively disseminated. When I first saw this, I imagined that it was some dirt or 
soot; but I found that it could not be washed off. It is not any thing exnc[\y upon 
the surface; it is seen through the surface; but we cannot rub it off, unless we de- 
stroy the membrane itself. I have sometimes seen the middle of the tongue of a 
jet black, wiihout any unhealthy state of the rest of the organ; and without sordes, 
or any dangerous symptom. 

Of the Entire Skin. — I think there is a very curious circumstance analogous to 
this. I have never seen it; but there are, perhaps, nearly twenty cases on record 
within my reading (and beyond it there may be far more), of white persons who 
have become black. A change will now and then take place over the whole of the 
skin; so that a white person shall become entirely black. I have seen portions of 
the arm become black; but I have never seen an extensive change of that kind 
throughout the body. Others suppose (and I coincide with them) that this is a 
melanotic disease, on a very extended scale; — that melanoid substance is diffused 
solely upon the skin, and in the most extensive manner. When we consider, that 
if the disease be formed in a mass, it always bears a resemblance to the " pigmen- 
tum nigrum" of the eye, we must suppose that, when a white person is converted 
into a black, it is nearly the same affection. 

Black divine and other Excretions. — Persons occasionally discharge from the 
stomach, or the intestines, a black liquid; and the discharge of this is called, in old 
authors, by the peculiar name " wefena," — " the black disease." This stuff, when 
perfecdy black, has (I believe) no smell; at any rate, when it happens to be dis- 
charged pure, without faeces, it has no smell; and cases have been noticed, in which 
a large collection of precisely similar black liquid matter, has been found in the 
peritonaeum. Some such cases are upon record. Dr. Prout has seen two or three 
instances (thougltl have not seen any myself) in which the urine was perfectly 
black; — not bloody, but black. The black secretion of the bronchia, in some peo- 
ple, IS probably dependent on the same dye. When we come to consider yellow 
fever, we shall find that persons vomit stuff of a black colour, which is called 
'• black vomit." It is found to be tasteless; so that some have indulged themselves 
in drinking it. Others have put it into their eye, to see if it were acrid; and others 
have made an extract of it, and formed it into pills, and taken several in the course 
of a day; and they all concur in slating, that it is just like the melanotic matter of 
which I have just spoken, as deposited in solid masses; — tasteless, inodorous, and 
perfectly innocent when taken into the stomach. 

Nature of these Excretions. — With respect to the discharge from the intestines, 
it may either be entirely black, or a little reddish, — so that we observe a slight 
hue of red in the black. Indeed, it may occur of various kinds, down to absolute 

• See Pagre 210. 



214 NEW FORMATIONS. 

blood. I think that these discharges which take place from the alimentary canal, 
are blood that has undergone a certain change. 

Discharge not Dangerous. — Persons are exceedingly exhausted by this black 
discharge; but as it comes away through the intestines, it produces no pain, and (in 
general) no irritation; — nothing but exhaustion. It is admirably remedied by small 
and frequent doses of oil of turpentine; — just like h2emorrhage from the same parts. 
It appears to be (and I believe we must look upon black vomit as similar) an ex- 
ceedingly mild substance; — as nearly like the blood as possible, except in colour. 

Pathology of Melanosis. — What the change that has been undergone really is, 
I do not pretend to know, but the black urine, the black discharge from the intes- 
tines, the blackness of the skin, when a patient is converted (partially or generally) 
from white to black, the blackness of the peritonaeum, of the mucous membranes, 
and of cicatrices in various parts of the body, and the black masses and substances 
in various organs, — all appear to be the same affection in different forms, and in 
different degrees; and it would appear to be merely blood which has undergone a 
very slight change. As taken from the horse, it is found (by analysis) to contain 
the elements of the blood, — fibrin, albumen, (fee; but nearly one-third is a highly 
carbonized substance, — probably altered cruor. Every other constituent is in far 
less proportion. In the cells of the ovaria, we often see a black substance, — fre- 
quently blood; and all shades may be traced between the two; so that blood here 
appears capable of being changed to this black substance. 

Prognosis. — Melanosis appears to be perfectly harmless, except from the quan- 
tity of the substance which is formed. There may be an inconvenience arising 
from its bulk, its pressure, and its hardnes?; and of course when it is discharged, 
in a liquid form, there may be exhaustion from its quantity; but, independently of 
that, I believe that the disease is not one of any malignity. Still it is to be remem- 
bered, that it is very frequently united with malignant disease; for, in a mass of 
"fungus haematodes," a black deposit often appears. This is not to be wondered 
at, when we consider that, in " fungus haematodes," there is blood effused into 
the different cells. It is also seen in scirrhus, as well as encephaloid disease; and 
all these diseases are oftentimes observed to be mixed together in the same indi- 
vidual; — scirrhus, melanosis, and encephaloid disease, in one mass; but when con- 
fined to itself, I believe it is thought, by the greater number of persons, not to be 
a malignant disease. 



SECTION IV.— KIRRHONOSIS. 

Definition. — There is a disease, in which a substance of a yellow colour is de- 
posited, in spots or patches, in the substance of the viscera, or upon the skin, or 
upon different membranes. A German author (Lobstein) says, that he has seen 
various parts of a membrane so coloured; and he calls this affection " kirrhonosis."* 
It seems particularly to affect the membranes of the head, chest, and abdomen; and 
when jaundice occurs in young children, Andral imagines that it is really this par- 
ticular disease, and not true jaundice. I can give no opinion, from experience, 
respecting it. There is a species of jaundice which occurs in young children, and 
which is speedily removed by castor-oil; or which, even if no measures were 
adopted, would often cease spontaneously in a day or two; but besides that, there 
is sometimes jaundice, the disposition to which is congenital; for many families 
have died of it in succession. There are many children who are said to have jaun- 
dice; but which affection is supposed to be an instance of this yellow disease. 
Laennec calls it "cirrhosis;'"* and says it is deposited in masses, or layers, or some- 
times in a cyst, — such as we occasionally see in melanosis; and he conceives that 
a hard tuberculated liver, such as is seen in gin-drinkers, is an instance of this 

a From xtpfoc. yellow. 

^ A term under which it is treated and known by the majority of modern writers. 



NEW FORMATIONS. 215 

affection. I recollect having' once seen, in the liver of a child who had scrofulous 
tubercles of the lungs, a cyst filled with this peculiar yellow matter. It is alto- 
gether a rare disease; unless the small brown tubercle of the liver be it. We are 
led to believe, from its general history, that it is an innocent affection; — that the 
deposit is as innocent as that of melanosis. 

Coexistence of many New Formations. — When these new formations (tubercles, 
scirrhus, fungus haematodes, melanosis, and kirrhonosis) coexist in the body, it is 
nothing more than a fact analogous to the circumstances which I formerly stated, 
respecting transformations.^ It was remarked, that the various transformations 
sometimes, coexist in the same organ; — that cartilage may be found in one part 
of an organ, and bone in another. And so it is with respect to mare changes in 
size and consistence. We find them coexist in the same organ; so that one part 
of an organ will be indurated, and another softened; — one part hypertrophied, and 
another atrophied. Diseases of consistence, and of size, and those of transforma- 
tion, sometimes blend together, — just like the diseases of new formations. And 
not only so; but new formations, and changes of consistence and of size, — all blended 
together in the same person, — are not unfrequently observed. 

» See Pages 184 to 189. 



816 



PART II. 

UNIVERSAL DISEASES 



The diseases of which I have now spoken, are those which may affect almost 
any part of the body; namely, inflammation,* scrofula,'' changes of consistence*' 
and of size,* transformations,^ and new formations/ I have spoken first of diseases 
■which will affect any part. It is not meant that each of these diseases will affect 
any one part; but they may be situated either here or there. Besides these, how- 
ever, there are other diseases which may be called "general," — not from their 
being common to any part of the body; so that they may affect one person to-day 
in one part, and another in a different part to-morrow (as is the case with inflam- 
mation), — but because they are "general" in another sense; — they appear to affect 
the whole body together. Whether these general diseases have their origin in some 
one spot, I do not knov/; but, so far as I can observe, they exist (more or less) 
throughout the whole body. One of these is a disease called "anaemia" [blood- 
lessness); — a very curious disease; and there is another called "scurvy." I do 
not know whether these diseases spring from the state of any one part of the body, 
more than of another; for we see a person bloodless throughout, without any local 
affection that can be discovered. They become pale, — blanched throughout, and ex- 
cessively weak; and we cannot say that any one organ is lobouring under disease, 
lather than another. So, in scurvy, the whole mass of blood, as well as of the 
solids, is affected; — so that these are general diseases in another sense; or, perhaps, 
we ought rather to say, they are universal diseases; — those being properly general^ 
which are able to exist here or there. Those of which I shall next speak, therefore, 
are rather universal diseases; and perhaps the distinction I have drawn between 
general and universal^ will be seen to be proper. 

Again: there is another set of diseases which may themselves be local; but which 
produce effects so universal, that if they have really a local seat, it is at one spot 
in one patient, and at another spot in another patient. I refer to fevers; for there 
are various kinds of what is called "fever" — independently of eruptive diseases. 
Many persons speak of fever (whether intermittent, remittent, or continued) as 
having a particular locality; but I do not think they have proved the correctness of 
their assertions; and, according to our present state of knowledge, — though ready, 
of course, to change my course, when more knowledge is imparted to us, — 1 shall 
prefer considering these also as universal diseases. 

Besides those general and these universal diseases, there are other affections, which 
consist of a mere affection of function; and in which, at least in many cases, there is 
no structural disease. It is possible that all diseases may be more or less struc- 
tural; but I cannot help believing that some diseases are eyiiweXy functional. With 
respect to diabetes, for instance, I have frequently opened persons who have died 
of it; and if its pathology were estimated from an examination of the viscera, the 
disease would appear to be entirely functional. The labours of Bright and Front 
have abundantly shown, that this affection (formerly thought to be only functional) 

» See Page 71. i> See Page 190. «= See Pages 176 and 178. 

<* See Pages 180 and 183. • See Page 184. ' See Page 189. 



ANEMIA. 217 

depends upon a definite derangement in the processes of assimilation, and conse- 
quently in the circulating fluids. In cases of insanity, also, frequently no disease 
of the brain has been discovered. It appears to have been entirely functional. Of 
course the disease is corporeal; but "corporeal" is not "structural." A disease 
may be corporeal and yet merely '' functional f^ for there may be no change of 
structure. 

There are other diseases, entirely mechanical. Hernia is one of this class. 
Even fractures ar^l luxations are classed, in systems of nosology, as diseases; but, 
at any rate, hernia is called a disease; and it is entirely mechanical. 

There are other diseases which arise from another animal having taken up its 
abode with us. Such is the case with worms in the alimentary canal; and the 
existence of various insects upon the surface of the body. 

Diseases, then, may be "general," — attacking any one part; and there may be 
likewise "universal" diseases; which, according to our present state of knowledge, 
appear to be diffused throughout the whole body, without any particular locality. 
Again: it will be necessary to speak of diseases which are "functional" — affecting 
particular functions; not organic at all, but entirely functional; and affecting only 
special parts. Diabetes, for instance, as regards the kidney, and insanity as respects 
the brain, must be functional. Spasmodic asthma, also, is often a functional dis- 
ease. Persons who have died of or with the disease have been opened, where no 
trace of disease could be found. " Mechanical" affections likewise, and the exist- 
ence of parasitic animals, — " parasitical" diseases, are brought frequently under 
our notice. 

But I shall content myself with the general account already given* of inflamma- 
tion and "structural" diseases; and shall consider "functional," "mechanical," 
and " parasitical" diseases, not in general, but only in detail, — when speaking of 
the diseases of each part of the body. Previously to this, however, I must give 
an account of "universal" diseases. 



CHAPTER I. 

ANEMIA. 



General Definition. — The first of these universal diseases of which I shall speak, 
is called " anaemia;" — a word which explains itself; — " the want of blood."* Blood 
is present; but there is a great deficiency of it. I have no doubt that the fault 
resides in some one particular part of the function of forming blood; but, in our 
present state of knowledge, we can only speak of it as a " universal" disease. 
When a person labours under this affection, we might state, a priori, what the 
symptoms must be. In the first place, there is great debility; in the next place, 
the skin is soft, and of a deadly pale wax-colour; in the next place, the white of 
the eye is bluish, the inner part of the mouth is colourless, the lips are exceedingly 
white, and even the tongue is pale. The pulse is, in general, about eighty; but 
exceedingly feeble, and very easily excited; — the least stimulus, — the least mental 
emotion, as well as corporeal movement, produces a great momentary acceleration. 
Respiration also is hurried on the least exertion. The appetite is bad; and it is said 
that there is constant thirst. There is oedema of the legs at last; and, finally, sweating; 
— sweating induced by the great debility. After death, the colour is much the 
same as it was during life; — the corpse is not paler than the living subject; for when 
his disease is intense, persons are really corpses in appearance. 

• See Pages 71 to 316. »> From av, without; and aifxa, blood. 



218 CHLOROSIS. 

»^ggravated Species. — So far, I think, one might beforehand portray the disease, 
merely upon reflection; — without ever having seen or read about it. But, in certain 
cases of this disease, the stools have been observed to be dark-coloured and foetid; 
the appetite to be bad; and almost every thing, at last, to be vomited. When per- 
sons have been opened, there has been found universal internal paleness, softness, 
and want of blood, and more or less excess of fluid in the serous membranes; — a 
fact corresponding with oedema of the legs, and with sweating in the last stages. 

Endemic Variety. — This disease, in a peculiarly marked form, occurred formerly 
in France, to a great number of workmen in one particular gallery, at a coal-pit 
situated at Anzain, near Valenciennes. The disease was preceded by tormina, 
retching, green stools, thirst, and wasting, for ten or twelve days; and then the 
affection appeared, as I have now described it. It lasted for six, or even for twelve 
months; and then ended in death. At length, the proper treatment was discovered. 
A description of this endemic disease is given by Professor Halle. It might be 
called *' endemic," from having been confined to a particular mine, and even to a 
particular gallery in a mine; — as though it arose from some effluvia. Dr. Combe 
describes a similar case, in the first volume of the " Edinburgh Medico-Chirurgical 
Transactions."* The patient \yas a corn-merchant's son, in whom no evident cause 
for the disease could be discovered. 

Treatment. — Mercury was given to the French patients, and did them a great 
deal of harm; for it is a state of the system in which mercury is very injurious. 
Opening one patient, and finding the internal vessels almost bloodless, they no 
longer gave mercury, but carbonate (or rather oxide) of iron in considerable quantity, 
with opiates, tonics, and good food; and the patients got well. They exhibited 
signs of improvement in the course of eight or ten days; and from that time the 
greater part, I believe, recovered. A similar occurrence took place at Dunkirk; 
and the treatment there was exactly the same (the exhibition of iron); and the patients 
recovered equally well. It was found, however, that relapse was very usual; and 
that the remedy had therefore to be continued for a considerable time. I believe 
the patients at Dunkirk, were persons who had been sent from the mines to which 
I before referred; but the same treatment was adopted, and was followed by the 
same success. In anaemia from loss of blood, as well as from deficient formation 
of it, iron is one of the best remedies. I must mention that Dr. Combe used both 
the sulphate and carbonate of iron; but he does not mention the doses, or the length 
of time they were given. Mercury, which appeared to be injurious in France, was 
also exhibited; as well as a number of other drugs; — so that the iron did not appear 
to have a fair chance. 



CHAPTER 11. 
CHLOROSIS. 



There is a disease common to young women, either about the time they ought 
to menstruate, or soon after they have begun to do so. It is called " chlorosis;"" and 
appears to be a state exceedingly similar to that of anaemia. It sometimes occurs 
to persons more advanced in life; and a similar affection also occurs to men. 
Strictly speaking, it is not chlorosis in men; because we say that one of the symp- 
toms of chlorosis, is an absence of the menses; — the menses not appearing at the 
proper time of life, or retiring just after they have presented themselves. Of course, 
this is not a symptom of the disease in men; although, in them, when the actual 

* Page 194. »» From x>^»foc, green. 



CHLOROSIS. 219 

condition of the system is considered, it may be correctly termed " chlorosis." 
But let us consider things, rather than words. It is a fact, then, that men will 
sometimes fall into a state of anaemia and debility, very similar (in all appearance) 
to that state which in women is called "chlorosis." 

These diseases, although they are not spoken of by authors as analogous affec- 
tions, are all of the same family. There is a want of the production of blood; 
though wherein the defect consists, I do not know. In the cases which occurred 
in France, one would suppose that some deleterious substance affected the functions 
of the body. In chlorotic women, frequently, no cause can be discovered. In 
organic disease of the heart, patients will continually fall into a condition of the 
system, similar to that which we observe in chlorosis; but with palpitation ten 
times greater than ever occurs in that affection. In various visceral diseases, espe- 
cially of the spleen and stomach, anaemia occurs. 

[With reference to the question in dispute, as to whether the term "c/?7oro,'??s" 
ought to be exclusively restricted to the anaemial state dependent upon disordered 
menstruation, the following practical observation on its varieties, by Dr. M. Hall, 
are important: — " Sometimes there is less pallor of the countenance and prolabia; 
but a ring of tumid darkness round the eye, and perhaps a tumid state of the upper 
lip. Sometimes the complexion is of a more yellow or icterode hue. Sometimes 
the complexion is of a peculiar lead-colour. There is sometimes a peculiar state 
of coldness, cold moisture, and lividity of the hands and fingers, and a lilac-hue of 
the nails; the tips of which often become white and opaque. The state of chlorosis 
consequent on hsemorrhage, also deserves to be distinctly noticed: there are pale- 
ness, and slight yellowness of the complexion, exanguious prolabia, a greater 
degree of loss of flesh, and great fluttering and nervousness. There are more 
chronic forms of this affection; in which there is a continued (though variable) 
state of sallowness, of yellowness (or icterode hue), of darkness, or of a wan, 
squalid, or sordid paleness of complexion; or a ring of darkness surrounding the 
eyes, and extending a little, perhaps, towards the temples and cheeks, and some- 
times encircling the mouth; — without tumidity, paleness of the prolabia, and 
oedema.*] 

Symptoms. — When a woman becomes the subject of this disease (which is 
common), there is general paleness, with swelling of the face and ankles; weak- 
ness; a great sense of tension of the legs and feet; dyspnoea; palpitation; the pulse 
either quick or easily rendered so; and a deficiency of menstruation. These are 
the symptoms of chlorosis mentioned by authors; and they are, for the most part, 
exactly the symptoms that occur in the disease called "anaemia." I have no doubt 
the pathology, or proximate cause of these two diseases, is exceedingly similar. 
In women who have chlorosis, the alimentary canal is often very much disturbed; 
and that was the case with the Frenchmen whom I have mentioned." There is 
sometimes a great derangement of the stomach; or, if the cause of hunger is cere- 
bral, we must say " a derangement of mental feelings." Patients will long for all 
sorts of things; such as chalk, sealing-wax, or brown paper, with impunity. Such 
is the departure from the natural state of things. Very frequently, too, there is 
constipation. They will sometimes eat the most filthy things; — things that one 
would never think any human beings would touch, except cannibals. They will 
even take pleasure in offensive smells; and long to eat what they do eat in a privy. 
That, however, is an intense state of the affection. 

State of the Blood. — [Among other changes which occur in the progress of 
chlorosis, there is none more constant than an impoverished condition of the blood; 
which is thin, light-coloured, and weakly coagulable; — being deficient in fibrin, and 
still more in the proportion of the red particles. To the latter cause is to be 
attributed the diminished temperature of the surface, and likewise the universal 
pallor and waxy slate generally exhibited by the subjects of this disease. The 
deficiency of colour in the catamenia, and the pale stain which haemorrhages from 

» " Principles of Medicine; by Marshall Hall, M. D." Page 205. " At Page 218. 



220 CHLOROSIS. 

the nose leave on the linen, are also referable to the same cause. In ag-orravated 
cases, if blood be drawn from the arm, the crassamentum is observed to be of a 
pale rose-colour, and small in proportion to the serum. It is to be regretted that 
in this, as in most other cases of morbid blood, padiologists have contented them- 
selves with a general observation of facts. The only analyses of chlorotic blood 
of which P can find a record, are given by Mr. Jenkins, in two well marked cases 
of chlorosis; the one of a girl aged fifteen, the other of a young woman aged 
twenty-one. In these cases the blood contained 871 and 852 parts in a thousand 
(respectively) of water, instead of 780, which is the healthy standard; and the 
colouring matter amounted to 41*7 and 52 instead of 133. The albumen and salt 
were in the usual proportions.''] 

Its Stages. — [Chlorosis steals insidiously on the patient; — so insidiously, some- 
times, that P have known parents even to be unconscious of its existence, until it 
has been distinctly pointed out to them; although it may have attained its most 
'marked form. It has three tolerably distinct stages; — the incipient, the confirmed, 
and the inveterate. 

The incipient stage of this morbid affection is more particularly characterized by 
paleness of the complexion, an exanguious state of the lips, slight tumidity of the 
countenance, and puffiness of the eyelids, — especially the upper one. Along with 
this marked state of the countenance, there is sometimes a slight tinge of green, 
of yellow, or of slate-colour. In the confirmed stages of chlorosis, the state of 
pallor of the complexion is still more marked; and the tongue, as well as the lips, 
is exanguious; — perhaps with a slight lilac-hue in the upper lip. There is usually 
tumidity of the integuments in general, and of the eyelids in particular. In the 
inveterate or last stage, this state of the countenance is apt to be modified by a 
degree of loss of flesh on the one hand, and by increased cedema (perhaps partially 
disposed) on the other. 

State of the Tongue. — In the first stage of this aff'ection, the tongue is rather 
white and loaded; and somewhat swollen, and marked by pressure against the 
teeth. Its papillae are enlarged; it is slightly formed into creases or folds; and its 
colour is rather pale. The gums and inside of the cheeks are, like the tongue, 
somewhat tumid; and the cheeks, like the tongue, are also impressed by the teeth. 
The mouth is generally clammy, and the breath tainted with a peculiar odour. In 
the confirmed stage of chlorosis, the tongue becomes clean, smooth, and exanguious; 
with a slight appearance as of transparency, and a slight lilac-hue. It is flat upon 
its surface, and still somewhat indented by pressure against the teeth. In the last 
stage, the tongue frequently becomes smoother still, and slightly shining; and P 
have, in some cases, observed an odour of new milk in the breath of the patient. 

General Pallor of the Surface. — In the beginning of this morbid affection, there 
is an increasing pallor of the general surface, hands, fingers, and nails; an opaque, 
white, and tumid state of the skin; a slight tendency to oedema of the calves of the 
legs, and ankles, and to loss of flesh. In the more confirmed stage, the skin is still 
smooth, but rather dry; and the integuments are exanguious, puffy, opaque, and 
perhaps yellowish, with the same or increased tendency to oedema. The nails are 
exanguious; and, in some instances, slightly split or exfoliated. In the confirmed 
stage, the appearances are the same, with the addition of some loss of flesh, and 
perhaps increased oedema. The nails are sometimes slighUy split, and their tips 
opaque. 

Deficiency of Nervous Energy. — The patient in chlorosis is languid, listless, 
sedentary, indisposed to exertion, easily overcome by exercise, nervous, low- 
spirited, and frequenUy a prey to singularities of temper. There is generally severe 
recurrent headache, or vertigo; sometimes heaviness for sleep; and sometimes an 
impaired state of the memory, and of the faculty of attention. 

Palpitation and Breathlessness. — There is frequently palpitation, either recur- 

* Dr. Babington. ^ " Cyclopaedia of Anatomy and Physiologyj" Volume 1; Page 428. 
« Dr. Marshall Hall. 



CHLOROSIS. 221 

ring in attacks, or of a more permanent character: and, more frequently still, a sense 
of fluttering in the praecordia, with irregular action of the heart, or imperfect syn- 
cope. The pulse is sometimes rather frequent, — always easily accelerated. There 
is usually a degree of breathlessness experienced on any exertion; sometimes fits 
of dyspnoea, sometimes a sonorous cough. 

Pain of One or Both Sides. — Frequently, also, there is a singular and peculiar 
pain of one or both sides, either together or alternately; — situate over the false ribs; 
and spreading a litde upward, backward, or downward; — so as to occupy the space 
between the false ribs and the ilia. The recurrent nature, the particular situation, 
and the alternating character of this pain, are altogether peculiar and characteristic. 
The patient perhaps complains on pressure; but, on a careful examination, this 
pain will be found not to be aggravated by a deep inspiration. For this purpose 
the inspiration must be repeated; as it may appear, at first, to increase the pain; 
but afterwards it will be found not to do so. 

Appetite Impaired. — The appetite is generally impaired, capricious, and even 
depraved; — inducing longings for some indigestible substances; such as acids or 
pickles, magnesia or chalk, tea-leaves, flour, grits, wheat, cinders, sand, &c. The 
patient likes to have some one of these substances in her mouth; but especially 
when affected by agitation or anxiety. 

State of the Borvels. — The bowels, in the incipient stages, are always consti- 
pated. Afterwards this state alternates or leads to diarrhoea, and sometimes to 
haematemesis or melaena. The evacuations are usually scanty, dark-coloured and 
foetid. 

State of the Menstrual Discharge. — The flow and condition of the catamenia 
are, in general, very early aff'ected in this disorder. They become irregular in 
their returns, inconstant or of short duration in their flow, defective in quantity, 
and pale in colour. Sometimes they are discoloured; sometimes they do not cease 
kindly, but are continued into a state of leucorrhoea; at other times, and especially 
in the latter stages of the disorder, there is amenorrhoRa. In some instances, each 
return of the catamenia has been preceded and attended by much pain in the back, 
and in the region of the uterus. 

In the more Advanced Stage. — In the inveterate stage of this disorder of the 
general health, the symptoms assume a modified but still more aggravated character. 
There is a very slow but progressive loss of flesh; the languor assumes the form of 
permanent debility; the oedema increases, and assumes the aggravated character of 
anasarca; the pulse becomes more constantly frequent; and there is altogether less 
of the character of functional derangement, and more of that of disease. The local 
complications become more permanent, or are renewed by the slightest causes; and, 
in some painful instances of this aflection. the patient has been unable to bear the 
most ordinary occurrences of domestic life; and has, perhaps, been compelled to 
remain altogether in her room, or upon the sofa or bed. In this stage of the disor- 
der, there is sometimes an almost permanent pain of the head, perhaps with intole- 
rance of light or of noise; sometimes incessant pain of the chest, with tenderness, 
difficulty of breathing, and cough; and there are frequently pain and tenderness of 
the abdomen, with sickness, and constipation or diarrhoea. Various other symp- 
toms prevail in different instances; such as locked-jaw, clenched hand, contracted 
foot, twisted jlimbs, palpitation or other forms of dyspnoea, fits of coughing, hic- 
cup, retention of urine, <fcc. 

Pathology of Chlorosis. — P should despair of giving any thing accurate or spe- 
cific, with regard to the pathology of this form of disorder of the general health. 
There appears to me* not to be a system, an organ, a texture, or even a fluid in the 
animal economy, which does not suffer in different instances of this multiform 
disorder. The complications of the more acute form of disorder of the general 
iieallli, diff'er totally from those of the move protracted, both in their various seats, 
and in their nature; — the former affecting the more vital organs, the latter the 

• Dr. Marshall Hall. 



222 CHLOROSIS. 

superficial textures. A similar remark equally applies to that form of disorder of the 
general health now under consideration. 

There is in chlorosis a remarkable state of the capillary system of circulation, 
both of the vessels, and of the fluids. It is this which gives origin to the exan- 
guious appearance of the countenance, lips, tongue, gums, and general surface; to 
the tendency to oedema; and to different species of haemorrhages, especially those of 
the mucous and cutaneous surfaces; such as epistaxis, melaena, hasmatemesis, and 
even purpura; and.it is from this circumstance that the catamenia become almost 
colourless and aqueous. P have observed the blood which has flowed from the 
nose scarcely to tinge the sheets; and that taken from the arm to resolve itself 
almost entirely into serum, with scarcely any crassamentum. Tliis disorder afibrds, 
therefore, one of the most unequivocal examples of the humoral patiiology. 

Causes. — It would be difficult to trace the series of causes and effects in the 
pathology of this affection; but I* do think the Jirst cause is in the state of the 
bowels; that a concurrent cause is the peculiarity of constitution just described; 
and that an exciting cause is the inactive and sedentary mode of life usually obtain- 
ing in female youth. The stomach suffers from its continuity with the intestines; 
the uterus possibly by contiguous, the head and heart by remote, sympathies. The 
pain of the side is peculiar, and too common to be a mere accidental complication, 
and it also, therefore, probably depends upon the state of the large intestines. 

The state of the circulating fluids is probably deteriorated, from defective diges- 
tion and assimilation; and this deteriorated condition of the blood probably becomes 
a cause, in its turn, of impaired vital energy; — the heart and the brain being imper- 
fectly stimulated. It is obvious, from these remarks, that blood-letting — so apt to 
be prescribed for painful affections of the head or side — should be employed with 
the utmost caution. 

The state of disorder has sometimes been mistaken for organic disease; but its 
character is so distinct, that there does not appear to me* any danger of mistake 
with the careful observer. The state of the complexion, especially when it has 
assumed somewhat of the icterode hue, — has, indeed, frequently led to the suspicion 
of disease of the liver. The diagnosis is, however, readily established, on com- 
paring the state of the lips, of the tunica conjunctiva, of the urine, and of the faeces; 
and by a careful examination of the region of the liver. 

Complications. — The patient affected with chlorosis, is extremely subject to 
attacks of various local affections in a more continued form. It is, therefore, essen- 
tial to distinguish the complications of this morbid affection from some sudden and 
some chronic diseases. The first case in which P saw the necessity and the im- 
portance of these distinctions, had been successively treated as inflammation of the 
brain, and inflammation of the liver, by bleeding, blisters, and leeches, to an almost 
incredible extent; — the patient having been first subject to severe pain of the head, 
and afterwards to pain of the right side. The case was distinguished by the usual 
appearances and symptoms of disorder of the general health; and it was perfectly 
and even promptly removed by the appropriate remedies. 

Diagnosis. — The diagnosis is founded upon the state of the countenance, of the 
tongue, of the general surface of the bowels, and of the catamenia; the multitude 
and variety of the other symptoms; the variable history of the case; perhaps, the 
suddenness and repetition of the attack; and the effects of remedies. The only 
difficulty is, when some topical inflammation comes on, in a patient previously 
affected with chlorosis. Even in this case the disease assumes a more settled and 
definite form, instead of the varying and complicated character of chlorosis; and 
may then be distinguished by a careful examination. 

These observations stricUy apply to the diagnosis of chlorosis with pain of the 
head, from inflammation of the brain or its membranes. In the latter disease, there 
are not the characteristic appearances and symptoms of chlorosis; — as observed in 
the countenance, tongue, general surface, and general symptoms; while there are, 

a Dr. Marshall Hall. 



CHLOROSIS. 223 

on the contrary, the peculiar and definite symptoms of inflammation of the ence- 
phalon; which it would be out of place to mention here. 

The cough and dyspnoea, the palpitation of the heart, the pain of the side, and 
the pain and tenderness of the abdomen, are to be distinguished from inflammation 
within the chest or abdomen, in the same manner, by comparing the general and 
local characteristics of chlorosis with those of each of these diseases; and by ascer- 
taining the history, and observing the eflfects of remedies. 

The pains of the side, or of the abdomen, so apt to occur as complications of 
chlorosis, are to be distinguished from pleurisy or peritonitis, by the same recur- 
rence to the state of the complexion, tongue, and general surface, to the other 
symptoms, and by their own peculiar character. These pains, for instance, are 
less constant (both in situation and duration) than those of an inflammatory nature; 
and though sometimes aggravated by a deep inspiration, are not invariably so; 
especially on repeating the inspiration a third or fourth time. The accession of 
pain of the side, in chlorosis, is apt to be sudden; the side afl^ected is sometimes 
changed; the degree of pain is sometimes extremely severe, at others less so; and 
there is more expression of pain than is permitted by the pain of iriflammation; 
which represses the movements of respiration implied in the loud expression of 
pain.*"] 

Treatment. — I believe the best remedies for chlorosis, are the preparations of 
iron, which were found useful in France.'' No medicine acts so beneficially as iron j 
I am not sure that the carbonate is better than any other preparation of that medicine; 
but with that I know practitioners will generally succeed. It is a disease not to be 
treated by bleeding, or profuse purging. The bowels are only to be maintained 
in a regular state. We must not allow a collection of trash to be formed in them; 
but, beyond that, purging does harm. All evacuants were found to do harm, in 
the cases of anaemia in France;'' and I know from my own experience (which is 
necessarily very extensive, in so common an aftection), that iron is by far the best 
remedy for chlorosis. Persons will lose their pufliness under it, — lose their difii- 
culty of breathing; and will gain strength, and soon gain colour. 

•When I come to treat of diseases of the heart, an aff'ection analogous to this will 
be met with. Persons will have violent palpitation, and become pale; and the 
state is not one indicating bleeding and purging; for in such a complaint as this, I 
know they will be made worse by those measures. But — very much to my sur- 
prise, when I first ventured on the practice, and frequently to the surprise of others 
— iron has remedied this morbid condition of the system, to a great extent. It will 
not cure organic disease; but when the heart, and body at large, have thus becom.e 
almost bloodless, and extreme faintness has been induced by it, — so that a quick, 
irregular, and sharp pulse results, — the patient will experience the greatest relief 
from the exhibition of iron. 

Regulate the Diet. — [With the view of filling the vessels with healthy blood, 
you should allow your patient a generous diet, apportioned to the powers of her 
digestive apparatus; and she may be supplied with all the food that she can take 
without producing symptoms of dyspeptic oppression, and oiTensive stools. Three 
meals, and perhaps four, she should take in the course of the day; — breakfast, an 
early dinner, tea, and a supper. In the way of peptic"= preparative, you may re- 
commend her, on rising in the morning, to take a tablespoonful of white mustard- 
seed, unbruised; and two or three pills, consisting of quinine, say one grain, and 
four grains of the best Cayenne-pepper (P say " of the best pepper;" for some is 
little better than sawdust); and this pepper should be powdered thoroughly; and 
mixed up with a little mucilage, or any other combining substance which is likely 
to dissolve soon in the stomach. This peptic medicine may be taken four times a 
day; about half an hour before each of the four meals. The quantity of it ought 

^ Dr. Marshall Hall's " Commentaries on some of the Diseases of Women; Part Ij Chap- 
ter 4; First Edition, 
b See Page 218. 
« Digestive; from ttewtm, to ripen. ^ Dr. James Blundell. 



2.24 CHLOROSIS. 

to be measured according to the effect produced; — warmth of the stomach, and a 
little gnawing pain there, being perhaps the best criteria that the medicine is in 
action. At breakfast she may use biscuits, or dry toast, or stale bread; with fresh 
butter, perhaps a new-laid eg-g, and one litde cupful of hot black tea; — as hot as 
the mouth will bear it; in order that it may warm the stomach, and stimulate the 
inner membrane; for these hot drinks, though hurtful to the healthy, may be found 
very useful in a diseased stomach; and, much in the same manner as heated water 
is found to swell the hand immersed in it, and to excite the capillary circulation, — 
so as to produce reddening and perspiration, — the hot tea may be reasonably 
thought to produce its action on the capillaries of the stomach. The patient should 
be confined to one cupful of tea, that she may not deluge the stomach; for some 
women are very fond of taking tea in excess; and, in this way, they may overload 
the gastric cavity, and dilute the gastric juice, so as gready to impair its digestive 
and solvent powers. At about one or two o'clock, — namely, five or six hours 
after breakfast, — another spoonful of the white mustard-seed and the peptic pill 
may be used; — being administered half an hour before the dinner. At this meal, 
be it observed, boiled meat is preferable to roast meat; white meat, to red meat; 
that which is well-Aoxie, to that which is ?iwc?er-done; the i?iside, to the ow^side; 
and potatoes, to every other vegetable. The food is to be thoroughly masticated, 
and eaten slowly. There should be no drink; or if there must be some, then take 
half-a-tumbler of very hot water; but, in general, the drink required ought to be 
taken two hours before dinner is begun. Toast-and-water, table-beer, or other 
aqueous fluids, are to be preferred. The pepper and the mustard-seed will super- 
sede the alcoholic stimulus. Three or four hours after the dinner, the tea may be 
ordered; — not sooner, lest it should disturb the digestive powers. This meal is to 
be similar to the breakfast; and three or four hours after tea, the patient may sit 
down to supper, in the form of a very light dinner. With respect to the general 
beverage, my opinions are a lilUe unsettled. To the alcoholic stimulus I* have an 
aversion, perhaps even a prejudice; and, certainly, if your patient under the use of 
this diet is acquiring strength, P should not give much stimulant of this kind; but 
if not, then wine, or ale, or porter, or spirit, may be given; and of the four I* give 
a preference to spirit, in measured quantity, and diluted with four or five times its 
bulk of water. These fermented liquors, you may tell your patient, must never 
affect the head; and while she keeps clear of any unpleasant impression of this 
kind, she cannot be considered as indulging in marked excess. In general, in these 
cases, whatever beverage the patient uses, is better taken apart from the food; — say 
three hours afterwards; or, still better, two hours before. Both you and your pa- 
tients may read Ludovico Cornaro on longevity, with great advantage. 

Change of Air and Bathing.—SuW more to invigorate the patient, if she is in 
the midst of a large town, you ought to send her to the sea-side, or into the country. 
Indeed, V know of no means more efficacious for improving the digestive secre- 
tions, than change of air. P do not here except mercury itself. You may some- 
times have patients, for weeks together, in this large city ,^ with a metropolitan 
paleness of the cheek, and a commercial whiteness of the tongue; weak, sallow, 
emaciated; — rich and miserable; — in a word, labouring under gastric symptoms, too 
strong for your remedies; and yet these very patients, after having been eight or 
ten weeks, sometimes five or six only, in the country, acquire their full digestive 
powers, and become comparatively plump and fat. The cold shower-bath, where 
the patient is vigorous enough to react under it, may be used every day, or on 
alternate days. A dip in the ocean may be recommended, if the patient is at the 
sea-side; but it is better to defer the use of bathing, till the patient has a little re- 
covered her strength. One of the best proofs of the salubrious action of the bath, 
is the production of a full glow; but if the body, after plunging, is pale-blue and 
chilly, or if local pains are felt, we must refrain. These different measures having 

» Dr. James Blundell. »• London. 



SCURVY. 225 

been carefully pursued, the chylopoietic* viscera having been strengthened and 
amended, the quantity of red blood having been increased, and the vigour of the 
system corroborated, should araenorrhoea^ continue, you may have recourse to 
emmenagogue'' remedies. Chlorosis is no medical objection to matrimony.*^] 



CHAPTER III. 

SCURVY. 



Definition. — The word " scurvy^^ is said to be derived from some German 
words; — either fuom ''^ scharf-pocke^^ (meaning ^^sharp^^ or ^^ violent pock^^) cor- 
rupted to *' scharbock;'^ or from " sA«3/-;}oeA;e"^meaning '' scab'^ or ''scurf- 
pock''^). However this may be, it is from the word ''scharbock,^^ Latinized and 
corrupted, that ''scorbutus^'' is derived; and a very barbarous word it is. From 
this we are said to have our English term ''scurvy;'''' but I should rather think it 
came directly from the Danish word "scurv.^^ This name, "scurvy,^' is used 
by the vulgar in a very indefinite siense; — being applied by them to any ill-looking 
chronic cutaneous disease; but in our profession it is restricted to a particular 
affection. 

Pathology of Scurvy. — [It seems to be the universal opinion of those who have 
seen and written upon scurvy, that it owes its origin to a morbid change in the 
fluids, and especially in the blood. Notwithstanding this general belief, there has 
been no attempt (up to the present time) at any chemical examination of the pro- 
perties of scorbutic blood; and we have only the general observation made by the 
surgeons of Lord Anson's expedition (Messrs. Ettrick and Allan); — that in the 
beginning of the disease, it flows from the arm in different siiades of light and dark 
streaks; — that as this advances, it runs thin and black, and after standing turns thick 
and of a dark muddy colour; the surface in many places being of a greenish hue, 
without any regular separation of its parts; — that in the third degree of the disease 
it is as black as ink; and though kept stirring in the vessels for many hours, its 
fibrous parts have only the appearance of wool or hair floating in a muddy sub- 
stance; — and that, in dissected bodies, the blood in the veins is so fluid, that by 
cutting any considerable branch, the part to which it belongs may be emptied of its 
black and yellow liquor; — the extravasated blood being precisely of the same kind. 
The prevalence of scurvy, where there has been a long continued use of salted 
provisions, has given rise to the supposition that the salt itself actually finds its 
way into the circulation, and acts (as it is known to act on blood out of the body) 
by preventing its coagulation. This, however, is not correct; for the appearance 
of the blood, especially as the disease advances, is exactly the reverse of what it 
would be on the addition of salt; which — instead of making it black and causing it 
on standing to become thick, muddy, and of a greenish hue — would impart to it a 
fine scarlet tint, that would remain permanent until it began to putrefy.^] 

* From xuXof, chyle; and ttoisiw, to make. 

^ From a (privative), without; /wnv, a month; and gew, to Jlow. 

« From £jw|u»)v»tt, the menses; and ayco, to compel. 

d " The Principles and Practice of Obstetric Medicine. By James Blundell, M.D., late 
Professor of Obstetric Medicine at Guy's Hospital. Carefully revised and corrected, with 
numerous and important Additions and Notes. By Alexander Cooper Lee, and Nathaniel 
Rodgers, M. D." London: Joseph Butler, Medical Bookseller and Publisher, 4, St. 
Thomas's Street, Southwark. (Pages 647 to 649.) 

e Article "Blood," by Dr. Babington, in the "Cyclopsedia of Anatomy and Physiology;'* 
Volume 1; Page 424. 
VOL. I. 15 



226 SCURVY. 

General Symptoms.'— This disease is characterized by a bloated surface; and by 
petechise, vibices, and ecchymoses. By ^' petechide,^^ are meant minute dark red 
or livid points, little larger than the point of a pin; spots still larger than these are 
called *'m6zces;" and when instead of spots we have patches, the word "ecc/ii/- 
7nosis^^ is employed. They all relate to the same appearance, but denote a differ- 
ence in extent. With respect to colour, these points, specks, or patches, are of a 
dark red or purple hue; but may contain all the shades which we see in bruises. 
In this disease, then, the surface is bloated; and upon it are seen points, specks, 
and patches, generally of a red or purple colour, but sometimes of all the shades 
•which we see in common bruises. A very remarkable circumstance also attends 
the disease; and that is, the hardness of many parts, but particularly of the thiohs. 
If the thigh of an individual labouring under scurvy (though only in a very slight 
degree) be examined, I believe it will be found generally hard, but more especially 
under the hams. In severe cases, I have seen it as hard as a board. I have not 
seen many cases of the disease; but in all of them I have noticed this circumstance. 
The gums are particularly affected. They are spongy, and bleed; and either they, 
or the breath, or both, send fortli a very offensive odour. Such is the disease of 
the gums, that the teeth very frequently fall out; and, in addition to their being 
spongy and bleeding, they become enlarged and livid. 

General condition of the system in Scurvy. — This is a disease of great debility; 
and the spirits are always very much depressed. So great is the weakness, that 
people very frequently faint from time to time; and the pulse is found to be feeble, 
and the surface of the body cold. Very often, ulcers form upon the surface, and 
discharge a thin and foetid bloody fluid; and, at last, a coagulum of blood is formed. 
The gums are in precisely the same predicament. The blood which is discharged 
and coagulates upon tht ulcer, is with great difficulty separated from it; for it ad- 
heres to the ulcer and the flesh which is beneath; and, when this coagulum is 
removed, the flesh is found to be, like the gums, soft and spongy. If the clot be 
removed, it is instantly renewed. A fresh oozing of blood takes place; a second 
coagulum supplies the place of the first; and at length a fungus will sprout forth, 
— a soft, flaccid, dark looking fungus. It sprouts as fast as it is taken away; and 
is called, by sailors, "bullock's liver." It may attain an enormous size. If this 
fungus be repressed, a gangrenous tendency is frequendy observed. The leg will 
swell, and become more spotted and painful. When a fungus sprouts forth from 
the "dura mater," after a fracture of the skull, it is known to be very dangerous 
to repress it. If the part be compressed, dangerous symptoms are very likely to 
ensue. In like manner, it is found injurious, in scurvy, to repress this "bullock's 
liver;" because the pressure induces a gangrenous tendency. The very slightest 
bruise, inflicted upon a patient labouring (to any considerable extent) under scurvy, 
will generally produce an ulcer of the description I have mentioned. 

Reappearance of Old Wounds. — There are some other remarkable circumstances, 
respecting this disease. Old wounds, and even fractures, have a tendency to recur 
under it. Wherever an ulcer has existed, — wherever a solution of continuity in 
soft parts has taken place previously, although the parts may have been well cica- 
trized, yet under this disease the wound often opens again. Nor is this occurrence 
confined to soft parts; but even bones themselves (as just now stated) which were 
foimerly fractured and repaired, become again disunited; — showing that the callus 
of bones is not so strong, as the original parts of the body; and that it suffers, when 
the rest of the bones do not. Another very singular circumstance connected with 
this disease, is the occurrence of hemeralopia,* (or, as some authors improperly 
say, nyctalopia''), — "night-blindness." Patients labouring under scurvy, frequently 
become blind, either altogether or in part, when night comes on. 

Causes. — The great cause of this disease, appears to be the want of fresh ani- 

* From rijUE^tt, the day; and o-],, an eye. 

b From vu^, \mioq, the night; and ca^, an eye. 



SCURVY. 227 

mal and fresh vegetable food. It is on this account that the disease was formerly 
very common at sea; for, at one period, sailors were supplied with nothinor but 
salt provision. So badly were ships formerly provided for, and so faulty was the 
general management, that in the year 1726, when Admiral Hosier sailed to ihe 
West Indies with seven ships, he buried his ship's company twice; and then died 
himself of a broken heart. Deaths to the amount of eight or ten a-day took place, 
formerly, in a moderate ship's company. The bodies, after being sewn up in 
hammocks, were washed about the deck, for want of sufficient strength, on the 
part of survivors, to throw them overboard. Lord Anson, in the year 1741, lost 
one half of his crew, by scurvy, in six months. Out of nine hundred and sixty- 
one men who sailed with him, only three hundred and thirty-five were alive at the 
end of the year; and, at the end of the second year, only ssventy-one were fit for 
the least duty. Sir Gilbert Blane says, that the disease used to appear in about 
six or seven weeks from the beginning of sea-victualling. 

Historical Account of Scurvy. — A better description of the dreadful mismanage- 
ment formerly prevalent, in regard to the navy, cannot be found than that in 
" Roderick Random." Smollett, both in that work and in his "History of Eng- 
land," gives an account of the armament which, about the same time that Lord 
Anson's expedition took place, was sent out against Carthagena.'' The description 
is from his own observation. He says^ the provision consisted of putrid salt beef, 
salt pork, and musty bread. To the salt beef the sailors gave the name of "Irish 
horse;" — I suppose that it looked like horse-flesh, and that the contractors lived in 
Ireland. The salt pork came from New England; and was neither fish nor flesh, 
but savoured of both. The bread came from the same country; and the biscuit, 
like a piece of clock-work, moved by its own internal impulse; — owing to myriads 
of insects that dwelt within it. The butter was served out by the gill; and was 
exactly like train-oil thickened with salt; and though there was water enough to 
allow each man half-a-gallon daily, for six months, yet each had only a purser's 
quart a-day;*" and this in the torrid zone, where a gallon would have been hardly 

a The expediiion against Carthagena, which took place in 1741, is described in " Roderick 
Random" (Volume 1, Chapter 31 to 34), and Smollett's "Continuation of the History of 
England" (Book 2, Chapter 7); as well as in a " Compendium of Voyages." The follow- 
ing particulars from " Roderick Random" (Volume 1, Chapters 25 and 33), as to the gene- 
ral management of the sick on board of ship, a hundred years ago, are valuable; from the 
author's opportunities of personal observation: — "At seven o'clock in the evening, Morgan 
visited the sick; and, having ordered what was proper for each, I assisted Thomson in 
making up his prescriptions; but when I followed him into the sick-berth (or hospital), and 
observed the situation of the patients, I was much less surprised that people should die on 
board, than that any sick person should recover. Here I saw about fifty miserable distem- 
pered wretches, suspended in rows, so huddled one upon another, that not more than four- 
teen inches space was allotted for each, with his bed and bedding; and deprived of the light 
of the day, as well as of fresh air,— breathing nothing but a noisome atmosphere of the 
morbid steams exhaling from their own excrements and diseased bodies; devoured with 
vermin hatched in the tilth that surrounded them; and destitute of every convenience neces- 
sary for people in that helpless condition." 

" The sick and wounded were squeezed into certain vessels, "U'hich thence obtained the 
name of 'hospital ships;' though (methinks) they scarce deserved such a creditable title; — 
seeing that lew of them could boast of their surgeon, nurse, or cook; and the space between 
decks was so conhned, that the miserable patients had not room to sit upright in their beds. 
Their wounds and stumps, being neglected, contracted filth and putrefaction; and millions 
of maggots were hatched amidst the corruption of their sores. This inhuman disregard was 
attribaied to the scarcity of surgeons; though it is well known that every great ship in the 
^ fleet, could have spared one (at least) for this duty;— an expedient which would have been 
more than sufficient to remove ihis shocking inconvenience. But, perhaps, the general 
was too much of a gentleman to a&k a favour of this kind from his fellow chief; who, on the 
other hand, would not derogate so much from his own dignity, as to ofi!er such assistance 
unasked." 

b " Roderick Random;" Volume 1; Chapter 33. 

c We loitered here [ai the island of Vache] some days longer, taking in wood, and brack- 
ish water; in the use whereof, however, our admiral seemed to consult the health of the men, 
by restricting each to a quart a-day. — " Roderick Randovi;'" Volume I; Chapter 31. 



228 SCURVY. 

enough to repair the waste of perspiration.* It cannot be wondered, therefore, 
that scurvy formerly prevailed to the dreadful amount vve have stated.,, 

Scurvy in London.— -The disease prevailed likewise on shore, however. Indeed 
scurvy, at one period, was one of the most fatal diseases in London; so that, even 
so late as the seventeenth century, there were from fifty to ninety deaths from it 
annually; and in the year of the plague,"^ there were not fewer than one hundred 
and five deaths. These frightful occurrences took place regularly; and not during 
a particular year. The same reason existed for the prevalence of scurvy in London, 
which produced it at sea; for the food of the Londoners was then salt beef and 
pork, with a little veal. The lower orders, in the time of Henry Vllt, had very 
little else. The fact was, that only pasture land was then common; for very little 
was cultivated. x4.nimals, therefore, could feed only during the summer and au- 
tumn. Hay being a later improvement, it was impossible to feed them longer than 
that period; and therefore, as the winter came on, they were killed and salted; and 
thus a store of provision was laid up until the next spring. Vegetables, too, were 
extremely scarce in those days; so that Catherine of Arragon, one of the numerous 
wives of Henry VIII, was actually obliged, in the beginning of the sixteenth cen- 
tury, to send to the Netherlands for a gardener to raise her a salad; — so ignorant 
were the gardeners of this country, of what is now considered within the reach of 
every body. Cabbages, and other vegetables, were not cultivated in England 
before the reign of Henry VIII. Government too, at that period, seemed to encou- 
rage the consumption of this meat; for the price of meat was fixed by law at one- 
tiveniieth of what it is now; whereas wheat was fixed at only one-tenth of its 
present price. Care was thus taken to have a good supply of animal food; but 
vegetable food was comparatively neglected. I may mention that, in 1700, a cab- 
bage cost three pence; while, in 1760, it cost only one halfpenny. Such was the 
advance of art, and the increase of knowledge, that this great difference occurred in 
the price of a cabbage, at those two periods. Other greens too, at first, were pro- 
portionably dear; and vegetables were only used, at that time on Sundays, and (as 
a great dainty) when people had company. 

The use of salt or putrid meat, appeared to be the cause of scurvy. But it was 
not the salt; for salt, though taken in the greatest excess, will not occasion scurvy; 
and scurvy will take place where no salt is used. Nay, persons will have scurvy, 
who eat no meat at all; and therefore it is not this, but the want of other food, — 
the want of fresh animal and vegetable food, — that induces the disease. 1 have seen 
several, — not a large number, — but several cases of scurvy, in individuals who had 
eaten no meat at all. They had been deprived of meat of every description; and it 
arose in them from the want of food. In the *' Transactions of the College of Phy- 
sicians,'"^ two cases are mentioned by Dr. Francis Milman, of women that had the 
scurvy in the country. They had eaten no meat whatever; but had lived on tea 
and bread, after having been accustomed to better food. Sea and land-scurvy, I 
believe, are exactly the same; and Dr. Musgrave (who published a work on the 

a Instead of small beer, each man was allowed three half quarterns of brandy or rum; 
which were distributed every morning, diluted with a certain quantity of water, without 
either sugar or fruit to render it palatable; for which reason this composition was not 
unaptly styled "wecessa^/." This fast must, 1 suppose, have been enjoined by way of penance 
on the ship's company for their sins; or rather with a view to mortify them into a contempt of 
]ifej_thai they might thereby become more resolute and regardless of danger. How simply, 
then, do those people argue, who ascribe the great mortality among us to our bad provi- 
sion and want of water; and affirm that a great many valuable lives might have been saved, 
if the useless transports had been employed in fetching fresh slock, turtle, fruit, and other 
refreshments, from Jamaica and other adjacent islands, for the use of the army and fleet; — 
seeing, it is to be hoped, that those who died went to a better place, and those who survived 
were The more easily maintained. After all, a sufficient number remained to fall before the 
walls of St. Lazar; where they behaved like their own country mastiffs; which shut their 
eyes, run into the jaws of a bear, and have their heads crushed for their valour.— "i?o<Zmc^ 
Random;'' Volume 1; Chapter 33. 

^ At Page 227. •= A.D. 16G5. ^ Volume 2; Page 471. 



I 



SCURVY. 229 

gout, in 1703) mentions, that this disease was common in Somersetshire; — so that 
it prevailed at sea, in large towns, and in the country. 

There can be no doubt that many circumstances conspire to the production of this 
disease. Cold and the want of exercise unquestionably encourage it; for sailors are 
observed to suffer in cold latitudes, when they are placed under precisely the same 
circumstances, with the exception of latitude, in which they escape it in warm 
climates. This fact strikingly illustrates the effect of cold. As to tlie want of exercise, 
Captain Cook says that the people of Kamschatska, who are habituated to hard 
labour, never have the scurvy; while the Russians and Cossacks in garrison, who 
live in the greatest indolence, are subject to it. Sir Gilbert Blane says, that only 
the prime seamen, who were exempted from pumping, were attacked with scurvy. 
He instances the case of a particidar ship's crew; and says, that the prime seamen 
suffered from the disease; whereas those who were obliged to work hard at the 
pump, from time to time, — the ship having proved leaky, — escaped. Moisture is 
also said to have a considerable etfect; especially, I presume, when united with 
cold. La Perouse attributes the prevention of scurvy, in his crew, very much to 
the vessel being kept dry by fumigation, and by braziers of hot coals. Captain 
Parry ascribes the first case of scurvy, in one of his expeditions, to moisture. 
When scurvy prevailed at the Penitentiary at Millbank, a few years ago, it was 
observed, that the persons employed in the kitchen always escaped; perhaps, how- 
ever, they got better food than the rest, or more of it; but, at any rate, they had a 
warmer place. Captain King told Dr. Macmichael, (as he stated in a paper^ read 
at the College of Physicians,) that, in a voyage round the south coast of America, 
no cause of scurvy was apparent, — the crew having had plenty of lemon-juice, — 
except that there was a remarkably cold and moist state of the atmosphere. I do 
not believe that moisture alone will occasion it; but moisture certainly aggravates 
the effects of cold in this disease; as it does in all others. 

Mode of Prevention. — The difference between ships' crews now and formerly, 
is very striking. While the crew of Lord Anson suffered so much in a voyage 
round the world, that of Captain Cook, in a voyage subsequently performed, suffered 
nothing. The difference arose from this circumstance: — Captain Cook had a good 
supply of portable soup, sour crout, and fresh meat; and he kept his men in regular 
exercise; and took care, at the same time, that extreme cleanliness and ventilation 
should be observed. In addition to this, they were away from land only about 
three weeks, on their longest cruise; although absent from home so long. Such 
measures as he adopted will generally prevent scurvy, even if there be no fresh 
provision on board, provided there is a supply of lemon-juice; and sometimes, in 
spite of the neglect of all these particulars, lemon-juice alone will prevent it. 

Remedies for Scurvy. — The great remedy for scurvy, is fresh food, — animal and 
vegetable. Farinaceous vegetable substances alone are insufficient; but when fresh 
meat cannot be procured, 1 believe lemon-juice will be found the most efficacious, 
medicine. The effects of lemon-juice on the disease are speedy and wonderful; — 
so wonderful, that the compiler of "Lord Anson's Voyage," after describing the 
disease, and the horrors which took place from its ravages, says that the cure of 
such a complaint seems impossible, by any remedy or any management that can be 
employed.'' Scurvy was formerly set down, without hesitation, as an incurable 

» Published in the " London Medical Gazette;" Volume 8; Page 184. (No. 179; May 7, 1831.) 
** In Anson's report of March 31 [1741], he makes the first mention of the scurvy, as fol- 
lows: — "Men falling down every day with scorbutic complaints." 

Soon after our passing Straits Le Maire, the scurvy began to make its appearance among 
us; and our long continuance at sea, the fatigue we underwent, and the various disappoint- 
ments we met with, had occasioned its spreading to such a degree, that at the latter end of 
April, there was but few on board, who were not, in some degree, afflicted with it; and, in 
that month, no less than forty-three died of it on board the Centurion. But though we 
thought that the distemper had then risen to an extraordinary height, and were willing 
to hope, that as we advanced to the northward its malignitv would abate; yet we found, on 
the contrary, that in the month of May we lost nearly double that number; and as we did not 
get to land till the middle of June, the mortality went on increasing; and the disease ex- 



230 scuRvr. 

disease; — not only as a disease incurable then, but as being- so formidable in its 
nature, that it never could be cured; and yet, in almost every case, we can now 
cure it with the utmost facility. It is not only lemon-juice that will cure it, but all 
the hesperideae; such as the lime, and Seville and unripe China oranges. Malt 
and sour crout are thought to have a simUar property. Lemon-juice is preserved 
by mixing one-tenth of spirit with it. The custom,! believe, is to give three table- 
spoonfuls every morning to each man, for the purpose of keeping the disease away. 
One ounce of lemon-juice, with one ounce and a half of sugar, is the present navy- 
allowance; and it is said that scurvy rarely occurs now in the longest voyage. 
Citric acid is thought to be inferior to lemon-juice. During the nine years previous 
to this supply, the average number of sick sent to the hospitals, was one man in 
three and nine-tenths of the whole navy; while, in the succeeding nine years, it 

tended itself so prodigiously, that after the loss of about two hundred men, we could not at 
last muster more than six fore-mast men in a watch capable of duty. 

This disease, so frequently attending all long voyages, and so particularly destructive to 
us, is surely the most singular and unaccountable of any that affects the human body. For 
its symptoms are inconstant and innumerable, and its progress and effects extremely irregular; 
for scarcely any two persons have the same complaints, and where there hath been found 
some conformity in the symptoms, the order of their appearance has been totally different. 
However, though it frequently puts on the form of many other diseases, and is therefore not 
to be described by any exclusive and infallible criterions; yet there are some symptoms 
which are more general than the rest; and therefore, occurring the oftenest, deserve a more 
particular enumeration. 

These common appearances are large discoloured spots dispersed over the whole surface of 
the body, swelled legs, putrid gums, and (above all) an extraordinary lassitude of the whole 
body, especially after any exercise, however, inconsiderable; and this lassitude at last de- 
generates into a proneness to swoon on the least exertion of strength, or even on the least 
motion. This disease is likewise usually attended with a strange dejection of the spirits, 
and with shiverings, tremblings, and a disposition to be seized with the most dreadful terrors 
on the slightest accident. Indeed, it was most remarkable, in all our reiterated experience 
of this malady, that whatever discouraged our people, or at any time damped their hopes, 
never failed to add new vigour to the distemper; for it usually killed those who were in the 
last stages of it, and confined those to their hammocks who were before capable of some kind 
of duly; so that it seemed as if alacrity of mind, and sanguine thoughts, were no contempt- 
ible preservatives from its fatal maligriity. 

But it is not easy to complete the long roll of the various concomitants of this disease; for 
it often produced putrid fevers, pleurisies, the jaundice, and violent rheumatic pains; and 
sometimes it occasioned an obstinate costiveness, which was generally attended with a dif- 
ficulty of breathing; and this was esteemed the most deadly of" all the scorbutic symptoms. 
At other times, the whole body, and especially the legs, were subject to ulcers of the worst 
kind; attended with rotten bones, and such a luxuriancy of fungous flesh, as yielded to no 
remedy. But a most extraordinary circumstance, and one that would be scarcely credible 
upon any single evidence, is, that the scars of wounds which have been for many years 
healed, were forced open again by this virulent distemper. Of this, there was a remarkable 
instance in one of the invalids on board the Centurion, who had been wounded above fifty 
years before, at the battle of the Boyne; for though he was cured soon after, and had con- 
tinued well for a great number of years past, yet, on his being attacked by the scurvy, his 
wounds, in the progress of his disease, broke out afresh, and appeared as if they had never 
been healed; nay, (what is still more astonishing,) the callus of a broken bone, which had been 
completely formed for a longtime, was found to be hereby dissolved, and the fracture seemed 
as if it had never been consolidated. Indeed, the effects of this disease were, in almost every 
instance wonderful; for many of our people, though confined to their hammocks, appeared to 
have no inconsiderable share of health; for they ate and drank heartily, were cheerful, and 
talked with much seeming vigour, and with a loud strong tone of voice; and yet, on their 
being the least moved, — though it was only from one part of the ship to the other, and that 
in their hammocks, — they haveimmediately expired; and others, who have confided in their 
seeming strength, and have resolved to get out of their hammocks, have died before they 
could reach the decks, and it was no uncommon thing for those who were able to walk the 
deck, and to do some kind of duty, to drop down dead in an instant, on any endeavours to 
act with their utmost vigour; — many of our people have perished in this manner, during the 
course of this voyage. — "A Voyage round the World, in the years 1740, 41, 42, 43, and 44. 
By George Anson, Esq. , Commander in Chief of a Squadron of His Majesty^ s Ships, sent upon 
an Expedition to the South Seas. Compiled from papers and other materials of the Right 
Honourable George, Lord, Anson; a.nd published under his direction. By Richard Walter^ 
M. A.; Chaplain of his Majesty'' s Ship the Centurion, in that Expedition." Book I; Chapters 
8 and 10. {Smithes " Standard 'Library'^ Edition; Pages 25, 31, and 32.) 



SCURVY. 231 

was only one in eight and fonr-tenths. The juice is also said to improve the general 
health. I may mention, as a good illustration of the power of lemon-juice, that the 
ship " Suffolk" left England in April 1794, and had no communication with land 
for twenty weeks and a day; and yet, during all that time, she had only fifteen sick, 
and those slightly. They were soon cured by an augmentation of the first allow- 
ance of two-thirds of an ounce; and, at her arrival, not one had the scurvy. In 
1800, the channel-fleet — consisting of twenty-four ships of the line, besides smaller 
vessels — had no fresh provisions for sixteen weeks; but they had plenty of lemon- 
juice, and not a single instance of scurvy occurred; whereas, in 1780, the channel- 
fleet could not keep at sea beyond ten weeks, and was worn out with scurvy and 
fever. Two thousand five hundred men were sent into port with the scurvy. We 
read in Purchas's " Pilgrim,"'' that Commodore Lancashire sailed from England, 
with four ships, for the Cape of Good Hope, on the second of April; and arrived 
at Saldanha Bay on the first of August. The Commodore's own ship was in per- 
fect health;— owing to the administration of three tablespoonfuls of lemon-juice, 
every morning, to each of his men; whereas the other ships were so sickly, as to 
be unmanageable for want of hands; and the Commodore was obliged to send men 
on board, to take in their sails, and hoist out their boats. 

Antiquity of Lemon-Juice as a Remedy. — This disease, of course, occurred in 
ancient times. It was known in the Roman army in Germany, and also in the 
*' Holy Wars" (as they were impiously denominated); but it was first particularly 
noticed in the crew of Vasco di Gama, in 1497. We find it mentioned by Pliny, 
as occurring in the Roman army, under the command of Germanicus. But with 
respect to the remedy, its discovery appears to have been left for modern times; 
but still not for recent times; for we find it mentioned as far back as 200 years ago. 
There is a curious fact connected with it, and one which is very instructive; — as 
teaching us not to despise any thing without good reason. It is said that when 
the London College of Physicians was applied to by Government, for a cure for 
scurvy, they advised vinegar, which has very little power in the aflfection; and 
that a fellow of the College, who wrote on the disease in 1753, never adverts to 
lemon-juice at all in his treatise; and yet that, two hundred years ago, it was men- 
tioned in the " Surgeon's Mate, or Military and Domestic Medicine;" — a work 
published in 1636, by " John Woodall, Master in Surgery." He ends his praise 
of it by saying, that he dare not write how good a sauce it was, with meat; lest the 
chief in the cabin should waste it, to save vinegar. It is said to have been men- 
tioned even still earlier, — in Purchas's "Pilgrim," published in 1600. Dr. Lind, 
of Haslar Hospital, revived the knowledge of it, more than one hundred years 
afterwards. He stated its peculiar powers, in the third edition of his work on the 
"Diseases of Seamen," in 1772; but even then it was not brought generally into 
use; and the navy actually suffered most frightfully from scurvy till 1795. Although 
the remedy was mentioned two hundred years ago, and again in a well known 
surgical work in 1636, yet the navy suffered from the want of it till 1795. Earl 
Spencer, the father of the present JEarl,'' was then at the head of the Admiralty; 
and, on the representations of Dr. Blair and Sir Gilbert Blane (who were commis- 
sioners of the board of sick and wounded seamen), a good supply of it was ordered 
by Government. In less than eighteen months afterwards, there was not a case of 
scurvy in Haslar Hospital. In 1780, there had not been fewer than 1457; in 1806, 
and in 1807, there was but one. 

So great is the effect of this remedy, that we find the following passage in Sir 
William Herschel's work, published in Dr. Lardner's " Cyclopedia," on the cul- 
tivation of the physical sciences:*" — " At present, the scurvy is almost completely 
eradicated in the navy; — partly, no doubt, from an increased and increasing attention 
to general cleanliness, comfort, and diet; but mainly from the constant use of a 

=^ Volume 1; Page 149. f* A. D. 1841. 

<: " Preliminary Discourse on the study of Natural Philosophy;" Chapter 3; Paragraph 
44. (" New EdiiioDj" Pages 52 to 54.) 



232 SCURVY. 

simple and palatable beverage, — tbe acid of lemon, served out in daily rations. If 
the gratitude of mankind be allowed on all hands, to be the just meed of the phi- 
losophic physician, to whose discernment in seizing, and perseverance in forcing it 
on public notice, we owe the great safeguard of infantile life;* it ought not to be 
denied to those, whose skill and discrimination have thus strengthened the sinews 
of our most powerful arm; and obliterated one of the darkest features, in one of the 
most glorious of all professions. 

Prevention of Scurvy, — The scurvy is now prevented, by great attention to 
cleanliness; by giving sailors food as wholesome as possible; [)y attention to exer- 
cise and cheerfulness; and by a regular supply of lemon-juice. In spite of all this, 
however, sporadic cases still occur; but, in general, that is all. I have myself had 
several cases of this disease in London; and some of them were in persons who 
had never been at sea, and who had eaten no salt meat; but who had been deprived 
of food nearly altogether. Others were sailors, who came on shore labouring under 
the disease; for, in merchant-ships, there is frequently the greatest neglect. I had 
one patient, a few months ago, who had been sixteen weeks at sea; and had nothing 
but biscuit and the hardest salt beef, during the whole voyage. There was no 
medical man on board; but that, I suppose, is unavoidable in small ships. He was, 
as might be expected, labouring under scurvy to a great extent; and he said that 
several of the crew had died. I am not sure that the lemon-juice, which I gave 
these patients as a matter of course, did them any good; for they were allowed fresh 
meat and greens every day, with porter, and other articles of good diet; and this 
was quite sufficient, I am sure, to cure the disease.* I gave them lemon-juice in 
addition; because we have such great authority for its employment. However, 

a Alluding to Dr. Jenner, and the Cow-Pock. 

^ All the hands we could muster, capable of standing at a gun, amounted to no more than 
seventy-one; most of which number, too, were incapable of duty; but, on the greatest emer- 
gencies, this was all the force we could collect, in our present enfeebled condition, from the 
united crews of the Centurion, the Gloucester, and the Tryal; which, when we departed 
from England, consisted altogether of nearly a thousand hands. 

When we had furled our sails, the remaining part of the night was allowed to our people 
for their repose, — to recover them from the fatigue they had undergone; and in the morning 
a parity, of which myself was one, was sent on shore [at Tinian] well armed, to make our- 
selves masters of the landing-place; — as we were not certain what opposition mightbe made 
by the Indians on the island. We landed without difficulty; for the Indians had fled into the 
woody parts of the island. We found on shore many huts which they had inhabited; and 
■which saved us both the time and trouble of making tents. One of these huts, which the In- 
dians made use of for a store-house, v/as very large; being twenty yards long, and fifteen 
broad. This we immediately cleared of some bales of jerked beef (which we found in it), 
and converted it into a hospital for our sick; who, as soon as the place was ready to receive 
them, were brought on shore; — being, in all, a hundred and twenty-eight. Numbers of these 
were so very helpless, that we were obliged to carry them from the boats to the hospital upon 
our shoulders. Notwithstanding the great debility and the dying aspects of the g'-eatest part 
of our sick, it is almost incredible how soon they began to feel the salutary influence of the 
land; for, though we buried twenty-one men on this and the preceding day, yet we did not 
lose above ten more during our whole two months' stay here; and, in general, our diseased 
received so much benefit from the fruits of the island, particularly the fruits of the acid kind, 
that, in a week's time, there were but iesfi who were not so far recovered, as to be able to 
move without any help. 

This place was not only extremely grateful to us, from the plenty and excellence of its 
fresh provisions, but was as much perhaps to be admired for its fruits and vegetable produc- 
tions; which were most fortunately adapted to the cure of the sea-scurvy, which had so ter- 
ribly reduced us. For in the woods there were inconceivable quantities of cocoa-nuts, with 
the cabbages growing on the same tree; there were besides, guavas, limes, sweet and sour 
oranges, and a kind of fruit peculiar to these islands, called by the Indians " rima,"butby us 
"the bread fruit;"— for it was constantly eaten by us during our stay upon the island, instead 
of bread; and so universally preferred to it, that no ship's bread was expended during that 
whole interval. — Besides the fruits already enumerated, there were many other vegetables 
extremely conducive to the cure of the malady we had long laboured under; — such as water- 
melons, dandelion, creeping purslain, mint, scurvy-grass, and sorrel; all which, together with 
the fresh meats of the place, we devoured with great eagerness; prompted thereto by the 
strong inclination which nature never fails of exciting, in scorbutic disorders, for these pow- 
erful specifies, — "tI Voya<(e round the World]" by George Anson, Esq. Corafiledby Richard 
Walter, M. A. Book 3; Chapter 2. {Smith's " Standard Librarif Edition^ Pages 94 to 96.) 



INTERMITTENT FEVER. 233 

some persons now begin to say that the lemon-juice does no good; — that the benefit 
entirely arises from the other means that are employed; and that the neutral salts, 
particularly nitre, answers a better purpose. I dare not say, however, that authority 
respecting tiie powers of lemon-juice, so accumulated and so immense as it is, is at 
all to be disputed. I certainly cannot but think that, till we have further facts, it 
is our duty in every case to supply lemon-juice, or similar things (if that cannot be 
obtained); — in the hope of doing away with the ill effects, which a want of fresh 
food occasions. I may also mention that, with regard to local applications, lemon- 
juice is found to be one of the best. When there is a scorbutic ulcer, 1 believe a 
slice of lemon laid upon it is one of the best applications that can be employed. 
Pere Lebat is said to have mentioned this in his *'Voyage to the Antilles." 

Nature of Scurvy. — This disease, I should say, is of a chemical nature, — if any 
one be so. In one sense, the constitution is not at all in fault. All the fluids and 
all the solids appear to be changed; but we have only to give a different chemical 
state to the body, and the disease is cured. We need give nothing which acts by 
a specific operation; — no drug, I mean, which acts as a medicine; but we employ 
fresh articles of diet, and thus remedy the depraved constitution of the whole mass 
of soliils and fluids.* I have, therefore, mentioned this disease, before I came to 
any of those which are clearly seated in particular parts. I am not aware that it 
attacks any one part in particular. It seems to be a cachectic state of the whole 
frame; and if any affection be an instance of " universal disease, I should certainly 
say that it was scurvy. 

There is an affection very similar to the scurvy in some respects, which has been 
arranged and described, by Willan, among cutaneous diseases; and which is called 
"purpura." Some are of opinion that this is the same as scurvy; but I cannot 
think so; — for reasons which I will slate when speaking of diseases of the skin. 



CHAPTER IV. 

INTERMITTENT FEVER. 

Fevers are divided, generally, into three kinds; — intermittent, remittent, and 
continued. Some divide them into intermittent and continued only; and subdivide 
the latter into those which continue unremittingly, and which are therefore called 
"continent;" and into those which have remissions, and are called "remittent." 
We may divide them in either of these ways. I shall first speak of " intermittent" 
fever. 

* Besides a great number of plants, of various kinds, which are to be met with upon the 
island [Juan Fernandes], but which we were not botanists enough either to describe or 
attend to, we found there all the vegetables which are usually esteemed to be particularly 
adapted to the cure of those scorbutic disorders, which are contracted by salt diet and long: 
voyages. For here we had great quantities of water-cresses and purslain, with excellent wild 
sorrel, and a vast profusion of turnips and Sicilian radishes. The two last, having some 
resemblance to each other, were confounded by our people under the name of " turnips." 
We usually preferred the tops of the turnips to the roots, which were often stringy; though 
some of them were free from that exception, and remarkably good. These vegetables, with 
the fish and flesh we found here, were not only extremely grateful to our palates (after the 
long course of salt diet which we had been confined to), but were likewise of the most salu- 
tary consequence to our sick, in recovering and invigorating them; and of no mean service 
to us who were well, in destroying the lurking seeds of the scurvy; from which, perhaps, 
none of us were totally exempt; and in refreshing and restoring to us our wonted strength 
and activity."— ^TisoTi's " Voyage round the World:' Compiled bv Richard Walter, M. A. 
Book 2; Chapter 1. {Smith's "Standard Library" Edition; Page 36.) 



234 INTERMITTENT FEVER. 



SECTION I.— SYMPTOMS AND VARIETIES. 

Pyrexia. — All fevers, whether intermittent or continued, are characterized by 
those symptoms which I before spoke of,* when treating of inflammation, under 
the name of " pyrexia;" — that particular set of symptoms denominated " pyrexia." 
In speaking of inflammation, I mentioned*" that there are only two stages well 
marked in the pyrexia of that complaint, — cold and heat; but in an attack of real 
fever there are often three; — a cold, a hot, and a sweating stage. In intermittent 
fever, these are very distincdy marked. In continued fever we may have a shiver- 
ing at the beginning; but then it will terminate in the course of the disease, and we 
shall have to treat long-continued heat. It is only towards the last, that there are 
any sweats; and frequently, there are none of a remarkable character; for there is 
often merely moisture of the skin, as the disease declines. But in intermittent 
fever there are usually three distinct stages; — a cold, a hot, and a sweating stage; 
the first of which is the cold stage. 

Cold Stage. — When this stage is about to commence, the patient feels himself 
very weak and listless. He begins to yawn, gape, and stretch. He finds his mind 
less active; and his external senses are more or less dull. Sometimes there is even 
real stupor; but in all cases the patient's mind is very dull. He is unable to go on 
with what he is about; and even his external senses are impaired. There is also, 
at the same time, a great depression of spirits. Very soon a sensation of coldness 
is felt, — first of all in the back; and the patient will complain of chilliness, before 
others who touch him can perceive it. As soon as the cold stage has begun, the 
surface becomes pale and dry; and the mouth and fauces also become dry. Then 
the patient begins to tremble slightly. He becomes really cold; — the temperature 
falls perceptibly to others. He trembles more and more, and becomes colder, till 
he is in a state of downright shivering; and then his jaws chatter. The constric- 
tion of the skin at this time is so great, that it becomes rough; and, in common 
language, is called "goose's skinf but in Latin, " cutis anserina." Such is the 
shrinking, that rings which previously fitted very well will fall off. There is a 
sense of creeping and shuddering over the skin; the hairs of which stand on end; 
and this state is called "horripilatio." The urine which is made at this time, is 
pale and scanty. Probably the same constriction of the secreting vessels of the 
kidneys takes place, which occasions the dryness of the surface of the body. It 
is the same constriction, I presume, of the secreting vessels, that gives rise to the 
dryness of the mouth and (fauces, and also to the thirst. This is altogether a state 
of debility; and consequently the pulse is weak, and sometimes slow; and the 
breath is generally short; — from the accumulation of blood, I presume, in the in- 
ternal parts. Sometimes the stomach is affected with vomiting. In a very intense 
cold stage, the face, hands, and feet, become blue; the fingers shrivelled, and the 
eyes sunk. 

Hot Stage. — In the cold stage the blood has receded from the surface, and pro- 
bably from all the small vessels; so that it has accumulated, in great quantity, in 
the large vessels of the interior. After this state has existed a certain period, of 
very various duration, the skin relaxes. It regains its warmth, colour, and sensi- 
bility; and the pulse becomes quick and fuller. The heat, the colour, and the 
sensibility of the skin, go on increasing; till at length they exceed their natural 
standard, and the pulse grows full and very rapid. Such js the excitement now, 
that not unfrequentl)' the patient complains of headache; and even delirium occurs. 
The thirst, the dryness of the skin, and the deficiency of the urine continue; — pro- 
bably because the extremities of the secreting vessels are still in a state of constric- 
tion; though the small vessels have become filled with blood. The urine, however, 
changes its character. From being pale and watery, it becomes high-coloured: but 
it is still clear. The breath becomes fuller; most probably from the blood getting 

» See page 88. b See page 88. 



INTERMITTENT TEVER. 235 

into the small vessels; and the patient can take a deep inspiration. There is not that 
slow breathing-, which there was at first; but still there is more or less oppression; 
for the heart is in violent action; and when that is the case, there is always a 
degree of dyspnoea. That state which is vulgarly called " fever," now takes place. 
If the disease intermit altog-ether, it is called " ague;" from the French word 
"ai^we" ("sharp," — " acute"). But the common people limit the word "/et'er" 
to the hot, or hot and sweating stages; and denominate only the cold stage "ague;" 
— so that it is common to hear one of the lower orders say that he has got "the 
ague and fever;" but " ague," properly speaking, includes the whole of the three 
stages. There is a passage in "Macbeth," where the poet says, — 



The obscure bird 



Clamour'd the livelong night: some say the earth 
W a.s feverous and did sfiakeJ'''- 

It appears, therefore, that the word "/ever" was applied, in those days, to tlie 
cold stage, as well as to the liot. There can be no doubt, that both the expressions 
'"''■pyrexia''' and ^'•fever^ though made by medical writers to include the whole 
stages, imply properly the hot only; as the former is derived from Ttvp, — " fire;" 
and the latter from "/e?'z;eo," — " to be hot." 

Sweating Stage. — After the hot stage, the skin at length becomes still softer. 
It also grows moist; and the moisture augments, till at last the person is in a pro- 
fuse sweat. The same relaxation of the internal secreting vessels takes place; in 
consequence of which the thirst declines; the urine becomes copious; and the 
vessels let through so much substance, that it forms alateritious'' sediment. 

After the sweating has continued an indefinite time, the pulse gradually grows 
slower; and the sweating and all the other symptoms diminish. The appetite, 
which is generally absent in all the three stages, now returns; and the patient is as 
well as though nothing had happened. If the disease last very long, the patient 
becomes shattered by it; but in general, — if the disease be not very severe, if there 
be no local affection, and if the patient have not laboured under it long, — when the 
paroxysm is over, he is much about the same as he was before. 

There is great variety in the intensity of every one of the symptoms which I 
have mentioned. There is great variety in the relative intensity of the diflf*erent 
stages; and great variety in the intensity of the whole disease together. 

Incidental Symptoms. — This, however, is not all. There are, occasionally, 
incidental symptoms; such as tetanus, convulsions, fainting, violent delirium, and 
the appearance of petechias'' on the skin. Som.e persons, while in the paroxysm, 
have been known to have their muscles rigid; — absolutely in a tetanic state. Others 
have been violently convulsed; fainting has occurred; and delirium, in the hot stage, 
is very common. Sir John Pringle mentions violent delirium, as the character of 
an epidemic intermittent which he saw prevail. He also mentions that, at Copen- 
hagen, in 1652, petechiae appeared in the hot stage of an intermittent which pre- 
vailed there. Bartholini gives an account of an epidemic, in which petechiae 
appeared in the hot stage, — always disappearing afterwards. I have not seen the 
whole of these symptoms. Delirium, in the hot stage, is common enough; and in 
two cases I saw, in the cold stage, there was violent clenching of the hands, — so 
that the fingers and thumbs were drawn together in the most violent manner, and 
continued so until the cold stage was over. 

Periodical Recurrence. — These stages may all take place in the course of one 
day, and never return; and then the disease has been called "ephemera;" — "a dis- 
ease of a day's duration." But, for the most part, these stages return not only 
regularly, l^t periodically; so that you do not have ephemeral ague, but intermit- 
tent fever. The intermission between two paroxysms, is usually part of one day, 
at least; or it may be a whole day, or two days. By "f/a?/," in medicine, we 

* Act 2; Scene 3, t From " later," " lateris," a brick. 

« From the Italian " petechio," a flea-bite. 



J336 JWTERMITTENT FEVER. 

mean day and night; — llie twenty-four hoijrs. Beyond two days, the intermission 
is rarely regular. If the intermission be only part of a day, — that is to say, if the 
attack returns every day, — the fever is called "quotidian." If there be an inter- 
mission of a ivhole day, — so that the patient has an attack every other day, — it is 
called "tertian." It assumes this name, because the first day is counted as well 
as the third. The day on which a person is attacked, is the first; the day of 
intermission, the second; and the day of the second attack, the third. It is, there- 
fore, called " tertian." If the intermission extend two days, — so that the patient 
shall have a fit on Monday, none on Tuesday, none on Wednesday, but one again 
on Thursday, — then it is called "quartan." The day of the paroxysm constitutes 
the first; then follow the two days of intermission, — making three days; and then, 
on the fourth, we have another paroxysm. These are the most common forms of 
the types of intermittent fever; and, in London, the quotidian and tertian are far 
more frequently seen than the quartan. 

But the intermission may be still longer; so that we have, not a quartan, but a 
quintan, a sextan, a septiman, or even a deciman. In the last there is an interval 
of nine days; and the first day, being counted, makes up the ten. I heard a gen- 
tleman observe, that he saw a septiman take place for three weeks; that is to say, 
the person had a paroxysm after an interval of six days, occurring on the seventh 
day, regularly for three weeks. In 1827, I myself had a patient in St. Thomas's 
Hospital, with a septiman. He regularly had his disease, after an interval of six 
days. During the same year I had another patient, who had an interval always of 
four days; so that his disease was a quintan. I once treated a double octavan. A. 
man had a paroxysm every Sunday and Thursday; — the Sunday paroxysm being 
at one hour; and the Thursday paroxysm always at another. When they extend 
to these periods, — when they are more than a quartan, — when the intermission is 
longer than two days, the disease is called "erratica;" — it wanders out of the usual 
regular course. The epithet "err«^fc«" is also given to an ague which observes 
no regular period; — which at one time is quartan, at the next, quintan, &c. The 
term '■^erratic''' is employed by authors in both these senses. 

Double Tertian. — These are, for the most part, all the varieties which it is ne- 
cessary to recollect; but, as a matter of curiosity, I may mention that the disease 
has sometimes other types. Sometimes we have more than one paroxysm in a 
day, — more than a quotidian; and I heard a gentleman say, that he witnessed a 
case in which there were four paroxysms daily. I never did. But it is very com- 
mon indeed, to see what is called "a double tertian;" in which there is a paroxysm 
every day; but where the paroxysms occur two days in succession, yet do not 
belong to each other. For example: suppose a patient has an attack every day in 
the week; but the paroxysm on Monday is at eight o'clock in the morning, and the 
paroxysm on Tuesday at four in the afternoon; while the paroxysm on Wednesday 
is at eight o'clock in the morning, — like the paroxysm on Monday; so that the 
paroxysms on Monday and Wednesday agree; whereas the paroxysm on Thursday 
is at four o'clock in the afternoon; — the same hour as the Tuesday paroxysm. 
Now this appears a quotidian, because it occurs every day; but it is, in reality, a 
double tertian; for it is as if the patient had a tertian which came on every Monday 
and Wednesday; and another which came on every Tuesday and Thursday; and, 
inasmuch as the paroxysms which occur every other day agree, it is called not "a 
quotidian,'''' but "a double tertian^"* (in Latin "tertiana duplex.") But it will 
sometimes happen, that there are two fits on the day of attack, and none on the 
following day. Supposing the disease come on every other day (as, for instance, 
Monday and Wednesday), but that, on each of those days, there are two attacks: 
it is then called "a duplicate tertian" ("tertiana duplicata.") That is the dififer- 
ence between " tertiana rfiz/j/ea?," and " tertiana 6/w/)/iC«/«." 

Respecting the double tertian, — the one which comes on every Monday and 
Wednesday, for instance, and every Tuesday and Thursday, but at different hours, 
— we sometimes find scarcely any intermission between the Monday's and the 
Tuesday's paroxysm; while the intermission between the Tuesday and Wednesday 



INTERMITTENT FEVER. 237 

paroxysm is distinct enough; or, vice versa, that the one is hardly over when the 
other begins; and it is then called " sfmi-terlian," — " Aa^-tertian" {'yjy.it ^Ltaia)* 
The jtaroxysms are brought so near, that it is almost remittent fever; and it is 
scarcely worth while to call it any thing else than "remittent." Though the 
interval between the attacks on the first and second day is very short, yet the inter- 
mission between the second and third is much longer. We may, however, not 
only have a double tertian; — one on Monday and one on Wednesday at a certain 
hour, and again on Tuesday and Thursday at another hour; but on Monday there 
may be two fits, and on Wednesday two fits; and then this is called " a triple 
tertian." 

We may also have a ^^quartana duplex" (" double quartan;^'') — there being an 
additional paroxysm on the first day of the intermission, at its own hour; and " a 
quartana duplicatci'^ [''^duplicate quartan;") — two -paroxysms on the day of attack; 
and also " a tripled quartan;"-^three paroxysms on the day of attack. The ob- 
servations I have made, are sufficient for all practical purposes; and I only wish it 
to be remembered, that these extraordinary deviations do sometimes take place. 

Duration of the Paroxysm. — A paroxysm of intermittent fever, including the 
three stages, is generally finished in eighteen hours. It is a rare occurrence for it 
to last longer than that period. Dr. Good, however, quotes an author, who stated 
that he saw a paroxysm which lasted exacdy one minute. How the stages were 
divided I do not know. What was the severity of the cold stage, it is impossible 
to conceive; but I should think, that when each of these stages was over, the man 
might have doubted whether he had been ill or not. But authors may be quoted 
for any thing. 

Time at which it Occurs. — The paroxysm of ague is said (like almost all fevers, 
indeed) more frequently to begin in the day than in the night. As a general rule 
it may be stated, that the paroxysms commence between eight o'clock in the morn- 
ing, and the same hour in the evening. Of course there are numerous exceptions; 
but, in the majority of cases, the paroxysm begins in the day. It is mentioned by 
authors, that a quotidian usually has its paroxysms in the morning, a tertian at noon, 
and a quartan in the afternoon. I believe there is some truth in the observation, 
that a quartan generally begins late in the day; but tertians very frequently come 
on in the afternoon, quartans at noon, and quotidians in the evening. It is said, 
likewise, that a quotidian has the shortest cold stage, but the Xowgesi paroxysm 
altogether; that a tertian has a longer cold stage, but altogether a shorter paroxysm; 
whereas a quartan has a still longer cold stage, but nevertheless a shorter parox- 
ysm than either of the others. But for these particulars there is no universal rule. 
The Body sometimes only Partially Effected. — Some very curious cases of 
paroxysms aflTecting only a part of the body, have been recorded by authors enti- 
tled to credit. There is one case mentioned, in which a vertical half of the body 
suffered an attack of the ague; and during the cold fit, the other half became con- 
vulsed. What is still more singular,— the same half was not always similarly 
aflTected, but the symptoms changed sides. There is likewise a case mentioned, 
where paroxysms of ague affected one half of the body horizontally. In some 
cases it has only affected half the head; and Dr. Macculloch says that a paroxysm 
may affect one limb only. Now these facts are not at all insulated. They are 
perfectly analogous to many others which are occasionally observed in the human 
body. Epilepsy will sometimes affect only one half of the body; nay, sometimes 
it will affect only one limb. Catalepsy will do the same; and paralysis does this 
so continually, that one of the established forms of palsy, is hemiplegia; and ano- 
ther is paraplegia. Dr. Abercrombie, in his work on the Pathology of the Brain,* 
says that a friend of his, when in exercise, only sweats in a vertical half of the body; 
— that there is a line upon the forehead, perfectly distinguishing the sweating from 
the dry side; but that if he takes very violent exercise indeed, then the dry side is 

a " Pathological and Practical Researches on Diseases of the Brain and the Spinal Cord; 
by John Abercrombie, M. D." 



238 INTERMITTENT FEVEB. 

at last forced to perspire a little, like the other. In the work of Andral* (another 
modern writer), will be found instances in which sweating took place in one half 
of the body only. In some of these cases it was a vertical, and in others a hori- 
zontal half. We find a case mentioned by Dr. Falconer, in which a child became 
pale and emaciated in one half of the body only. 

Changes in the Type. — Intermittent fevers, during their progress, frequendy 
change their type. From tertian, they will frequendy become quotidian; from quoti- 
dian, tertian; and from either of these, quartan; while from quartan, again, they will 
become either of the former. Sometimes they will change their type once; sometimes 
more than once; and sometimes they will continue changing, — so as it observes no 
rule at all; and then, as I have already said,** they are called "erratic." Another 
variety is, that they will not change their types: — they will still remain quotidian, 
tertian, or quartan; but they will change the hour of Uieir attack. Instead of begin- 
ning at the same hour, they will begin later and later, or the reverse; and sometimes 
they will begin with such irregularity, that a patient never knows when to expect 
them. Sometimes they will be very irregular at first, and then at last they will 
grow regular; — seeming only to make up their mind, after a time, how they shall 
go on. At other limes, they will grow milder only. It is a general rule that the 
paroxysms grow later and later as they grow milder. As the paroxysms become 
more severe, — more intense, and the disease gets worse, they generally come on 
earlier and earlier; but when the paroxysm grows later and later, and at the same 
time milder and milder, it at last degenerates into nothing more than a little chilli- 
ness, a lilde heat, a litde sweating, or a Hide of all combined. It is very common, 
at last, for the paroxysm to show itself only a litde at a certain time of the day; or 
there is only a little sweating, or a litde chilliness. These diseases occur chiefly 
in spring and autumn. Authors therefore frequently write of vernal and autumnaU 
ague. The quartans usually take place in autumn; — that is to say, there are more 
quartans among autumnal than among vernal agues. 

Variety in the Paroxysms. — Although agues have generally these three stages, 
the paroxysms are sometimes imperfect, even before the disease has much declined. 
I have often seen and cured an ague, in which the cold stage took place, but was 
never succeeded either by the hot or sweating stage. Sometimes the hot stage 
alone will come on; — not being preceded by the cold stage. A paroxysm is gene- 
rally terminated by the sweating stage; but sometimes there will be no sweating 
at all. We may have either of the three stages alone. This is worthy of remark; 
and it is an undoubted fact; for I have witnessed it, over and over again. Cullen 
says that the cold stage is necessary to the others. He considers that the cold 
stage excites the " vis medicalrix naturas;" — that, to get rid of the cold stage, 
nature bestirs herself, and brings on the hot, and then the sweating stage. But 
this is a fallacy; for I know we may have the hot stage, without any cold prece- 
ding it; and that we may have the cold stage, without any subsequent hot stage. 
Sometimes there is no regular paroxysm at all; but patients with ague will have, 
at various periods, a general chilliness, with great depression of spirits; — so that 
they will cry, yawn, stretch, and often be even a litde silly, and have a number of 
odd feelings. Now this slate of things is well known by the lower orders; and is 
called by tiiem, very significandy, " the dumb or dead ague;" — an ague which is 
not at all lively, or does not speak or show itself in an open and manly manner. 
It is, liowever, to be treated exacdy like all other forms of the complaint. 

I have mentioned, respecting the variety in the paroxysms, that sometimes 
there will be one stage alone without the others; but one author tells us that he 
saw all the stages reversed; that the disease began with sweating; then the hot 
stage came on; and the paroxysm was closed by the cold stage. Before this 
disease is fully formed, the attack is sometimes preceded by headache, by pains in 

■ " Clinique Medicale, ou Choix d'Observations recueillies k I'Hopital de la Charit6; par 
G. Anclral." This work, which is a vast repository of valuable pathological facts, has re- 
cently been translated by Dr. Spillan. 

b See Page 236. 



INTERMITTENT FEVER. 2 39 

the nerves (neuralgia), by vomiting, by general indisposition; and all this may last 
for a ionsier or shorter time. These symptoms may cease on the appearance of the 
disease; or they may continue, more or less, when the afiection is established. 
Even continued fever has preceded ague. 

Duration of Ague. — The duration of ague is various. It may be ephemeral, — 
consistins: of one paroxysm; or it may last for many years; — at least, it did so 
before we could cure it so etiectually as we can now. One case is said to have 
lasted eiffht-and-forty years. Lommius, who wrote in beautiful Latin, mentions 
a case which lasted twenty years. One unfortunate fellow (Valescus of Tarenta) 
is said to have had it all his life. Dr. Gregory^ said that he saw one case which 
had lasted four years. On the other hand, Dr. Mason Good^ quotes Senac for a 
case, in which the disease destroyed life the moment it began. When it proves 
fatal, Sydenham says it is in the cold stage; because, when the hot stage comes on, 
nature is getting the better of the disease; and that a patient cannot die from it if 
nature be recovering, as is the case in the hot stage. But the truth is, that it ivill 
kill in the hot stage. In hotter climates than our own, there is great congestion of 
the internal parts of the head; and persons will fall into a state of coma, as they 
sometimes do here in the first stage. I have known some people have it every 
spring for many years. Although we have never seen people that have it regularly 
all the year round, yet most of us have seen individuals who have the disease regu- 
larly once a-year. Respecting its duration, however, quartans are said to last the 
longest. Tertians and quotidians are more like an acute disease; but the quartan, 
coming on after an intermission of two days, partakes more of the nature of a chronic 
affection; and being chronic in its character, so really it is chronic in its duration. 
Certainly it is the quartan that, in general, lasts longer than the others; and it is 
generally more difficult to cure. On the same principle, again, it is said that a 
tertian, left to itself, lasts longer than a quotidian. 

It Affects every Period of Life. — Ague affects all ages. It is seen in young 
children even at the breast; and 1 had under my care, for this affection, a man about 
eiglity years of age. It is said to afiect children earlier than when at the breast; — 
to affect them before they are born. Cases are mentioned, not only in which the 
children had a paroxysm of ague the very moment that they came into the world, 
but in which a child had the disease before it was born. In Dr. Russell's " History 
of Aleppo," there is an account of a woman who had a tertian ague. This woman 
was with child, and she shook every other day; but the child within her she felt 
shaking regularly on the day when she was disposed to be quiet. She shook, for 
example, on the Monday and Wednesday; but the litde one shook on the Tuesday 
and Thursday; — so that she had one tertian, and the child had another. If it had 
not been for this diversity, she could not have ascertained that the foetus had an 
ague, nor could the doctors. What farther proves that the child had a different 
ague from the mother, is that Peruvian bark was given to the latter, and that it 
cured both her and the child; but as the child was so much younger, I suppose the 
bark had more effect upon it: for it was cured one paroxysm before the mother. A 
gentleman informed me, that he saw a similar case at a dispensary in London. The 
woman came shaking with ague; and the child within her shook like herself, only 
at a different time. I suppose there is no doubt of the truth of the case related by 
Dr. Russell. There is no question about children having had the small-pox in the 
womb. Mr. Abernethy used to mention the case of a clnld that had the disease, 
though not the peculiar syjnptom of hooping-cough, before it was born. It was 
affected by the contagion; though, for want of breath, it could not hoop before birth; 
but it embraced the very earliest opportunity it had of doing so; — so that the first 
thing it did was to hoop, instead of cry. 

It is liable to Return. — When this disease has once occurred, it is very liable to 
return, from common causes. Cold, wet, and (in this country) the east wind par- 

» Dr. James Gregory, author of the " ConjNpectus Medicinae Theoreticae." 
b " Study of Medicinej" Class 3; Order 1; Genius 2\ Species 5. 



240 INTERMITTENT FEVER. 

ticularly, have a tendency to bring it back. Whether it will recur spontaneously 
I do not know. Whether, without cold and moisture, and without an east wind, 
or some wind charged with malaria, it will return, I cannot say; but certainly, when 
a person has once laboured under it, frequently the slightest cause will bring it back. 
Dr. Gregory* saw two persons, in whom ague returned, from some common cause, 
after having been absent forty-seven years. Dr. Gregory also stated that it had 
been known to recur, after a lapse of years, at the very day and hour on which it 
originally began. 

It Modifies the Character of other Affections, — The existence of this disease 
gives an intermittent, or remittent tendency, to many other affections that may be 
present. Suppose a person has a disease, and that he is then attacked by ague;— 
the first disease will have a tendency to blend with the ague; so that he will have 
remissions, if not intermissions of it. When ague prevails epidemically, though 
persons may be exempt from any other disease which they may have at that period, 
it will show a tendency to an intermittent or remittent character. This, however, 
is chiefly seen in fever. When ague prevails, or persons are exposed to the cause 
of ague, Continued fever has a tendency to put on the remittent form; and remittent 
fever appears to be a combination of continued and intermittent fever. 

Complications of Ague. — Ague is very frequently followed by rheumatism. I 
am not acquainted with a more frequent occurrence, than that of ague being followed 
by severe rheumatic pains in the extremities, or in the head. Occasionally it will 
alternate with rheumatism; so that the rheumatism shall cease, and the ague return, 
and vice versa. Dr. Gregory* used to mention, that he saw ague alternate with 
epistaxis; and in another case he saw it alternate with hsematuria, — bleeding from 
the urinary passages; which bleeding, however, ceased at last; and then the ague 
returned, and was followed by paralysis. He used also to mention, that he saw 
two cases of ague continue four years; at the end of which they were cured by bark; 
but periodical delirium came on in its stead. 



SECTION II.— COMPLICATIONS AND EFFECTS. 

Local Inflammation. — Ague is very often attended by local inflammation; some- 
times by inflammatory pains of the head; sometimes by inflammatory affections of 
the chest, and likewise of the abdomen;— particularly gastritis and hepatitis. In 
autumn, and in hot climates, it is the abdominal viscera that suffer the most severely; 
and ague is likewise very frequently attended (when there is no inflammation of 
these parts) with bilious vomiting and purging; and even by jaundice and dysen- 
tery. In some places (Zealand, for instance) Sir John Pringle mentions that ague 
is called '* gall-fever." It is on account of the great irritation of the liver that takes 
place, and the abundant secretion of bile, that aguish diseases is thus called. 

Congestion and Effusion. — After death during intermittent fever, we often find 
congestion and effusion in the head, chest, or abdomen. The mucous surface of 
the alimentary canal, is likewise in a state of great congestion; and the liver con- 
tains a large quantity of bile. When this disease proves fatal, it frequently does 
so by great internal congestion; whence there is fulness of all the blood-vessels 
of the head, chest, stomach, and intestines; and a large quantity of bile on the liver. 
When the disease has continued for a considerable time, we have various organic 
aflfections; — such as dropsies, and other diseases which I shall mention hereafter. 
But when a patient dies in a paroxysm, or dies after the disease has existed only 
for a short time, we find decided marks of internal congestion. 

Enlargement of the Spleen. — The chronic form of the disease, is very frequently 
attended by other afl'ections; and frequently, after ague has ceased, other diseases 
make their appearance. It is very common, for example, when ague has continued 
any time, for the spleen to become enlarged. So common is this, in some places, 

• See Note to Page 239. 



INTERMITTENT FEVER. 241 

that the tumour is called (by the vulgar) " ague-cake." The tumour thus formed 
by the s})Ieen, occupies the left hypochondrium; or, perhaps, the whole left half of 
the abdomen. Dr. Cleghorn, who wrote a very excellent work on the diseases of 
Minorca, mentions having seen a spleen, after ague, which weighed eighty ounces. 
Dr. Gregory* used to speak of one that weighed twelve pounds. We frequendy 
see this enlargement of the spleen in the case of infants. I have seen many enor- 
mously large spleens, in infants who had been the subjects of ague. We fre- 
quently, likewise, see enlargement of the liver and jaundice. Enlargement, both 
of the spleen and the liver, is common; but particularly of the former. In the 
case of the spleen, the patient is for the most part pale; — he falls into a state of 
anaemia (bloodlessness); while, in the case of the liver, he becomes more or less 
jaundiced. 

Ascites and Anasarca. — When this affection has existed for any length of time, 
it is common also to see ascites, as well as enlargement of the spleen. Very fre- 
quently there will be anasarca, as jvell as ascites; and not unfrequendy without any 
ascites, there will be anasarca; and these affections generally remain, for a longer 
or shorter time, after the ague has ceased. They will occasionally come on while 
the ague exists; and occasionally not till it has ceased; and, in the former case, 
they are all the worse for the continuance of the ague. It was formerly imagined, 
that these affections arose from the ague being stopped; but this I am convinced is 
a mistake. Persons will have them, who still have ague very violently; and these 
complaints are the worse for the ague. Patients will bear them much better if we 
cure the ague. The ague shatters the constitution; and renders it a more easy 
prey to any visceral disease that may exist. I do not believe these affections 
are the effect of ague. On the contrary, I am satisfied they are the result of the 
same cause which produces ague, and of which I shall presently speak; for I have 
seen people labour under enlargement of the liver, enlargement of the spleen, and 
dropsy of great intensity, who had but one fit of ague; and a fit which bore no 
proportion to the severity of these other complaints. It appears to me, that the 
same cause which produces the ague, — a poisonous exhalation, — produces likewise 
these various effects; and, indeed, they render the ague more obstinate. It is 
sometimes almost impossible, or quite so, to cure an ague while these affections 
exist; but if we remedy them as well as we can, — by mercury, bleeding, purging, 
and the usual remedies of chronic inflammation, — we shall frequendy cure the ague 
whhout any trouble. If they arose from the ague being suppressed^ we should not 
have them while the ague continued; and if they depended on the ague, and not 
on the cause of the ague, they ought to bear some proportion to its degree and 
continuance; but they appear to bear a proportion, in some measure, to the con- 
tinuance and intensity of the cause of the ague. Still the continuance of ague, by 
debilitating the system, does make them worse. 

Idiocy. — Another circumstance, mentioned by some authors as an effect of ague 
(or, perhaps I should say, of the cause of ague), is idiocy. The faculties of the 
mind frequendy become impaired, by a long exposure to the cause of ague. Sy- 
denham mentions a degree of idiocy, or (at least) of impairment of the mental 
faculties, which he calls " amentia quartana" (" quartan fatuity"). There can be 
no doubt that the continuance of ague increases such affections, by debditating the 
constitution; but I do not believe that ague gives rise to them; but that they pro- 
ceed from the same cause which produces ague. 

Local Complications dependent on the Time of Year. — Vernal, or spring inter- 
mittents (those which make their attack between the winter and the summer sol- 
stice) are chiefly attended by affections of the chest; — that being the period at which 
affections of the chest are most prevalent. The autumnal intermilteuts (those 
which take place between summer and the winter) are particularly attended by 
abdominal symptoms; — by inflammation, for instance; — and sometimes by intense 
bilious vomiting, purging, and jaundice. At this time of the year, too, ague has a 

» See Note to Page 239. 

VOL. I. 16 



242 INTERMITTENT FEVER. 

great tendency to become continued fever; — that is to say, the excitement is dis- 
posed, not to cease^ but only to remit. When the autumnal intermillents prevail, 
we have as many remittent fevers as agues; and some of these become continued. 
This , conjunction most probably arises from the fact, that the causes of these 
various local excitements, and also of continued fever, coexist with the cause of 
ague. Without any ague at all, we are all disposed to affections of the bowels, 
and of the stomach and liver, in hot seasons of the year; and if, therefore, the 
causes of ague are joined with the causes of these common affections, ague will, 
of course, be accompanied by these other diseases. Still it is possible that the 
cause of ague may be modified; so as to produce peculiar effects at this season. 

Sometimes Stops other Diseases. — Sometimes ague, so far from being accom- 
panied by other diseases, actually puts a stop to diseases which had previously 
existed. Dr. Gregory^ used to mention, that he saw palpitation cured by ague; 
that the man lived afterwards for many years; and died free from the palpitation, 
under which he had suffered till the ague seized him. Dr. Fordyce mentions, 
that he has seen ague cure many diseases. In fact, ague has been thought so 
capital a thing, that some writers contend it never should be cured; and a proverb 
once prevailed that — 

" An ague in spring, 
Is fit for a king;" — 

not, however, for a subject, T think. Boerhaave says, in his Aphorisms,* that it 
disposes to longevity, and clears the body from inveterate diseases. His words 
are, — " Casterum (febres intermittentes) nisi malignae, corpus ad longaevitatem dis- 
ponunt; et depurant ab inveteratis malis."" 

Aggravates other Coexistent Diseases. — There is no doubt, however, that 
agues shatter the constitution. They shorten life; they may be speedily fatal; and 
if any other disease exist at the time, they for the most part aggravate it. Dr. 
Macculloch believes, that when they appear beneficial, it is generally not by curing 
other diseases, but merely by their assuming a regular type. Ague, as I mentioned 
before,*^ is sometimes obscure, — does not declare itself fully; and is then called 
**dumb or dead ague;" and, in these circumstances, we sometimes have extraordi- 
nary symptoms, which will disappear if the ague come on in a regular, straight- 
forward style. It is therefore mentioned by Dr. Macculloch, and appears very 
plausible, that when benefit appears to arise from ague, it is from the disease having 
existed previously, but in so strange a manner, as to produce all sorts of symptoms; 
and from its having all at once become regular. It cannot be one thing and another 
thing at the same time; but when it becomes regular, then, for the first time, a 
person thinks he has got an ague, and has lost some other disease. 

Effects on the Adipose Tissue. — The continuance of ague usually causes emaci- 
ation of the body,, unless it produce hepatic, or splenic disease, and dropsy; and 
then the body will look bloated; but still it is pale, and evidently greatly diseased. 
It is even said that (in some parts of Flanders, especially) ague has a tendency to 
produce obesity; and sometimes very rapidly; but I imagine that the fat cannot be 
what people call ''good fat." There is a sort of bloated blubbery fatness; and 
when it is remarked that such a person has got f\it, people will shake their head, 
and say — " It is not good fat."*" It is said that this obesity will occur there, whether 
the disease has been acute or is chronic; and when there is no suspicion whatever 
of organic disease. It is said, too, that if the disease return there, or if the seasons 
be very unhealthy, and a patient becomes emaciated, the obesity returns when all 
this is over. Many fat Dutchn»en live in places where malaria prevails; but still 
they do not look healtliy. The ill effects of the disease are so manifest, that no 
one who has an ague, ought to be much displeased with the doctor for curing him 

^ See Note to Page 239. ^ Aphorism, 754. 

« " Iniermiilent levers, unless of a malignant description, dispose the body to longevity, 
and clear ii from obstinate disorders." 
«> See Page 238. « See Dr. Macculloch's "Malariaj" Page 430. 



I 



INTERMITTENT FEVER. 243 

of it. Oliver Cromwell,* and James the First, are said to have died of ague, caught 
ill London. Dr. Caius says, that so fatal was ague in London, in the year 1558, 
that the living could hardly bury the dead. Bishop Burnett says, in his "History 
of the Reformation," that so universaltwas it in London, and so contagious (though 
that was a mistake), that it raged like the plague.'' Sydenham and Morton both tell 
us, that from 1661 to 1665 it was the most fatal disease in London. In our unfor- 
tunate expedition to Walcheren, in no more than five weeks, — that is to say, during 
the last week of September, and the whole of October, — our effective force was 
reduced by ague, or by remittent fever, — aguish disease, to one-third; and ten thou- 
sand men died of what was called " Walcheren fever;" which was neither more nor 
less than an aguish fever.*" 

Does it Antagonize other Diseases? — If it should so happen that a much worse 
disease than ague is arrested by its occurrence, we might allow the latter to go on; 
but even then I should be inclined to stop the ague gradually; and to use, at the 
same time, the remedies calculated to remove the other disease. For example: 
ague, I suppose, is preferable to phthisis; and if a patient were actually in a stale of 
consumption, and the consumptive symptoms ceased on the occurrence of ague, 
one might be disposed only to mitigate the ague, but not altogether to cure it. 
However, I never met with any of these cases. A very eminent man, Dr. Wells 
(one of my predecessors in St. Thomas's Hospital), fancied he had good ground 
for suspecting, that phthisis and ague were opposite; — so that where ague prevailed, 
there was no phthisis; and vice versa. It really appears that there is something 
in this; — that ague does lessen the tendency to phthisis; but still the matter is not 
so important as Dr. Wells imagined. The opposition of one disease to the other, 
is nothing like what he fancied it to be. The question is argued by Dr. Southey, 
in a book on Consumption;*^ in which he has taken great pains to collect documents 
from aguish parts; and proves that there is phthisis enough in those parts. I have 
seen several persons die of phthisis, whde they had more or less ague. Some have 
carried Dr. Wells's opinion so far, as to send a patient, who was half dead with 
phthisis, to stand in a ditch at night; — in order to catch an ague. 

Effect on the Countenance. — One of the effects of ague is shown in the counte- 
nance. The face in ague, and long after, is often 'very peculiar. It is of a dirty- 
straw-colour; and is so well characterized, that it has been called "aguish face." 
The face is not yellow, nor of the colour of c/ea/i straw; but presents a sort o^ dirty 
straw-coloured look. Without the occurrence of aorue, the mere residence in an 
aguish place gives the same hue; — so that it is the effect of the cause of ague. 



SECTION HI.— CAUSES. 

a. Predisposing Causes. 

Bad Health. — I shall now speak of the causes of ague; and, among the predis- 
posing, must be first mentioned bad health. If a person be out of health in any 
respect, he is more likely to be affected by the causes of ague; — ^just as is the case 
with respect to all other diseases. A general weakness of body, independently of 
the presence of any particular disease, must have the same effect. High health, in 
general, is certainly one of the best safeguards against it. The father^ of the late 

» See Dr. Macculloch's " Malaria;" Page 4. 

»> See Dr. Macculloch's "Malaria;" Page 128. 

" It is said ihat ten thousand men were lost by Walcheren, How far the campaign itself 
was lost through the same cause, it is not needful to 2isk.— ''Malaria: by John Maccullvch, M. 
or Page 227. 

^ " Observations on Pulmonary Consumption; by Henry Herbert Southey, M. D." 

e The physician who wrote two very excellent works, disiin^ished by refined ideas 
and a high tone of moral sentiment, entitled, — "A Father's Legacy to his Daughters," and 
" The Duties of a Physician." 



244 INTERMITTENT FEVER. 

Dr. Gregory," — the latter was one of my preceptors, — used to mention, that when 
he was a student at Leyden, — for then, if persons wished to get a good medical 
education, they were obliged to go to the Continent, — there were twenty-four stu- 
dents who always dined together, and were very much in each other's society. 
Twenty-three of them regularly, every day, drank a bottle of claret each; but one 
confined himself to water. The twenty-three escaped; while the poor water-drinker 
caught an intense ague. This strikingly exemplifies the advantage of keeping up 
the vigour of the body, when persons live in an unhealthy situation. It was claret 
which they drank, — not port; but that was quite sufficient to keep up a degree of 
excitement of body, and strength of mind, which enabled them to resist the disease. 

The good effects of wine, in keeping up the strength against this disease, are 
also shown in the fact, that people find it indispensable in the marshy parts of 
France.'' They cannot resist ague there, unless they drink wine. Sir John Pringle 
mentions, that wine and full diet are the best safeguards against it.'' The Dutch 
are in the habit of exciting themselves, by taking spirits, before they go out in the 
morning;'' and it is highly necessary, — exposed as they are to the exhalations of 
their putrid ditches. 

Depression of Spirits. — Depression of spirits will have just the same effect as 
too low a scale of living. Any thing which lowers the body at large, will have the 
same effect; — whether it be over-exertion of the body, or of the brain or mind 
(whichever we choose to say); or the want of good food and clothing, or of plea- 
surable excitement of mind; or the presence of any thing which can depress the 
spirits. It is said, that the effects of the mind were seen at Walcheren; and probably 
they were; — owing to the following circumstance:— When the men arrived there, 
all full of the hope of military glory, they for some weeks continued healthy; but 
at last, when they saw that there was nothing to be done, — that the expedition 
would fail, they soon became the victims of disease. It is to be considered, how- 
ever, that latterly they had much greater fatigue to go through; and the longer they 
xemained there, the more they were exposed to the morbid cause of ague; but still, 
when they lost all mental excitement, by the failure of the hope of what is stupidly 
called " military glory," they nearly all fell victims to the disease. 

Predisposition from Age or Sex. — Though all ages appear liable to the disease, 
infancy and extreme age are less liable to it, than the middle period of life. Certainly 
tha greater number of persons whom I see labouring under ague, are neither infants, 
nor those much advanced in years. It is to be remembered, however, that persons 
i'A the extremes of age, are much less exposed to the cause of ague than others. 
Women too, less frequently have ague than men; but I should think this arises, not 
from the female constitution being less liable to it, but because (from spending a 
greater portion of time at home) females are less exposed than men to its cause. 
Sir Gilbert Blane states that, during the ten years he was physician to St. Thomas's 
Hospital, he had one hundred and ninety-two cases of ague; only thirty-three of 
which were in females. "^ I made an estimate of my cases of ague at St. Thomas's, 
during a period of five years; and found that I had one hundred and forty-two cases, 
of which only twenty-three occurred in women. 

Liability from going into an Aguish District. — It would appear that persons 
who have not been exposed to the cause of ague, are more liable to suffer, when by 
chance they are exposed; for those who have formerly lived among agues, if ex- 
posed at any subsequent period, will often escape, while the others sutler. Hence 
it is said that some farmers, in aguish parts, have made fortunes by marrying a 
succession of wives from healthy districts.® Coming fresh upon an aguish part, 

* See Note to Paj^e 239. 

b See Dr. Macculloch's " Malaria;" Page 283. 

« See Dr. Macculloch's " Malaria;" Page 281. 

«» See his paper oa *• Intermittent Fevers," in the third volume of the " Medico-Chirurgical 
Transactions;" Paj^e 32. 

e Dr. Macculloch, in quoting this opinion, intimates that the practice is not confined to 
England, but extends to France: — " It has sometimes been known, thai one man has married 
three, four, or even five wives;— the tale being told in Bresse, (if I am not mistaken,) of three 



INTERMITTENT FEVER. 245 

the wives have been taken hold of by the malaria; and a good, kind husband has 
been enabled to look out for a second, and a third, to love. However, although 
persons may become habituated to it (as they may to any thing else), yet it more 
or less injures the constitution; — so that those who live in aguish parts, unless they 
are well fed and in good spirits, suffer more or less. They seem to be gradually 
poisoned by the causes of ague; although these may not have been sufficient to ex- 
cite ague itself. 

&. Exciting Cause. 

The exciting cause of ague, — the true indispensable cause of it, I believe to be 
an exhalation from decaying vegetable matter;— what is sometimes called " phyto- 
septic*" matter," " vegeio-putrescent matter," *' miasm, "''" marsh-miasmata," or 
♦' malaria."" However, " marsh-miasmata''^ is an improper expression; for though 
it will come from a marsh, we may have it without the existence of any marsh at 
all. It is said that the causes of ague were not known to Sydenham, or to Stahl; 
and that they were first assigned by an Italian author (Lancisi), in 1717. It is 
said that neither Boerhaave (who wrote in 1747), nor Baron van Swieten (who 
wrote a few years afterwards), was aware of the cause of ague. Dr. Cullen, how- 
ever, from extensive reading, satisfied himself that there was but one real cause of 
ague; and that it was the exhalation which I have now mentioned. The ancients 
were quite aware that marshy districts were exceedingly unhealthy. The least 
acquaintance with the classics, will furnish us with lines enough to prove this.* 

The reasons for ascribing aguish remittent or intermittent fevers, to these exha- 
lations from vegetable matter in a state of decomposition, are the following: — 1. The 
disease prevails in the neighbourhood of marshes. 2. It declines in proportion as 
marshes are drained. 3. It rarely appears in any one, who has not been evidently 
exposed to the exhalations of decomposing vegetable matter.^ Every one has heard 
of the ague of the low countries, — of Flanders; every one has heard of the aguish 
fevers of the banks of the Ganges; every one has heard of the ague of the fens of 
Lincolnshire, the hundreds of Essex, and the lower parts of Kent. I mentioned 
that the disease is not by any means confined to marshes. It springs up around 
marshes, where persons are exposed to their exhalations; but every spot which 
contains decomposing vegetable matter, may excite the disease. On this account, 
I should prefer the term " malaria'^ (which, indeed, is now generally used) to that 
of " marsh-miasmata.^^ 

brothers who had married (between them) iifleen women." See Pages 447 and 448 of his 
"Malaria." 

a From <purov, a herb; and a-mro}, to putrefy. 

^ From fxictiVM, to infect. 

<= The Italian name for an intermittent fever, which is endemic in the neighbonrhood of 
Rome. 

^ By the testimonies of Solinus and Dionysius of Halicarnassus it is proved that the first 
settlers [at Rome] were obliged to abandon the Palatine Mounts, in consequence of the per- 
nicious exhalations of the Velabrum; and we are also informed by Columella, that the land 
near Tusculum, cultivated by Attilius Regulus, was pestilential. — We find, from Plutarch, 
that noted periods of sickness occurred in the time of Romulus, and in that of Numa; and 
Livy says that, in the short period of a hundred and seventy-three years, there occurred at 
Rome, or in the surrounding country, no less than nineteen distinct plagues; some of which 
lasted for two or three years. — Cato mentions places, where it was impossible to live on ac- 
count of the badness of the air; Livy speaks of tertians and quartans; and Varro advises the 
proprietor of an unhealthy farm to sell it at any price; or, in case that was impracticable, to 
abandon it. — It is related, by historians, that armies were often obliged to quit their encamp- 
ments near marshes, on account of diseases.— That the city and the country also were un- 
healthy, is a fact so very familiar, that it is superfluous to do more than remind the reader 
of the names of Strabo, Martial. Horace, Seneca, Galen, and others.— " Malaria- by John 
Macculloch, M. /)." Pages 1G9 ^<? 173, 

e Dr. Fletcher attributes marsh-miasmata to exhalations, not from decomposed, but from 
diseased, vegetables. See the "London Medical and Surgical Journal," for June 3, 1837. 
(Volume 1, 1837-8; No. 9; Page 254.) 



246 INTERMITTENT FEVER. 

Moisture alone is Insufficient, — It is not mere moisture which produces the 
disease; for there is no ague, however wet the weather may be, till swampy land 
is approached, or exhalations arise from a swampy part. No drenching by rain, 
will produce it; unless a person has had ague before, or has been exposed to mal- 
aria. But when a person has once had ague, taking cold (whether there be mois- 
ture or not) may re-excite it; or may render the system susceptible of the effects of 
malaria, which it had resisted before. In the thick fogs on the banks of Newfound- 
land, people never experience ague. The waters there come from the Gulf of 
Mexico; and are called " the gulf-stream." They are from six to ten degrees 
higher in temperature, than Newfoundland; in consequence of which the vapour 
which passes from the water, is immediately condensed. There is, therefore, a 
constant fog; so that the fishermen who reside on the great bank, are six months 
employed in fogs so great, that they can hardly see from one end of the ship to the 
other. But though they are thus constantly enveloped in moisture, they are never 
known to have the ague. There is more rain in the western, than in the eastern 
pans of England; and yet the inhabitants are not proportionately unhealthy. On 
the contrary, it is on the eastern side that ague particularly prevails; — as I shall 
mention hereafter. So much with respect to mere moisture. 

Exhalations. — With regard to exhalations, I may mention that Minorca, though 
it has a rocky bottom, and no marshes, is nevertheless subject to ague; because, in 
different parts of the island, there are pools of stagnant water. Much vegetable 
decomposition takes place in the stagnant pools; and the island is in the same pre- 
dicament as though it were marshy land. The soil of the Campagna of Rome, in 
the most fatal season, is dry; but then the Campagna is intersected with ditches 
and drains of water, quite sufficiently impregnated with vegetable matter to explain 
the aguish fevers of that country.* The fevers of Egypt begin with the subsidence 
of the Nile; and those of Bussorali with the subsidence of the Euphrates; and the 
Arabs, to revenge themselves upon the inhabitants, once" let loose the waters, and 
thereby produced a disease which destroyed fourteen thousand persons." In Artois, 
in Flanders, the south and south-west winds come over swamps; and though the 
part itself is not swampy, they bring aguish complaints to it; but as soon as the 
wind sets in from the sea, and from the north, these aguish complaints all disap- 
pear.* These north winds, which do not come over swamps, are^ accompanied by 
very dense and durable fogs; but no ague occurs from them. The same is the 
case in many parts of France and the Mediterranean. In 1528, the French army, 
in attempting Naples, was reduced from twenty-eight thousand to four thousand 
men; — simply from choosing an injudicious encampment near the Baiae.* Infinite 
is the mortality occasioned in this way, by ignorant or careless generals, from en- 
camping an army near a marsh; and by governments, from permitting marshy 
lands to continue in the neighbourhood of cities. The instance of Walcheren must 
ever be a disgrace to the government of this country. " There was no reason ap- 
parent," says Dr. MaccuUoch,^ " for perpetuating Calcutta; when, almost from the 
very hour of its foundation, by Charnock, its destructive situation had been demon- 
strated. That Holland should have persisted in inhabiting that Batavia, which it 
had studied to render more poisonous than nature had already done, by the model 
of its own pestiferous forefather, is a problem which Holland must be allowed to 
explain, as it best can." 

a See Dr. Macculloch's " Malaria;" Pages 84 and 184. 

'' In the year 1743. See Lind's " Essay on Diseases incidental to Europeans in Hot Cli- 
mates;" Part 1; Chapter 3; Section 4. (Second Edition; Page 110, compared with Page 
128,) The following additional circumstances are there mentioned: — '* The stagnating and 
putrefying water in the adjacent country, and the great quantity of dead and corrupted fish at 
that time lying upon the shore, polluted the whole atmosphere. Not above two or three of 
the Europeans who were settled there, escaped with life." 

c See Pages 19G and 197 of Dr. Macculloch's '< Malaria." 

d See Dr. Macculloch's " Malaria;" Page 273. 

e See Dr. Macculloch's " Malaria;" Page 227, 

' At Page 219 of his " Malaria." 



INTERMITTENT FEVER. 247 

Conditions on ivhich Putrefaction depends. — But although moisture is not the 
cause of ague, yet moisture is indispensable to the decomposition of vegetable mat- 
ter; and to the diseno^agement of the miasma. Decomposition requires a certain 
degree of moisture; and if we dry any thing thoroughly, whether it be a vegetable 
or an animal production, we prevent decomposition. A certain degree of moisture 
is necessary for the fermentation and putrefaction of vegetable matter; which fer- 
mentation and putrefaction give rise to the exhalations that produce ague. Thus, 
it is in a moderate swamp that dry weather may put a stop to the disease; — namely, 
by putting a stop to putrefaction. We also see why, in extremely wet situations, 
there is often no ague; — because too much fluid also impedes putrefaction; but this 
wet, by dry weather, may be reduced to just sufficient swampiness for vegetable 
decomposition to take place, and malaria to be produced. Just as dryness would 
prevent decomposition, so will extreme wetness and moisture. If the matter which 
is to be decomposed, be diffused in a very large quantity of water, the putrefaction 
ceases, or is not evident; so that some places which, while very wet, were healthy, 
have been made unhealtliy by being dried just sufficiently for putrefaction to go on 
vigorously; and, again, other parts which were dry, and which never gave out any 
exhalations, have been caused to do so, by a certain degree of moisture falling upon 
them. Thus, according to situation, the same additional moisture may produce an 
ill, or a salutary effect. High grounds, therefore, may suffer from the same cause 
which removes all unhealthiness from loio grounds. A certain degree of rain fall- 
ing upon high ground, will not all remain there, but will roll down. Still it has 
moistened the parts sufficiently for decomposition to take place above; whereas, 
when it comes on the low ground, and there collects, it may be so abundant as to 
dilute all the vegetable matter, and prevent it from putrefying; and may so put a 
stop to the unhealthiness of the part. In this way an aguish fever, whether inter- 
mittent or remittent, — for I intend to include both when I say ^'■aguish fever,'''' — 
has been put a stop to by inundating a swamp; and, on the other hand, inundation 
has moistened a dry part sufficiently for exhalations to take place. 

Very dry or very ivet Seasons check Fever. — By recollecting this, we may ex- 
plain a number of circumstances, which otherwise would appear contradictory. A 
river, by breaking loose over a marsh, has sometimes prevented it from being any 
longer the source of noxious exhalations. Where there was a marsh before, it 
has produced a sort of lake.* In Batavia, for example, the rainy season is com- 
paratively healthy; because the rivers and canals are then plentifully supplied with 
water, which flows on rapidly; and all the marshes are inundated. But in the 
months of July, August, and September, the waters are nearly evaporated; and 
fever is then much more malignant than at any other period. On the western coast 
of Africa, and in some of the West India islands, especially Barbadoes, fevers are 
rare during the long continuance of dry weather. There is not much water there, 
and what there is, is evaporated in dry weather; so that the vegetable matter be- 
comes too dry for putrefaction. Fevers, on the western coast of Africa, are observed 
to be arrested in long drought; whereas, in Batavia, they cease during the rainy 
season. At Charles Town, in South America, (which is a swampy situation,) bilious 
fevers prevail in hot summer weather; but in 1752 there was very intense heat, and 
universal health prevailed. The thermometer was 98°, even in the shade; the air 
was glowing; all vegetation was parched up; and decomposition was put a stop to 
by the intense heat. In summer, fevers frequently prevailed in certain parts, on 
account of the rivers diminishing to a great amount. All rivers, of course, diminish 
in summer; but some lose a very considerable portion of their depth; or rather, we 
sliould say, of their breadth. The lake Biviere, in Sicily, loses two-thirds of its 
dimensions in summer; the lake Cagliari, in Sardinia, loses much; and so does the 
Caspian Sea." Of course, the sides of a river are always more or less dry; but in 

* See Dr. Macculloch's "Malaria;" Page 200. 
•» See Dr. Macculloch's "Malaria;" Page 193. 



248 INTERMITTENT EEVER. 

summer a great portion becomes half-dry. There is just sufficient moisture for de- 
composition to take place; and therefore ague prevails when the rivers are shallow. 

llie Goodivin Sands. — A change in the course of a river, may drain a marsh 
completely; and in that way a part has become healthy, which before was exceed- 
ingly unhealthy. Sometimes the very reverse has taken place. By breaking over 
dry land, it has caused sufficient moisture for putrefaction to go on. The sea has 
done the same. It has sometimes produced the greatest unhealthiness in a neigh- 
bourhood, by making its way upon the country, and producing a permanent swamp; 
whereas, in other cases, it has produced something more than a swamp; — it has 
deposited such a body of water, that no exhalations could be given out, although 
before they were emitted in great abundance.* The Goodwin Sands are an instance 
of a cured marsh, though the land is lost.'' An immense deposit of sand has filled 
up the marsh. The retiring of the sea will frequently cause ague; by leaving a 
marsh only, where the part was previously deluged. 

The Lake of Wallenstadt, — As every river carries down a quantity of solid 
materials, so every river has a tendency to fill up its bed. It becomes more or less 
filled with solid matter, coming down from high land. A river may be completely 
filled up; so that the banks must be raised, or the country will become inundated. A 
marsh will be produced; and great unhealthiness take place. This is frequently 
remedied, for a time, by embanking a river; so that it shall still be confined within 
its proper bounds. I say " for a time" only; because the higher the river becomes," 
the more slowly it runs, and the less it drains the country; till at last it is useless.* 
But in some countries people are prejudiced, or careless; and parts which were ex- 
ceedingly healthy, become the seats of the most dreadful disease. There is an 
instance in Switzerland, of a part becoming very unhealthy to all* around. Aguish 
fevers extend from the lake of Wallenstadt, over a great district, as far as Zurich. 
A river there (the Linth) pours its water into another river (the Mag); and that 
again into the lake. The Mag became stopped up, through neglect; and the 
neighbourhood all round, a few years ago, became one of the most pestilential dis- 
tricts in Switzerland; — six thousand acres being thus converted into a marsh. At 
last, the authorities had their attention forced to it; and it was remedied simply by 
turning the Linth into the lake, instead of allowing it to empty itself into the Mag; 
and by widening and deepening the Mag. The lake, being a deep spot, receives 
all that comes down from the mountains; and the whole has now a free course. 
The obstinacy of the people — in living in the midst of a pestdence, when they had 
it in their power to remedy it — is hardly to be conceived; but it is no less true. I 
could give many illustrations; but they all come to this point; — that a certain degree 
of moisture is necessary to the disengagement of malaria; that if we diminish the 
moisture, we diminish the malaria in one case, and increase it in another; and that if 
we increase the moisture, we may also produce either of these effects. Thus it is 
that, according to situation, circumstances the most opposite will have the same 
eflfect; and circumstances which are exacdy the s«me, will have the most opposite 
eff*ect. 

Temperature necessary for Putrefaction. — But a certain degree of moisture, is 
not all that is necessary; — there must also be a certain degree of temperature. We 
can preserve any thing from decomposition, by an exceedingly low temperature; 
and by an exceedingly high temperature, we produce such changes that no decom- 
position can take place. We know that if meat be spoiling, we have only to cook 
it, and the putrefactive process is immediately arrested; and so it is with respect to 
the putrefaction of vegetable matter. A certain degree only of temperature is 
proper. If the temperature be increased, then we may have extreme decomposition, 

« See Dr. MaccuUoch's "Malaria;" Page 204. 

^ The loss of the Goodwin lands, by inundation, proved the remedy (pxpensive as it was) 
for a wide tract of poisonous m?yrsh. — '■^Malaria; by John Macculloch, M. D." Pas.e 204. 

c The Po is now, over a large tract, literally running on the summit of a wall. — '■^Malaria; 
by John Macculloch, M. />,'' Page 379. 

d See Dr. MaccuUoch's " Malaria;" Pages 198 and 109. 



INTERMITTENT FEVER. 249 

and disengagement of malaria; — so that while the cold weather lasts, the people 
will be comparatively healthy; but when the warm weather anives, the decompo- 
sition is such that the most fatal fevers prevail. Hence it is that aguish diseases 
are far more severe in hot countries, than they are in ours; and that they are far 
more severe in autumn, than at any other period. This, at least, is one reason; but 
there is another. In hot countries, and in hot seasons, there is far more vegetable 
matter to decompose. This is certainly to be taken into the account; but when we 
consider that an increase of heat produces a great increase of decomposition, we 
also see that fever must greatly be ascribed to the facility with which decomposition 
goes on in a warm temperature. A low temperature, however, may be short of 
that which is sufficient to stop the disengagement of malaria; and, therefore, if a 
country be very unhealthy, and very swampy, there will in cold weather be aguish 
diseases. The cold is not such as to stop putrefaction; and the land is so moist, as 
to produce a very considerable disengagement. The reason that ague prevails so 
much in the spring, is that the soil, which was caked and dried by the cold of 
winter, is now moistened; and the temperature of the weather has increased. The 
cake has consequendy been broken up; and therefore we have vegetable exhalations 
in abundance. The vegetable matter, which was left on the ground the preceding 
autumn, becomes decomposed by the increased temperature. The reason that ague 
is so fatal in the autumn., is that the summer has produced a fresh stock of vege- 
table matter. The surface of the earth is covered by vegetable matter; it is in great 
part dying, and lies upon the ground to rot; the rain comes in the hot period; and 
—what with the heat, the moisture, and the dead vegetable matter — exhalations 
take place. The great abundance of the vegetable matter to be decomposed, to- 
gether with the heat, renders the autumnal fevers far more severe, and far more 
numerous, than the vernal. 

The effect of moisture has frequendy been seen, in a striking way, when rain 
has begun suddenly after a dry season. When a quantity of vegetable matter has 
been lying upon the earth, and has become caked, a sudden rain has been attended, 
on many occasions, by the most fatal diseases. From the moistening of the vege- 
table matter, putrefaction has instantly taken place; and exhalations in abundance 
have been emitted. Again: the reason that, when the autumn is over, these fevers 
cease, is that the greater part of the vegetable matter has been decomposed; and the 
temperature of the atmosphere falls; and therefore not only is there less matter to 
putrefy, but the temperature is not sufficient for putrefaction to go on with vigour. 

Pasture- Land^'i. — Pasture-lands, from being constantly moist, are very aguish; 
and yet, on breaking them up and cultivating them, they are infinitely more so;''and 
this from the same reasons that I have now mentioned. All pasture-lands must be 
unhealthy; for they are all moist; — and they cannot be good if not moist; for the 
grass will not grow without moisture. But when broken up, they become more un- 
healthy. Previously, only portions died; but, when the lands are broken up, 
nearly all the vegetable matter is killed, and rushes into putrefaction; — so that it is 
always found, that the breaking up of pasture-lands is attended by far more disease, 
than existed before the land was so broken up. It may be a fact, however, that 
malaria is let loose from the earth by breaking it up. It is said that, in many 
countries, on the breaking up of the surface of the earth, these fevers are sure to 
prevail. In the West Indies, for instance, it is said that this process has been known, 
for two centuries, to be exceedingly dangerous. Cassan mentions that fevers, like 
the plague, will take place on land being broken up; — so that labourers will some- 
times die on the spot, if they remain there all night; whereas no harm arises if they 
be not broken up. Volney, the traveller, mentions this as an invariable observation 
in America.* 

Clearing of Woods. — It is found also, — and the fact is precisely similar,— that 
on clearmg away woods, the disease especially prevails. A quantity of malaria is 

• See Dr. Maeculloch's "Malaria;" Pa^es HI and 112. 

* See Dr. Maeculloch's "Malaria;" Page 112. 



250 INTERMITTENT FEVER. 

let loose from the forest, when the woods are cleared; and — more than that — a 
quantity of vegetable matter necessarily lies on the surface of the earth, which, 
although kept moist enough for decomposition, is prevented from decaying much, 
from the inability of the sun to penetrate to it; but, on clearing the wood, the heat 
of the sun is admitted to the surface, where the vegetable matter is lying; and it 
then falls into a state of rapid decomposition.* Hence it is found that the clearing 
of woods is always a dangerous process; and it may be so from two circum- 
stances; — first, the malaria which is pent up in the woods is let loose; and secondly, 
the sun has access to the vegetable matter which lies on the surface, and effects its 
decomposition. Besides, much vegetable matter must be killed by the process. It 
is said that the same effect will take place in Italy, if certain bushes be cut down.* 
Whatever malaria may be in them, has then an opportunity to escape; and fever is 
sure to prevail. The removal of woods has frequently been injurious, in another 
point of view; — by removing a protection. Some villages have been free from 
ague, while a wood existed between them and a marsh; but on cutting down the 
wood, they have become from that moment exceedingly unhealthy; — the wood 
having served the purpose of a screen. "^ Some have imagined that it was the 
knowledge of this circumstance, — of this advantage of woods, — that caused them 
to be so venerated, and held so sacred in ancient times. 

Stagnant Water. — It has been said that stagnant water alone will produce ague, 
without any vegetable matter being in it; but we are to remember that this stag- 
nant water will putrefy; which it certainly would not, unless it contained animal 
or vegetable matter. Water itself — pure oxygen and hydrogen — cannot undergo 
putrefaction; but soft water will putrefy; and, as that is the case, it must contain 
dead vegetable matter. If stagnant water, therefore, — although nothing can be 
seen in it, — does produce ague, we may explain the occurrence by supposing that 
it contains vegetable matter. It is well known that the Thames water, however 
good it may look, when put into casks will putrefy; and it is said that the decay 
of the interior surface of the cask, is quite sufficient to explain this; — that if pure 
water be put into a cask, yet the wood of the cask — being vegetable matter, and 
being next the water — becomes more or less acted upon by the water, and more or 
less undergoes the process of putrefaction, and so affords malaria.** It is on account 
of this liability of the wood to be destroyed, that casks are always charred within; 
by which they are enabled to resist the putrefactive process. 

Any portion of water (however small the collection) containing decayed vegeta- 
ble matter, is sufficient to cause intermittent fever. Many places, therefore, which 
have only a small pond, or a small lake, produce disease. Many places, no 
doubt, are suffered to give ague, and aguish diseases, from circumstances which 
are entirely within control. It is said that an inveterate ague was produced by the 
canal at Versailles, though it was little larger than a fish-pond.^ Monfalcon quotes 
an instance of a fish-pond at Chantilly, which was remarkable for its pestiferous 
character.^ Many country residences (there can be no question) have been made 
unhealthy, from the custom of ornamenting them with woods, and little lakes of 
stagnant water; — " pieces d'eau d'agrement," as the French call them; — " lacs 
artificiels."^ Edinburgh is now any thing but favourable to ague; but there was 
formerly in it a lake, called " the North Loch," which was famous for it.** Agues 
prevailed in that district till the spot was^ drained; but now no agues are there at 
all. When I say " ague," I mean fevers of an aguish character, — whether re- 
mittent or intermittent; and many diseases of this description are unquestionably 

* See Dr. Macculloch's " Malaria;" Page 44. 
^ See Dr. Macculloch's "Malaria;" Pages 367 and 268. 
c See Dr. Macculloch's " Malaria;" Pages 43, 44, 248 and 249. 
^ See Dr. Macculloch's " Malaria;" Page 143. 
e See Dr. Macculloch's «' Malaria;" Page 100. 

f He [Monfalcon] refers pointedly to the artificial water of Chantilly, as the source of 
frequent and serious epidemics. — ^^ Malaria: by John Macculloch, M. J9," Page 100. 
e See Monfalcon's opinion, recorded at Page 99 of Dr. Macculloch's "Malaria." 
b See Dr. Macculloch's " Malaria;" Page 191, 



INTERMITTENT FEVER. 251 

mistaken, every day, for real typhus. In order to the existence of ague, the situa- 
tion need not be low, nor need there be a marsh. At whatever height water be 
hemmed in, of course vegetable decay may take place; — ^just as though it were in 
a low situation. 

Clayey and Retentive Soils. — Clayey soils are the most favourable for these 
fevers, on account of the clay retaining the moisture; whereas gravelly soils let it 
escape.* It might be imagined, perhaps, that the Delta of the Nile would be a 
great source of ague. Ague (Sir James M^'Grigor says) is not unknown in Lower 
Egypt; but it is only seen sporadically. The reason of this is, that there is no 
stagnation of water; — notwithstanding the existence of so much vegetable matter as 
is brought down to the Delta. In fact, there is so much agitation, as to have the 
same effect as too much water; so that putrefaction does not take place. Strabo 
remarks the healthiness of Lower Egypt; and ascribes it to this cause. On the 
other hand, ague will continually occur in spots where there is lilde more than a 
pool, or a puddle; but then the water is completely stationary. Even a ship may 
contain a source of malaria. I believe the fevers of ships, are very often remittent 
fevers; but are mistaken for typhus. They have often arisen entirely from the 
bilge water. Captain Smith says, he never knew fever in any of his ships, during 
a long service in the Mediterranean; and Captains Parry, Cook, and Sir Henry 
Baynton, all succeeded in preserving the health of their crews. They all had the 
holds of their vessels washed out daily, by means of plugs, till the water came out 
perfectly clear; so that no accumulation of filth could take place; — no accumula- 
tion of vegetable matter. This fact may be contrasted with one relative to the 
Powerful, a seventy-four gun ship; the crew of which, on their voyage from the 
East Indies, were nearly all disabled by fever; and the cause was found to be 
merely the ballast, which consisted of moist and putrid mud. Ships laden with 
sugar have the greatest mortality; and sugar is a vegetable matter. In fact, the 
most unhealthy cargo that a ship can carry, is sugar.* 

Moats and Ditches. — The castle of Flamandville, in Normandy, is situated 
high; but an endemic prevails around, in consequence of a mere moat, containing 
a quantity of vegetable matter, which gives forth pestiferous eflluvia. A family, 
resident at the place for a length of time, was at last exterminated; but, before 
that, they underwent a loss both of mental and of corporeal power. The same 
thing has been observed in the neighbourhood of many castles. The besieged and 
the besieging have both suffered, when the baronial castles were attacked; and the 
source of all the disease, was the moat surrounding the casde. The sentries were 
the first attacked." Down to the middle of the last century, one-third of the inhabit- 
ants at Bourg en Bresse were incapacitated; in consequence of the ditches, around 
the fortifications, containing a quantity of decayed vegetable matter. At Havre de 
Grace the soldiers were once known to be giddy, and to experience violent head- 
ache, five minutes after they had approached the ditches; and then they had vio- 
lent fever.* I saw several cases of ague in London, arising from the moat around 
the Tower. A stupid negligence, with regard to the moat, prevailed for a long 
time; a great accumulation of filth took place; and I continually saw patients with 
ague, from that part of London. The first case I met with, was that of a lady; — a 
relative of a medical gentleman in the neighbourhood; and, not having been in the 
country, she could not imagine how she had contracted the ague. At last she told 
me, that she was in the habit of taking exercise on the ramparts of the Tower; 
and the circumstance of the moat, of which I had read so much in books, imme- 
diately occurred to my mind. I inquired whether it was in a filthy condition; and 
learned that it was so; but that the authorities would not clean it out. There was 
a difi'erence of opinion as to which department it belonged to; and some medical 
men (laughingly) said, that it could not be supposed they should press the subject; 

a See Dr, Maceulloch's " Malaria;" Page 20. 
^ See Dr. Maceulloch's " Malaria;" Pagfes 146 to 148. 
* See Dr. Maceulloch's "Malaria;" Pages 89 to 93. 
^ See Dr. Maceulloch's " Malaria;" Page 93. 



2'52 INTERMITTENT FEVER. 

because it brought ** grist to the mill." I believe, however, that (in consequence 
of the representations of the profession) it has been cleansed. 

Harbours, moats, and mill-dams, have all been sources of ague. In a mill-dam 
the stream is rapid; but the sides may be flat and wet.* Flax-grounds have fre- 
quently been proved to have given origin to the same disease; in consequence of 
the flax lying upon the ground, in a state of decay. In Italy and Germany, fevers 
frequently prevail in the neighbourhood of flax-grounds; and there are instances of 
ague in dry, sandy, high places, owing to the hemp being dried there; and the 
fevers regularly cease when the season for drying hemp is over. Indigo-manu- 
factories have also been the sources of this disease.'' The inundation of a cellar, 
has frequently caused these fevers to prevail in a family; and the passage of a drain 
under a house, has frequently caused the inhabitants to continue the victims of 
fever; — that is to say, the house has been rendered unhealthy; and all the people 
residing in it, have been more or less attacked with fever, from time to time. Nay, 
the removal of stores has frequendy been productive of fever.*' The water, under 
the stores, has been impregnated with vegetable matter, in a state of putrefaction. 
The removal of the stores has let loose the exhalations, which were pent up beneath 
them; and the men employed in removing them, have been known to suffer an 
attack of fever. 

High Susceptibility of some Persons. — When we consider the peculiar suscep- 
tibilities of different individuals to the eflfects of morbid causes, we shall not be 
surprised that persons will occasionally catch an ague, from the most trivial expo- 
sure to malaria. We know that some persons are singularly liable to be affected 
by particular causes. Many persons, on approaching a hay-field, will be seized 
with asthma; particularly if the grass be sweet-scented. I believe it is not the hay 
which produces the affection, but the flower of the grass; — so that they are attacked 
if they approach fields at the time they are in flower; which is at the period of 
hay-making. It is said to be not at all uncommon, for persons to be so aflfected 
from ipecacuanha. Some persons have been seized with asthma, from ipecacu- 
anha being powdered in the house; nay, it is said that some persons have been 
seized with it, merely from a box of ipecacuanha-lozenges being in the same room. 
As any rate, a trivial exposure to this drug, frequently produces the disease. We 
must have seen persons thrown into a violent salivation, from a grain of calomel; 
nay, I have seen it arise from the application of a little red precipitate ointment,* or 
mercurial ointment, to a sore leg. From these various circumstances, we must 
suppose that there are some people, who are peculiarly susceptible of the effects of 
malaria; and therefore I can imagine sporadic cases of ague to take place, from a 
person merely passing through a market, in which decayed cabbage-leaves may be 
lying. We all know that there is more or less putridity in these vegetable remains; 
— they continually emit a noxious smell; and I can conceive that, even in a most 
healthy town, we may thus have a cause of ague. Ague is sometimes ascribable 
to very common and trifling causes, without at all invalidating our general conclu- 
sions. A very slight collection of decayed vegetable matter may be supposed 
sufficient to produce ague, in a person extraordinarily disposed to it; and therefore, 
when we cannot account for the existence of the affection from the person having 
been near a swamp, it is very possible that the case may be one of extreme sus- 
ceptibility; — that a minute quantity of putrid vegetable matter, has been near the 
patient; or that minute malarious exhalations have been wafted to him. It is to be 
remembered, that these miasmata will extend to a very great distance; and that, in 
very aguish seasons, places which are usually healthy, and not situated near much 
stagnant water, frequently become unhealthy. Dr. Macculloch's works are the 

» See Dr. Macculloch's "Malaria;" Page 102. 
b See Dr. Macculloch's " Malaria;" Pages 140 to 142, 
c See Dr. Macculloch's " Malaria;" Pages 88 and 89. 
*Unguentum Hydrargyri Nitrico-Oxydi. 



INTERMITTENT FEVEE. 253 

best on this subject. They consist of two volumes on Marsh-Fever and Neuial- 
gia;* and one volume on Malaria." It is his opinion, — and also that of several 
Italian physicians, and able military men, — that a single inspiration of malaria, 
may be quite sufficient to cause disease.'' If all this be the case (and there is no 
reason to doubt it), we are not by any means to reject the belief that the disease 
always rises from such exhalations, merely because we can hardly tell how a par- 
ticular individual, in certain circumstances, may have been exposed to them. 

Distance to which Malaria may extend from its Source. — As to the distance 
to which malaria will extend, it is said that, in Italy, the ill effects of stagnant 
water are known to extend three miles; — that they have reached from the lake 
Agnano, as far as the convent of Camaldoli, which is situated on a high hill.* 
Lancisi (who first referred this disease to marsh-miasmata) says, that as thirty 
ladies and gentlemen were making an excursion of pleasure up the Tiber, the wind 
suddenly shifted to the south, — commgover the Pontine marshes; and twenty-nine 
were instantly taken ill; — only one escaping. They were all well before; but the 
wind coming over the Pontine marshes was impregnated with malaria; and 
twenty-nine were instantly affected by it. Dr. Lind, of Haslar Hospital, (who 
wrote on the Diseases of Hot Climates,) says that when Commodore Long's 
squadron lay off the mouth of the Tiber, two vessels that were close to the 
shore were affected, while the rest, lying a little farther off, escaped. The differ- 
ence of half a cable's length from the shore, has caused vessels to suffer or escape; 
yet Sir Gilbert Blane says that, in the West Indies, (and he heard the same 
respecting the channel leading to Calcutta,) the malaria was observed to reach a 
distance of three thousand feet, and more. In Zealand, the distance (he believes) 
is far less; — owing to the comparative mildness of the malaria, and also of the tem- 
perature. It is the opihion of many authors, that the hotter the climate, the farther 
does the malaria extend; — that if the quantity of vegetable matter be great, and the 
heat intense, it produces its effects at a very considerable distance; but that in cold 
climates, the vegetable matter and heat being less, the exhalations are milder in 
their nature, and less copious; and therefore it is supposed by Sir Gilbert Blane 
(who had great experience), that in Zealand the distance is far less, than in many 
other parts. He says that, at the time of the Walcheren fever, no persons on board 
ship were seized with the disease which was prevailing on shore; although the 
channel between Beveland and Flushing was only six thousand feet wide, and some 
of the ships lay nearer to one shore than the half of that distance. It is the opi- 
nion of many, that the malaria will not extend to any great distance. Sir Gilbert 
mentions, that when the ships watered at Rockford, ne found that if they anchored 
so near the shore as to smell the land, — the smell of land-air being sometimes very 
perceptible at sea, — they were affected; but if they remained only two cables' 
length from the spot where they smelt the malaria, no inconvenience was experi- 
enced. It is said by Lind that, atPensacola,^ a regiment lost a hundred and twenty 
men, and eleven out of twelve officers' wives who landed; but the whole crew of a 
man-of-war, which was lying one mile from the shore, remained perfecdy healthy.^ 
However, Dr. Macculloch believes that malaria may be conveyed to an indefinite 
distance.^ He has investigated this subject more than any one else; but has carried 

* " Essay on the Remittent and Intermittent Diseases; including Marsh-Fever and Neu- 
ralgia; by John Macculloch, M.D." 

'' "iVJalaria: an Essay on the Production and Propagation of this Poison. By John 
Macculloch, M. D." 

<= It is matter of observation, that a minute's exposure to Malaria, — a single inspiration, 
probably, is sufficient to excite its fever; and, very notoriously, to re-excite it in those who 
are subject to that morbid sensibiUty, derived from former or habitual fevers. — ''Malaria; by 
John Macculloc/i, M. D." Pa^es 53 and 54. 

^ See Dr. Macculloch's " Malaria;" Pages 241 and 242. 

« In North America. 

f This occurred in the vear 1765. See Lind's "Essay on Diseases incidental to Euro- 
peans in Hot ClimateN;" Part 2; Chapter 1; Section 2. (Second Edition; Page 169.) 

e See his remarks on the "Propagation of Malaria" (forming Chapter 7 of his Work); 
particulaily Pages 308 to 336. 



254 INTERMITTENT FEVER. 

his views further, perhaps, than most other persons will think justifiable. He is 
convinced* that it is conveyed from the banks of the Thames, over the hills of 
Kent; even to a distance of some miles from the coast.'' He argues*" in the first' 
place, analogically, that dogs will smell the land long before it is visible; and, on 
the other hand, that the sea may be smelt** very far inland; — that whales or sharks 
may be smelt, both powerfully and offensively, as far as the spouting of the animal 
is visible from the mast-head; and therefore he says,® that if these things can reach 
such a distance, and odours produce such an effect, so may malaria or vegetable 
exhalations. He mentions,^ that fogs and clouds go to an immense distance; — that 
malaria easily unites with fogs and clouds; and therefore he concludes, that as far 
as these will go, so far may tlie malaria extend. Moreover he asserts,^ as a fact, 
that he has found records in ships' books, of malaria having produced fever at a 
distance of five or six miles or more from shore; and that the danger was inslanUy 
made sensible by the smell; — so that the ship's crew would go below, or weigh 
anchor and run to sea. He says^ it is well known, that points in the coasts of 
Suffolk and Norfolk, and the eastern coast of Scotland, have ague; though there 
is no local source of malaria for many miles; and that there are some points where 
there is no source of malaria, for even a greater distance than that; and therefore 
he contends* that it must be brought from Holland, and the northern shores of the 
Continent. 

Influence of Easterly Winds. — The effect of the east wind, in causing and re- 
newing aguish diseases, is well known; but it can no more be the simple air itself, 
than pure water (oxygen and hydrogen) can produce ague. Wind, if pure, can no 
more be poisonous than pure water;'' and therefore the noxious property must be, 
as in the case of water, contained in it. Now the east wind is perfectly innocu- 
ous, in the regions which it reaches after having passed over healthy countries; and, 
vice versa, other winds are as unhealthy in some paits of the world, as the east 
wind is here; — that is, where those winds come over a marshy district; exactly as 
our east winds do. This is another argument adopted by Dr. Macculloch.* He 
says™, — siill pursuing his argument, — that land under the trade-winds, and ships in 
the equatorial seas, escape; and that St. Helena, being so much exposed to the 
east wind, ought never to be free from ague; whereas that is not the case. If the 
east wind blows over a frozen continent, or simply blows across the sea, (though 
of course, in its passage, it must imbibe moisture,) it is found to do no harm. In 
order to be injurious, it must blow over land where there is vegetable matter and 
moisture. For this reason, in one-half of the globe, the east wind is exceedingly 
injurious from the month of March to the month of October.'' In French Flanders, 

a He states that conviction at Page 309 of his "Malaria." 

b From any known and often very limited spot, this poison will proceed (through the air, 
or on the windt;) to distances of three or four miles; — exciting as much virulence as in its 
native marsh. This — to quote a familiar domestic example, out of hundreds that might be 
adduced— occurs on the hills of Kent, far from the marshes of Erilh, Northfleet,or Graves- 
end. — ''Malaria; by John MaccuUock^ M. D." Page 54. 

«: At Page 310 of his "Malaria." 

^ The smell of the sea is, in reality, the smell from fish. — ''Malaria; by John Macculloch, 
M. D." Page 310. 

" At Pages 309 and 310 of his "Malaria." 

f At Pages 310 and 311 of his "Malaria." 

s At Page 314 of his "Malaria." In addition to this general assertion, he gives the fol- 
lowing specific instance; in which, however, the distance is rather less, than in the case 
referred to in the text: — "In one case of a healthy ship and crew, anchored at least four 
miles from the shore, a sudden change of wind brought out the smell of the land; on which 
orders were immediately given for weighing the anchor; while, even before the cable chain 
could be cleared, most of the men working at it (who were the only ones first permitted on 
deck), were seized with a disease, which proved the fatal cholera to the greatest number." — 
("Malaria;" Pages 314 and 315.) 

h AtPage 317of his "Malaria." 

i At Pages 317 and 318 of his " Malaria." 

k See Page 318 of Dr. MaccuUoch's " Malaria." 

1 For this argument, see Pages 316 to 33G of his " Malaria." 

«n At Page 319 of his " Malaria." 

n See Page 320 of Dr. MaccuUoch's " Malaria." 



INTERMITTENT FEVER. 255 

the south and south-west winds do the same harm, as the east wind in other coun- 
tries.* The east wind in summer is dry.^ Hence it has less conducting power; 
and thus, though we get ague from the Dutch ditches in springs" we do not get 
their remittent fevers of autumn. The east wind is so dry at that time, that it 
will not conduct the malaria; for a certain degree of moisture is as necessary for 
its conveyance, as for its production. 

To show the healthiness of the east wind, where it does not pass over a marshy- 
district, I may mention that it is the salutary breeze of the burning islands of West- 
ern America; while many parts of France, Germany, Poland, and Russia, never 
feel its injurious effects."^ Dr. Macculloch says,^ that although "the east wind, 
after sweeping the burning sands of Africa, makes the side of Sardinia which is 
exposed to it a desert, and in Minorca will not suffer an orange-leaf to protrude be- 
yond a garden-wall, it is before the east wind that Mount Edgcumbe roots its 
splendid trees even into the sea; — not daring to show a leaf to the ivestern ones; 
while in Southampton river it is precisely the reverse." 

The Harmattan. — The east wind, from its excessive heat and dryness, or from 
its coldness and moisture, may be injurious in other ways than in producing inter- 
mittent fever. The Harmattan^ will not produce ague; but it is excessively hot 
and dry,= and therefore an injurious wind. Again: all experience an unpleasant 
feeling from the east wind in spring; — not by its producing ague, but by its being 
excessively cold, and excessively moist. 

Elevated Situations exposed to the Influence of Malaria. — Distant parts suffer 
more if they be hilly than if flat; and frequendy the immediate neighbourhood ofa 
marsh will escape in some measure, while a village or a town at some distance, if 
it be situated on a hill, suffers exceedingly. This- fact seems to be capable of ex- 
planation, from the circumstance of hills attracting from the clouds their moisture, 
and every thing united with it. Malaria is conducted by moisture, and moves with 
the clouds; and the clouds, being attracted to the sides of a hill, deposit their mois- 
ture and every thing else they contain; and thus a hilly part may suffer much, 
although it is situated at a great distance from a marsh. I mentioned^ that the in- 
mates of the convent of Camaldoli, which is situated three miles from the lake 
Agnano, suffer from ague. It stands upon a high hill. At Malta, the malaria pro- 
duced under a cliff, never affects the spot itself; but produces direful consequences 
on a village situated above it.' At Weymouth (in our own country), it is said that 
" the back-water" rarely affects the immediate inhabitants; while those at a dis- 
tance suffer. At St. Austle, in Cornwall, the disease prevails from some marshes 
at St. Blaisey. At Erith there is less ague in general, than could be expected; but 
houses that are situated high above it, often suffer very severely. 

Influence of Currents. — Sometimes a distant part will suffer, not from clouds 
conveying the moisture, but from currents of air. The locality of a part may be 
such, that a current will proceed in some particular direction. If currents pass over 
a swamp, the part exposed to them will necessarily suffer; and if there be a pecu- 

^ See Page 321 of Dr. Macculloch's " Malaria." 

•^ h is burning and drv in the Sahara, and even in our own English July." — '^Malaria; by 
John Macculloch, MB.'' Page 336. 

^ See Dr. Alacculloch's "Malaria;" Page 331. 

d See Dr. Macculloch's " Malaria-," Pa^es 334 and 335. 
" « At Pages 334, 335, and 336 of his " Malaria." 

f A prevailing wind on the coast of Africa, between Cape Verd and Cape Lopez, in the 
months of December, January, and February. It is a particularly dry wind,— from passing 
over the burning deserts of Africa; so much so, that, inavery short lime, the leavesolplanls 
become dry and crisp, and the skin of human beings dry and chapped, the nose and lips 
sore, the fauces arid, and the perspiration acrid; yet it is not pestilential; bit, on ihecontraiy, 
puts an end to epidemic diseases,"— Z?r. Hooper's ''Medical Dictionary;" Seventh Edition; 
Article ''Harmattan.' 

e See Dr. Macculloch's "Malaria;" Pages 3-20 and 331. 

t See Page 253. 

' According to Dr. Macculloch, the malaria sometimes leads to the ab.mdonment of this 
village. For this circumstance, and for the facts staled in the text respecting Weymouth, 
Erith, St. Austle, and St. Blaisey, see Pages 242 and 243 of his " Malaria." 



256 INTERMITTENT FEVER. 

liarity in a current, it will affect a part which, a priori, would not be expected to 
suffer. Captain Smith, in his " Statistical Table of Sicily," mentions seventy-six 
unhealthy towns and villages; and, out of that number, thirty-five are situated on 
hills or declivities, and at a great distance from a marsh. When the wind blows 
from the south, being a warm wind, it has a tendency to ascend; and it is supposed 
that the southern wind — blowing over a marsh, and tending upwards by its tempe- 
rature — affects high towns; while the colder northern wind does not affect those 
houses situated on the other side of the swamps, though placed equally high.* We 
can easily conceive of a swamp, and towns on each side. When the wind blows 
south it will ascend, and high houses will suffer; whereas, if it blow north, it will 
not ascend to a house of the same elevation, but will remain near the earth; and in 
that way the house will suffer very little; or not at all. Hence we must take into 
account a number of circumstances, when ague prevails in districts, where there is 
no marsh in the immediate neighbourhood. 

Partial Influence, of Malaria in some Districts, — In the prevalence of this dis- 
ease, however, there are singularities, which cannot he explained: — at least many, 
perhaps, will not be satisfied with the explanation that is given. It is said, that on 
the high road to Chatham and Feversham, — comprising a distance of twenty miles, 
— the effect of malaria is only noticed on one side of the road.* The injurious 
lands which afford the malaria, are situated about a mile off; but it is only detached 
houses on one side of a level road, that suffer. It is to be remembered, however, 
that the dews will spread in a similar way; — that they will spread to a particular 
spot, or stop at a certain bush. Every one may notice the same circumstance, in 
the case of a hoar-frost. Now, as far as these will extend, so may malaria; and 
they will explain the singularity of such an occurrence, in some instances. Dr. 
Bancroft was credibly informed, that only one side of a particular street in Rome, 
was affected by ague or aguish diseases; and Baglivi says, that the healthy spots of 
Rome are separated from the unhealthy by a wonderfully short distance. A similar 
circumstance is observed in Cadiz; and in many American states. In the latter, 
however, the reason is perfectly evident; — some streets are exceedingly low; and 
are built in districts near which there is a quantity of stagnant water. 

Lower Strata of Mr generally Most Dangerous. — It is in consequence either 
of the weight of these pestiferous exhalations, or of their uniting with moisture, and 
producing their effect when the moisture is deposited, that the lowest spots are 
generally the most dangerous; and this also accounts for these exhalations being 
most dangerous at night; for it may be laid down as a general rule, that malaria is 
most dangerous in a low situation and in the night. It is on the ground, and near 
the lowest parts of a house, that moisture is deposited; and, that being the case, 
the exhalations of malaria will be let loose there; and what is lowest will suffer 
most. Again: in the night the cold is greater than in the day; and, from the cold 
being greater, moisture is deposited, and with the moisture malaria. Hence we 
liave, in general, a sufficient explanation for the two facts I have just stated. 

I could give you plenty of instances of the influence of difference in elevation, in 
causing a liability to ague. In the barracks of Spanish Town, Jamaica, there were 
three cases of fever in the lower story, for one in the upper.'' Sir Gilbert Blane 
says he was informed, by a medical man, that in 1781, at St. Lucia, one regiment, 
situated on the top of a hill, lost two hundred and seventy-one men, from intermit- 
tent and remittent fever; another regiment, on the sides of the hill, lost three hun- 
dred and eighteen; and a third, which stayed at the bottom of the hill, lost four 
hundred and eighty-six. The hill was called " Morne Fortune;" and was situated 
eight hundred and seventy-two feet above the level of the sea. At Walcheren, the 
natives knew that those who slept in the upper stories, were far less liable to disease 
than those in the lower; and that if they caught ague, it was much milder. Sir 

* See Dr. Macculloch's " Malaria;" Page 244. 

*» The ague is unknown on the right side. — '^Malaria; by John Macculloch, M.D.'^ Page 
261. 

e See Dr. Macculloch's " Malaria;" Page 265, 



INTERMITTENT FEVER. 257 

Gilbert Blane also says he was informed, by Dr. Ferguson, that at St. Dominffo 
iwo-lbirds more were taken ill on the ground floor than on the upper floor. In 
Italy the difference is so great, thai an erect is known to be more safe, than a sitting 
or a lying posture. Although this is a general rule, however, yet there are excep- 
tions to it. In some parts of Norfolk, danger is confined to the upper stories;* but 
in those places there must be a particular current, which wafts the malaria in that 
direction. 

iMalaria mo st potent at Night. — The great danger of night is always strikingly 
illustrated. Dr. Lind says" that, in 1766, when the ship Phoenix lay at anchor for 
tweniy-seven days at Si. Thomas's, two hundred and eighty men, constituting 
nearly all the ship's company, went on shore, in parties of twenty or thirty, and 
rambled about the island; but none of those who did not remain on shore at night 
suffered; while none of those who slept on shore escaped sickness, and only three 
survived. Dr. Lind mentions" that, at Batavia, a boat belonging to "the Medway," 
was actually manned three times; — every one having perished; and simply from 
the men having to attend duly on shore, every night. It is found, that a cold night 
after a hot day is much the worst. During tlie heat of the day, there is more dis- 
engagement of malaria; and consequently, when night comes on, there is far more 
to be precipitated. Cold and wet are always most operative after heat. It is 
thought by some, that in Italy evening is more dangerous than night; and that 
there is no hazard after nine or ten at night. If this be a fact, I presume it arises 
from the whole quantity of malaria being by that time deposited.* The efTect of 
night, however, must be ascribed in some measure to m re sleep. It is right to 
take every thing into consideration; and all morbid causes act more powerfully in 
sleep, than in the waking state.® Sleeping on damp ground at night is injurious; 
not merely because the person has lain upon the ground, nor simply because he 
has lain there during the night; but because he has lain on the lowest spot, at a 
time when there is more malaria than in the daytime, and when the body is less 
capable of resisting it than in the day. 

Malaria Precipitated with Rain. — Lind*" and Mungo Park^ were convinced, 
that malaria was precipitated wiih the rain; and in this way they noticed, fre- 
quenUy, that rain was unhealthy. Park says that, on one occasion, the rain had 
not begun more than three minutes, before many soldiers seemed drunk, and fell 
asleep; while others vomited; and he mentions that, in a storm, he himself felt 
disposed to sleep; and could not help it, although he was on damp, and therefore 
dangerous ground. Dr. Lind says,^ that the most unhealthy rains in Guinea, are 
those which occur first in the wet season; (which looks as if malaria were pre- 
cipitated in the rain;) that in forty-eight hours, the rain rotted their shoes; and 

=^ See Dr. Macculloch's "Malaria;" Page 266. 

^ in his "Essay ou Diseases incidejital to Europeans in Hot Climates;" Part 2; Chapter 
2; Section 5. (Second Ediiion; Pages 235 to 239.) 

° In his " Essay on Diseases incidental to Europeans in Hot Climates," Part 1; Chapter 
4; Section 3. (Second Edition; Page 148.) The circumstance occurred in the year 1764; 
as will be seen by referring to the Essay just mentioned; Part 1; Chapter 3; Section 3. 
(Second Edition; Page 98.) 

^ See Dr. Macculloch's "Malaria;" Pages 277 and 278. 

« See Dr. Macculloch's " Malaria;" Pages 280 and 281. 

^ Lindsays that, even in England, a rainy season will produce remittents and intermit- 
tents, in the healthiest districts, or where malaria is unknown. — ^^ Malaria; by John Mac- 
culloch, M.D ;" Page 277. 

s Respecting the production of remittent fever, there is an assertion in which there may 
(or rather 7nusl) be a fallacy involved. According to the testimony of African travellers, 
and of Park in particular, it is produced immediatelv on the fall of rains;— as if the mere 
contact of the rain itself was the cause.—" Malaria; bi/ John Macculloch, M.D." Page 158. 

•> In his " Essay on the Diseases incidental to Europeans in Hot Climates;" Part 1; Chap- 
ter 2; Section 2. (Second Ediiion; Page 47 and 48.) The following additional particulars 
are there recorded:— " They (the first rains) stain clothes more than other rains; and, soon 
after their commencement, the ground, even in places formerly dry and parched, swarms 
with frogs. At this time, skins quickly generate large worms; and it is remarked thai ihe 
fowls, which greedily prey on other insects, refuse to feed on these." 
VOL. I. — 17 



258 INTERMITTENT FEVER. 

that when the clothes they had on were liung np to dry in the snn, they became, in 
a few hours, full of maggots; — showing, probably, that much injurious matter was 
contained in the moisture, and deposited with the rain. As the rain falls more and 
more, there is generally less and less unhealthiness. This may be ascribed to two 
circumstances; — in the first place, to the quantity of malaria deposited by the first 
rain; and, secondly, to the continued rain which falls upon the earth; — producing 
so much moisture, that vegetable decomposition will not so easily go on. Hence, 
again, disease increases when the moisture declines. 

The power of moisture to dissolve these exhalations, is rendered exceedingly 
probable from the fact, that a stench arises from pools and privies in damp weather. 
Every thing that affords an offensive smell, becomes worse in wet weather; and 
therefore the exhalations that produce ague, will also probably rise far more in wet 
weather than in dry. The effect of moisture is sufficiently seen in the increase of 
illness. 

Does Sea-Water prevent Malaria? — It has been well thought, by some, that a 
mixture of salt water with fresh prevents this injurious decomposition.* However, 
this is a mistake; for salt marshes, which are principally situated in the south, will 
give rise to ague in summer. For instance: around the Dol, in Normandy, where 
there is a salt marsh, scarcely an inhabitant escapes ague.* Very often there is a 
severe intermittent fever in Holland, after an inundation of the sea; and even when 
a place is well washed, — as Heron Bay, for instance, and the district around 
Reculver,'' — aguish fevers frequently prevail.*^ On the other hand, it has been con- 
tended,* that a certain portion of sea-water augments the prevalence of this miasma. 
This would be not at all to be wondered at; because it is a mere hypothesis that salt 
water prevents it. Sea-weed, being vegetable matter, has actually been the source 
of fevers of this description. 

Influence of Different Plants and Soils in the Production of Malaria. — It is 
very probable that certain plants, and certain soils, are more favourable to the pro- 
duction of malaria than others; for sometimes there is malaria in spots where we 
should not suspect it; — where the grass looks fresh and green; and where no signs 
of decomposition are observed; whereas, in other parts, where there is a degree of 
decomposition, persons are perfectly safe. A friend of mine, who was travelling 
in Syria, saw a spot of grass fresh and green, though rather moist; and he intended 
to pitch his tent there for the night. But he was warned by some of the people of 
the country; who rode in haste to him; and implored him, as he valued his life and 
the lives of his retinue, not to pitch his tent there. He could not conceive why; 
and they told him that whoever remained on that spot at night, was sure to be 
seized with severe fever. There was nothing in the appearance of the grass, that 
could lead him to suspect any thing of the kind; but, of couise, the lower portions 
were constantly dying and decomposing. It is, as I have just said, the opinion of 
many, that certain soils, and certain varieties of vegetable matter, are peculiarly 
favourable to the production of this malaria. Such would appear to be the fact, and 
very possibly is so; but whether this is to be attributed to the nature of the soil, or 
to the existence of certain plants, rather thrui of others, I do not know. Some 
believe, that the different kinds of ague arise from a difference in the vegetable 
matter. It is said, for instance, that tertians particularly prevail in Germany; that 
in Italy quotidians are most frequently seen; that in Hungary fevers of this descrip- 
tion are particularly attended with petechias; and the exhalations of the Pontine 
marshes, are said to produce fevers with short intermissions. Holland is remarkable 
for producing all sorts of fever; — quotidians, tertians, quartans, and every other 
variety. In Spain, Africa, and America, these fevers are remarkable for being 

» It is a common popular conviction, that salt marshes are innocent.—" Malaria; by John 
Macculloch, M.D.;" Page 35. 

*> See Page 36 of Dr. Macculloch 's " Malaria.", 

« Near Mar°;ate. 

d See Page 39 of Dr. Macculloch's " Malaria." 

e By many French and Italian writers, alluded to by Dr. Macculloch, at Page 37 of his 
" Malaria." 



INTERMITTENT FEVER. 259 

attended with black vomit, and with yellowness of the skin. In some parts of Italy, 
these fevers are particularly attended by apoplexy; and in many parts they are 
particularly followed, or accompanied, by neuralgia. In India and Africa, the 
liver chiefly suffers; at Walcheren the spleen. Even parts not distant from each 
other, are sometimes thus distinguished.* It thus appears that there are many 
peculiarities, according to situation; but whether this is to be explained by a variety 
in the malaria, I do not know. 

Peat-Bog. — There is one description of bog, which does not produce malaria; 
— namely, peat-bog. But here there is no putrefaction; — decomposition having 
taken place in a peculiar manner, 'i'he vegetable matter becomes carbonized; and 
there is not sufficient heat for putrefaction to occur. But it is said that peat-moss, 
when in a certain latimde and on a certain level, can putrefy; and then, I believe, 
ague does prevail. That peat-bog does not putrefy, is shown by a fact stated on 
good authority; namely, that animal matter thrown into it will not putrefy; but it 
is said that where peat-moss is placed in situations where it is warmer, and upon a 
proper level for moisture, it will putrefy and produce ague; — just as other kinds of 
vegetable matter will do.*" 

Jlnimal Matter does not produce Malaria. — Now that it is vegetable, and not 
nnimal matter, which produces ague, is proved by this circumstance; — that no 
person has this disease from being exposed to the most intense animal exhalations. 
Thousands of carcases are annually employed in many manufactories; as, for ex- 
ample, in manufactories of sal ammoniac; and yet no person is known to contract 
an ague from them. Indeed, so far from it, that the most crowded places generally- 
escape intermittent fevers. That part of Rome inhabited by the Jews, and called 
*' the Judaicum,^^ is full of animal filth; but it escapes ague; while the elegant 
streets in the neighbourhood, suffer from it very severely." 

Influence of Fire and Smoke in preventing Ague. — Fire and smoke (especialjy 
tobacco-smoke) appear to keep away ague."* Malaria not being the produce of 
dead animal matter, or effluvia arising from living bodies, but of vegetable exha- 
lations, the more rnen and animals are crowded together, the less access is there 
for the malaria; and it is generally supposed that the addition of smoke, of every 
description, has a great tendency to prevent it; and therefore those who live in the 
most smoky, crowded, dirty places, are situated in the most favourable manner 
with respect to ague. It was once imagined, however, that the smoke of coal was 
particularly injurious; and therefore it was made a capital offence to burn coal in 
London; and forges were only allowed in the vicinity. Sir Gdbert Blane mentions 
that, in the Tower, there is a document relating to a person who was executed in 
the time of Edward the First, for burning coal in London;^ though it has since 
been considered to be a great promoter of health. Perhaps smoke — whether of 
coal, of wood, or of tobacco — may act by merely taking the place of the exhala- 
tions, and preventing them more or less from entering. It may be, however, that 
they act by their warmth. Napoleon, when with his army in Italy, was in the 
habit of employing fires, to a great extent, to keep away malaria; and he did it 
with great success.' But here the heat must have been useful, by dissipating 
moisture and cold. Dr. Lind mentions, ^ that when the Edgar ship of war was off 
the coast of Guinea, in 1765, the crew were very sickly, and many of them died 
from fevers of this description; but in the crew of a sloop of war which always 
accompanied her, very few were ill, and none died. In the latter there was a fire 

'^ See Dr. Macciilloch's "Malaria;" Pages 425 and 426. 

''Dr. MaccuUoch has entered into this question respecting peat, in his " Malaria;" Pages 
61 to 66. 

"= See Dr. MaccuIIoch's "Malaria;" Page 292. 

d See Dr. MaccuIIoch's «' Malaria;" Page 281. 

« This is mentioned by Sir Gilbert Blane on the authority of Mr. Astle, Keeper of the Re- 
cords in the Tower, in the fourth volume of the Medico-Chirurgical Transactions, Page 101. 

f See Dr. MaccuIIoch's " Malaria;" Page 286. 

6 At Page 150 (Second Edition) of his " Essay on Diseases incidental to Europeans in Hot 
Climates." (Parti; Chapter 4; Sections.) 



260 INTERMITTENT PEVER. 

for conking, on the same deck where the men lay, and which filled with smoke the 
spot where they slept, whereas in the Edgar, from the particular arrangement of 
the vessel, there was no smoke whatever between the decks. Here were two ships 
otf a country which afforded a vast quantity of malaria. 'J'he crew of the one 
remained healthy; and that of the other became diseased, in the way 1 have stated; 
although the only difference between them was, that in the former the part where 
the men slept was constandy, or almost constanUy, filled with smoke. 

Jigue not Contagious. — It appears quite certain, that intermittent and remittent 
fevers are not contagious; though formerly ague was considered to be so. Dr. 
Fordyce, who was almost one of our own day, says (both from his own know- 
ledge, and a reference to the opinion of others) that ague is contagious. Dr. Cleg- 
horn, in his work on the Diseases of Minorca,* says the same. Dr. Wells, a col- 
league of Dr. Fordyc€ at St. Thomas's Hospital, accounts for the opinions of the 
latter by remarking, that he (Dr. Fordyce) fancied, that continued and intermittent 
fevers were mere varieties of the same disease; and as it appeared, in those days, 
that continued fever was contagious, so he was obliged to maintain that ague was 
contagious. Dr. Cleghorn's mistake is supposed to have arisen from his having 
observed, that most of those who were about the sick, in Minorca, had the disease; 
— forgetting that it did not arise in consequence of emanations from the sick, but 
from the situation in which they were placed. It is no proof whatever that a dis- 
ease is contagious, that it is caught from going to see a person labouring under it; 
for he may be in the very spot where he contracted it, from local circumstances; 
and in going to him, we go to the spot which has given him the disease; and which 
may therefore give it to us. In order to prove that a disease is contagious, there 
should be a sufficient number of instances of persons going from the place where 
they contracted the disease, to a healthy part; and there giving it to others. There 
is no reason whatever to suppose that agues are contagious; though, formerly, not 
only were ttiey supposed to be contagious, but even scurvy was also pronounced to 
be communicable to others.'' 

Chemical and Physical Qualities of Malaria, — The chemical nature of malaria, 
or raarsh-miasraata, is unknown. It is not carburetted hydrogen; and no known 
chemical substance has the same effect. The air of marshes is said not to differ 
chemically from the air of any other part, with respect to its quantity of oxygen. 
There is no reason to suppose that it is a deficiency of oxygen, or an excess of 
carbon, or the presence of carburetted hydrogen, that renders the air pestiferous in 
this ease.'' It is said by De Lisle, that malaria has no smell. Thus much, however, 
is known; — these exhalations may be suspended by aqueous vapour. Indeed, it is 
said that they never rise but with some lighter body; — that they require to become 
so suspended, in order to rise at all. Being, however, suspended by aqueous va- 
pour, they are even more deleterious than contagions; for, like contagion, a moment- 
pry application is sufficient, in many cases, to produce the disease; and, unlike 
contagion, they may be wafted, and produce their effect at a very great distance; 
whereas contagion spreads but a very short way, and after a certain distance is 
destroyed. Malaria, like other gaseous bodies, very easily finds a barrier; so that, 

a *' Observations on the Epidemical Diseases of Minorca, from the year 1744 to 1749, by 
George Cleghorn, M. D." 

b Dr. Brown ("Cyclopaedia of Practical Medicine"), from the result of cases which have 
fallen under his ob^^ervalion, still entertains a suspicion of its contagious nature; and, in 
confirmation of this opinion, he adduces the following case, related by Bailly: — "A lady 
arrived in Paris with an inlermittenl fever, which she had contracted in the country, in a 
marshy situation. This fever v^^as accompanied by violent vomitings, and other serious 
symptoms; which displayed themselves at every paroxysm, and forced me to give bark. 
Scarcely was she cured, when her husband, who had 7iever quitted Paris, but who had had 
the imprudence not to keep himself apart from her during her illness, was struck with the 
same symptoms, and in a manner altogether similar." 

c The accused gases have been carbonic acid, azote, hydro-carburetted gas, hydro-phos- 
phureited gas, hydro-sulphuretted gas, and even ammonia; — to say nothing of a yet undis- 
covered compound of azote and oxygen, called *' septon." — " Malaria; by John Macculloch, 
M. D." Page 421. 



INTERMITTENT FEVER. 261 

in Italy, a gauze veil is said to be efficacious in preventing its effects upon the hu- 
man body.* On this point I can only repeat what I have read. 

[Many attempts have been made to arrive at a knowledge of the physical quali- 
ties of this agent. Moschati and Broschi examined the atmosphere — the former 
of some very insalubrious rice-fields, the latter of an unhealthy spot in the papal 
states; from which examination it appeared, that the vitiated air contained albumin- 
ous flocculi, somewhat viscid in appearance, but the nature of which was not un- 
derstood; and that it possessed a certain weight; — as it did not appear to rise in the 
atmosphere, unless mingled with it by currents of air. All that is valuable on the 
constitution of the atmosphere of those places where ague is prevalent, may be 
summed up from the results of the extensive investigations made by M. Julia: — 
1. The air of these several situations contains the same principles, and in the same 
proportions, as the purest air of the most healthy situations. 2. Marsli-air contains 
a principle which eludes the test of the most delicate chemical reagents. S. Though 
the nature of the noxious vapour is unknown, there is reason to believe that its 
pernicious effects depend on a form of vegetable and animal substance in a state of 
decay, or on a solution of these substances in air, or on the gases resulting from 
their decomposition. 4. Experiment has not yet demonstrated in marsh-air the 
existence of azotic gas, carburetted hydrogen, ammoniacal gas, or any of the gaseous 
products of decomposition; and if they are present in this vapour, their quantity is 
too small to be appreciated. Whatever its constitution or essence may be, it at 
any rate appears evident, that in order to its production there must be present a 
certain quantity of moisture, vegetable or animal matter in a partial state of decom- 
position, and a degree of temperature which cannot be termed "cold;" for we 
see that it prevails in districts where such conditions obtain: — in the extended 
estuaries of rivers; in swamps which pass, under the exhaling influence of the sun, 
into a comparative state of dryness; on the banks of rivers subject to floodings; 
and on low, flat sea-shores.^] 

Period of Incubation. — If these exhalations be very strong, they may kill in- 
stantly. Many allow that fever may begin in half an hour after exposure. Occa- 
sionally the exhalations have been so intense, that labourers, in France and Italy, 
in breaking up the ground, have died on the spot. Other persons have been seized 
with giddiness, and some have even died on looking into a ditch, or a drain, around 
which aguish fevers prevailed. Persons who have been scarcely exposed to the 
deleterious exhalations, have been immediately seized with vertigo, vomiting, and 
gyncope; and from that moment have had regular intermittent, or remittent fever. 
But usually their effect does not occur till a certain period has elapsed. In South 
Carolina it is said, that eight or ten days is the sliortest time which elapses, between 
exposure and the appearance of tlie disease. The reason for so long an interval 
may be, that there is less heat there than in many other parts. Dr. Wells believes, 
that the autumnal agues of that country do not appear till spring; — that is to sav, 
the agues seen in spring, are the result of exposure in the precedmg autumn. He 
founds his opinion on the fact, that strangers visit South Carolina in the spring, 
with perfect impunity. Dr. Lind mentions having seen these fevers take place the 
very morning after exposure. Dr. Bancroft gives an instance of the disease occur- 
ring instantly; and then other cases, which did not lake place for many (even for 
nine) months. Dr. Bancroft likewise ascribes the agues of spring to the previous 
autumn; because he has seen pei'sons seized with ague, after they have returned to 
England from a warmer climate, where they had been exposed to miasmata; and 
they have experienced the disease at too early a period in the year, for it to have 
arisen from malaria at home. Probably, the earliness of the period at which ague 
occurs, is in proportion to the intensity of the heat, and to the qtiantity of moi^t 
vegetable matter. It is certainly very common, in England, for harvesters who have 
worked in aguish districts, and have been exposed to the exhalations in autumn, 

* Dr. Macculloch's "Malaria," Page 299. 

•» "Library of Medicine;" Volume 1; Page 233. 



262 INTERMITTENT FEVER. 

not to be affected till the east wind blows, in the following spring. I have seen 
very many cases of persons, who have left an aguisli part in perfect health, and 
have remained so for some time, — even for months; when by chance getting wet 
through, or being exposed to a cold damp wind, they have been seized with ague. 
Dr. Macculloch doubts these long intervals;* but 1 have seen them in too many 
instances, to entertain the least doubt whatever. 

Insusceptibility from Long Exposure. — By habit, persons become rather in- 
susceptible of the effects of these exhalations; by habit, they cease to have ague 
when exposed to malaria; or, if they do have it, it assumes a very mild character. 
This is very commonly observed, in what are called "^ i\\e pernicious districts" of 
Italy, France, and Sicily; in which districts those persons, chiefly, are susceptible 
of its operation, in whom glandular disease has been induced. To show the effects 
of habit, I may mention, that General Monnet (a French officer) found that, in a 
malarious situation in Walcheren, there was only one-half the sickness in a regiment 
during the second year, that there had been during the first; and that during the 
third year his men remained at the place, there was no sickness whatever. The 
inhabitants of one marshy district, when they go to another, suffer less than 
strangers; — less than persons who go to a marshy district, from a place that was 
perfectly healthy. A physician* in my parish" used to relate a story, from his own 
knowledge, of a party going up the Thames; of which party only one lady caught 
an ague. She had always lived in Edinburgh; — a high, dry, healthy spot; while 
all the rest of the party were inhabitants of a malarious place. 

Yet many persons, who have not been previously exposed to malaria, escape it 
as well as the Dutch, who have been accustomed to it. The Dutch, who live in 
the midst of it, will not allow it to be unhealthy; — exactly as a person of filthy 
habits, believes himself to be as clean as is necessary. Persons, although well- 
informed on these matters, will frequently, when they come to an unhealthy place, 
be obstinate, and act the part of mules; and many such have suffered for it. We 
find it stated in Captain Clapperton's "Travels,"** that the Captain himself, Mr. 
Pearce, Dr. Morrison, and Mr. Houlton (a surgeon), while on an expedition in 
Africa, lay all night on the banks of a creek, when there was no occasion for it; 
and the next night they lay in a market-place, though there were houses enough 
for them to have entered. The following day. Captain Clapperton was seized 
with fever; Dr. Morrison was seized in two days more; Captain Pearce the next 
day. Lander, their servant, was seized next; Mr. Pearce and Dr. Morrison died 
soon; and Mr. Houlton and Captain Clapperton died ultimately. They were all 
warned of the dangers of thus exposing themselves. Every day affords instances 
of this awful obstinacy; — this total disregard of human life. Because the Dutch are 
obliged to have dykes and ditches in their own country, they have surrounded 
themselves with them, where there is not the least occasion, in the East Indies;*-— 
merely, I suppose, to be like their brother frogs at home. 

But it is said, that one unhealthy place does not, by any means, always give 
indemnity to an individual who goes to another; and that a place to season an in- 
dividual perfectly for another, must be situated between the tropics, and not have a 
cold winter. It is found, for example, that Gibraltar will not season a person for 
the West Indies; but then Gibraltar is not situated beiween the tropics. Such a 
seasoning as would render a person altogether insusoeptihle of the disease, can only 
be obtained between the tropics; where we can conceive malaria to be produced in 

» I know not if physicians have fairly observed, that it may ba later than twentv-four 
hours from the exposure lo the cause. — ^^ Essay on Remittent and Intermittent Diseases; by 
John Macculloch, M. /)." Volume 1; Page 237. 

*> Dr. James, father of G. P. R.James, Esq., the Novelist. 

c Hanover Square, London. 

^ "Journal of a Second Expediiion into the Interior of Africa; from the Bio^ht of Benin, 
to Soccatoo, By the latter Commander Clapperton, R. N. To which is added the Journal 
of Ricliard Lander." 

e See Lind's " Essay on Diseases incidental to Europeans in Hot Climates;" Part 1; Chap- 
ter 3; Section 3. (Second Edition; Page 96.) 



INTERMITTENT FEVER. 263 

the most intense degree. It is also to be remembered, that when a person has once 
had ague, he is very liable to a return of it fiom a slight cause; — such as from the 
blowing of a cold, wet, east wind; or from getting wet through; or from being, in 
any way, thrown out of health. He is rendered liable to have the disease renewed 
from slight causes; but altogether he is much less sensible to the influence of 
malaria. 

Evil Effects of Malaria on the General Health. — Whether persons, however, 
have had ague or not, if they be constandy exposed to malaria, the constitution is 
impaired. They acquire a dull heavy h)ok, and are bloated, or they are emaciated, 
shrivelled, pale, sallow, and weak. Sir Gilhert Blane says, that the people residing 
at Walcheren were far less subject to aguish affections, than strangers; but that they 
all looked sickly. Yet these Dutchmen would not allow that their climate could 
be unhealthy; and when they saw one-half of the English sick, through their 
noxious climate, tiiey would not allow that it arose from the filthy ditches; but 
ascribed it to errors of diet, and the bad habits of the English. The liver and spleen 
are much disposed to become diseased; and dropsy to supervene. In the worst 
valleys of Switzerland, poor persons are shrivelled; young persons look old; and 
middle-aged persons appear in the greatest state of decrepitude. In these valleys, 
there is always a great quantity of malaria pent up. Indeed, so great is the injury 
produced by malaria, that whereas the average of human life in England is fifty 
years, in Holland it is only twenty-five. In some parts of France, which are very 
pestiferous through the malaria, the greatest average age is twenty-two; while in 
some it is only twenty and eighteen;"" and in others it is only ten. In some parts 
of Africa, and the East and West Indies, the averaofe is as low as this. 

[The following passage from Dr. Macculloch's book on Malaria, depicts in fearful 
colours the efTects of malaria on the physical, moral, and intellectual qualities of the 
body: — 

*' There is nothing in these pernicious countries more striking to a cursory 
traveller, than the appearance of age which occurs at a very early period of life. 
Even the children are frequendy wrinkled; and, in France, in perhaps all the worst 
districts, a young woman, almost even before twenty, has the aspect of fifty; while, 
in men, the age of forty is equivalent to sixty in healthier countries, — both in ap- 
pearance and vigour; — the very few who live to fifty, appearing to have arrived at 
the protracted term of fourscore. Of personal beauty in females, there appears to 
be little trace at any time; but whatever may have existed is rarely prolonged 
beyond seventeen. And the expression of countenance keeps pace with all else; — 
being that of unhappii^ess, stupidity, and apathy: an habitual melancholy which 
nothing can rouse, and an insensibility to almost every thing which operates on the 
feelings of mankind in general. A slow and languid speech, a similar languor in 
the walk and in all the actions, indicate equally the condition of the mind and of 
the body, in these wretched countries. 

"The condition of the mental faculties, whether intellectual or moral, is scarcely 
less remarkable, while it is more interesting; and if there should appear any ex- 
aggeration as to some particulars, or should any special fact, as asserted, depend on 
collateral causes of another nature, the general bearinor of the whole, as related of 
Italy and France, has been confirmed too often by remarks of a similar nature, made 
in America and elsewhere by very competent observers, to leave any doubt as to 
the leading circumstances. 

"That apathy which was just noticed as expressed in the physiognomy, is a 
character which influences the whole conduct of these degraded and unfortunate 
beings; — often proceeding to such a decree, that they are scarcely elevated above 
the beasts, in point of feeling. Seeking solitude, shunning society and amusements 
alike, without affections, without interest in any thing, they make no exertions to 
better their condition; — not even to avoid the sources of danger which surround 
them, or to take die most common precautions that are pointed out; while, attached 

• See Dr. MaccuUoch's " iVlalariaj" Page G. 



264 INTERMITTENT FEVER. 

to the soil (from habit or indolence rather than from regard), they will not be con- 
vinced of its nature or dangers; — fatalists in practice, and even in belief; and 
refusing to admit that there is any other lot in life than that which is their own. 

"That the general intellectual facuhies are degraded, is a universal remark; 
while, in many places, and very notedly in the Maremma of Tuscany, it is ob- 
served that absolute idiotism is common. This circumstance might naturally be 
expected, from physiological considerations connected with the general influence 
which malaria exerts on the body. And that this condition is even propagated, 
seems fully proved; — so that a universal degeneracy of both mind and body, appears 
to be the certain lot of those races, which a combination of unfortunate circumstances 
has placed in countries, that seem to have been intended rather for the habitations 
of reptiles and insects, than for those of man."*] 

Effects the Lojoer Jinimals. — It is said that, in very unhealthy places, even brutes 
are known to sutfer.'' Dr. Macculloch says he heard that a dog, at Guernsey, had 
a tertian ague;'' but whether this is correct, I will not pretend to say. He adds** 
that epizootic^ diseases frequendy prevail at the same time with marsh-fevers; and 
that, in St. Domingo, the dogs are always the first affected.' 

Malaria is the constant scourge of the earth; — not the occasional, but the fon- 
stant scourge. It produces not only fevers, but (very frequently) dysentery,* 
cholera,^ and sometimes neuralgia;'' and it causes an intermittent or remittent cha- 
racter to be given to other diseases. Even when it causes no positive disease, it 
undermines the health. Malaria abounds to a frightful extent in Greece, Italy, 
France, America, Asia, and Africa.* We know nothing of it here, compared with 
the violence of its ravages in those parts. 

Extent of its Ravages in England. — It was once far more injurious in this 
country than it is now; but, from the energy and industry of the English character, 
such extraordinary improvements have been made in every thing to promote the 
well-being of man, that nothing abroad can be compared with our advantages. 
Southwark was once an entire swamp; and at Westminster there is a toll-gate, 
called the " Marsh-Gate;" — from being situated in a place where formerly (and 
not very long ago) there was a marsh. From the improvements that have been 
made, however, ajjue is now comparatively rare in London. It prevailed to a great 
extent before the fire of London, in 1666; but from that time the place was better 
drained; — so that the fire did good. Before the fire, ague raged like a plague. 
Between 1667 and 1692, no less than two thousand persons died in London of 
dysentery;^ — arising, no doubt, from the same cause as ague. So great, however, 
has been the reduction, that in 1728 there were only forty-lour deaths from ague; 
in 1730, ordy sixteen; and in the bills of mortality for the first ten years of the 
present century, there are recorded only four deaths from ague. Witliin the last 
five or six years, agues have increased through the country, and in London; and 
this may be easily explained. They have not increased to what they were for- 
merly; but still there has been an increase. Sydenham says that they disappeared 
in London from 1674 to 1678; and they disappeared in Plymouth (Huxham says^) 

=» " Malaria; by John Macculloch, M. D." Pages 432 to 435. 

^ See Dr. Macculloch's "Malaria;" Page 454. 

« The animal whs submiiled, for examinaiioo, to the surgeons of Guernsey; and, as the 
disease continued for some years, — the cold paroxysm always takingr place at three o'clock", 
— there was ample opportunity of verification. — " Mzlaria; by John Macculloch^ M. £)." 
Pages A&d andi^l. 

^ At Page 455 of his " Malaria;" — quoting the opinion from Lancisi, Bailly, and others. 

* From sTTi, upon; and ^-.ov, an animal. 

' See Page 460 of his " Malaria." 

K See Dr. Macculloch's " Marsh-Fever and Neuralgia;" Volume 1; Chapter 5; Pages 
216 to 234. 

h The whole of the Second Volume of Dr. Macculloch's "Marsh-Fever and Neuralgia," 
is devoted to a consideration of Neuralgia in general, and iis different varieties. 

' See Page 36 of Dr. Macculloch's " Malaria." 

k See Dr. Macculloch's " Malaria;" Page 128. 

> " Observationes de Aere el Morbis EpidemicisPlymuthi factse." (" Observations, made 
at Plymouth, on Air and Epidemic Diseases.") 



INTERMITTENT FEVER. 265 

from 1755 to 1760. They were absent from Portsmouth for three or four Tears. 
They returned again in London epidemically in 1751, 1753, and 1754. Sydenham 
says that they returned again from 1677 to 1688; and they also prevaded at the 
beginninor of the last century. These are all accidental occurrences. It has been 
said by Dr. M'Michael, of the Middlesex Hospital, that durijig the few years that 
ag-ue prevailed so much, the average heat was greater than wlien it disappeared. 
The heat being greater, of course there was more vegetable decomposition. To 
show the increase of late, I may mention that in 1823 1 had but eight cases of 
ague; in 1824, I had fourteen cases: in 1825, fifteen cases; in 1826, forty-four 
cases; in 1827, fifty-three cases. The number then declined; so that in 1828 I 
had twenty-seven cases; and in 1829 I had only eight. If we had accurate ac- 
counts, we should perhaps find that when ague increased in former times, the 
average heat was higher than usual; — ^just as it has been observed to be by Dr. 
M'Michael, during the last few years that ague has become prevalent again. 

// gives to Other Diseases an Intermittent Type. — Persons who have once had 
ague, or who have it upon them, are much disposed to exhibit a more or less aguish 
form of any other disease under which they may hibour; — that is to say, when a 
])erson is the subject of ague, it is very common for diseases to become more or 
less intermittent; and this is especially noticed in aguish countries. Rheumatism, 
ophthalmia, vomiting, and purging, may all be intermittent, and even periodical. 
However, it is quite certain that, independently of malaria, many diseases will 
become intermittent. Insanity is sometimes intermittent. I have seen a person 
mad once a-year, or once in three years. Palsy is likewise occasionally intermit- 
tent; and in one case I saw it periodical. It came at a particular hour in the day; 
but the patient had had ague, many years before. Dr. Macculloch, however, 
ascribes a vast number of diseases to malaria;* but I think there cannot be a doubt 
in any one's mind but his own, that he has carried his ideas to an extravagant pitch. 
He has done great good by attracting the attention of persons to malaria, more 
than it was before; and his writings are very powerful and learned; but I think no 
one can read his publications without perceiving, that he had one idea constantly 
before him." That idea was ma/aria; and he ascribes infinitely more to it than 
reason can justify. But although I am satisfied of the extravagant length to which 
he pursues his ideas, yet I am equally satisfied that too often we do not ascribe 
diseases to malaria, when they really arise from that source. We frequently meet 
with sporadic cases even of ague, which cannot be easily traced to malaria; but I 
have no doubt that, if we could ascertain all the circumstances, we should find that 
the individual has a striking tendency to it; and has been exposed to malaria by 
passing through a market, or some other place, in which there was vegetable mat- 
ter in a state of decay. It is also to be remembered, that though the influence of 
malaria is so great, yet cold and wet, and other causes of debility, will induce 
ague, without the reapplication of malaria, when a person has once had it. Some- 
times, too, when malaria has been applied, the disease does not occur till such 
circumstances as these have taken place. I mentioned,'' in my introductory re- 

^ •These diseases are ague, dysentery, cholera, headache, vertigo, tic-doiiloureux, rheuma- 
tism of ihe face, neuralgic ophthalmia, neuralgic affections of all parts of the body, dyspep- 
sia, and derangements of the liver and spleen. See Dr. Macculloch's Volumes on " Marsh- 
Fever and Neuralgia;" and Chapter 10 of his " Malaria;" (Pages 419 to 427). At the end 
of the former work, there is a systematically arranged table of the various diseases said to 
be produced by the poison in question. 

^ If the sword has slain its thousands, malaria has slain its tens of thousands. It is dis- 
ease, not the tield of action, which digs the grave of armies; it is malaria by which the 
burning spirit, fitted for belter things, is quenched, and in the coward's bed of death. This 
is the destroying angel, — the real pestilence which walks at noonday; and to which all the 
other causes of mortality are but as feeble auxiliaries in the work of destruction. This is 
malaria; — the neglected subject to which I am desirous of calling attention; in order that, 
by this attention, its powers may be diminished: malaria, from which even ourselves, here 
in England, are not free; though, from ignorance, unaware of it; or, from unwillingness to 
receive conviction, shutting oiar eyes to the ln\ih.—" Malaria; by John Macculloch, M. D." 
Pages 8 and 9. 

« See Page 45. 



^66 INTERMITTENT FEVER. 

marks, that the predisposing will sometimes become the exciting cause. The 
exciting cause of ague is (unquestionably) malaria; but sometimes it will only act 
as a predisposing cause; for it will lie dormant in the system till the person gets 
wet through; — in which case the latter is really the exciting cause. From all the 
circumstances, I am convinced that many cases are aguish, where there is no sus- 
picion of their true nature. 

^ c. Proximate Cause, 

The proximate cause of ague — the real essence of that state which is always 
present when the symptoms occur — is unknown. We can say, with certainty, 
that it is a peculiar state; for a person, in the intermission of ague, is perfectly 
well. There is frequently no disease to be found, whether inflammatory or other- 
wise, of any particular organ. Again: ague frequently cannot be removed by anti- 
phlogistic measures; though occasionally it certainly may; as well as by any thing, 
in fact, which makes an impression on the system. Again: inflammatory diseases 
are not cured by sulphate of quinine, and remedies of that description. The dis- 
ease may be inflammatory, and often is so; and requires antiphlogistic measures; 
but its essence is not inflammatory; — at least, I know no proof of it. It may be 
inflammatory; but there must be something more than inflammation. 

Curative Influence of certain Remedies. — It is impossible to say how it is cured 
by the measures which are specifics in the disease; — as, for instance, bark. It 
cannot be by curing inflammation; neither can it be by irritating the stomach. 
Some have afl^irmed that bark only acts by irritating the stomach; but if thnt were 
the case, brandy and cayenne-pepper would do just as well; and so would corro- 
sive sublimate. Nor can I conceive that specifics operate by strengthening the 
patient. We might give a person full diet, and take care that he has regular exer- 
cise, and improve his strength in every way we can; yet we should not cure his 
ague; whereas a few grains of quinine,^ — a quantity too small to strengthen the 
body directly, — continually puts a stop to it. I cannot pretend to say how it is 
that remedies act in curing the disease; but of this I am satisfied, that it is not 
what people pretend it to be. The remedies do not cure it, as people allege, by 
strengthening, or by stimulating, or by any similar operation. We can only say 
there is a peculiar state; and that remedies cure it by a peculiar operation. This 
is, I acknowledge, saying nothing; but, at any rate, it is not advancing unfounded 
hypotheses; and fancying ourselves wise, when we are really ignorant. Arsenic, 
which cures ague very well, is not a tonic. It will debilitate the body, cause it to 
tremble, and depress the powers of the system; and yet a small quantity will stop 
the disease. Why a remedy of this sort is called a tonic, I do not know. 

State of the Blood, — [In those fevers which arise from marsh-miasmata or con- 
tagion, it is an opinion held by Dr. Stevens, and supported at great length in his 
work on the blood, that a diseased condition of that fluid is the first in the train of 
symptoms which occur, and the immediate cause of those which follow. " The 
blood itself," says Dr. Stevens, " is both black and diseased, even before the 
attack. During the cold stage, it is very dark. When first drawn, it has a pecu- 
liar smell; and it coagulates, almost invariably, without any crust. There are 
black spots on the surface of the crassamentum; the coagulum is so soft, it can 
easily be separated by the fingers; and, during its formation, a large quantity of 
the black colouring matter falls to the bottom of the cup. In the hot stage, it be- 
comes more red; and, in some cases, it is even florid for a time; but, during the re- 
mission, it is darker in colour than healthy blood, and decidedly diseased in all its 
properties. In milder cases, the blood which is drawn may coagulate without a 
crust on the surface; but in the more severe forms of this aflfection, when the 
blood was drawn at an advanced period of the disease, a part of the albumen 
coagulated on the surface of the fibrin, and formed a diseased mass, which in ap- 

' From " quinquina," the name given by the French to Peruvian Bark. 



INTERMITTENT FEVER. 267 

pearance had a greater resemblance to oatmeal-g-ruel, than to healthy blood. The 
serum which separated was also diseased; it had a brownish colour, and in some 
cases an oily appearance; which is never met with in the clear serum of healthy 
blood."^] 

Cause of Intermittence. — [Intermittence, so far as we yet know, is an unex- 
plained pathological fact. Among the various hypotheses that have been offered 
on the subject, the most ingenious and inductive in its nature, is that which has 
been proposed by M. Bailly. He first observes that, in situations and seasons in 
which intermittents affect the human species epidemically, epizootics reign among 
the lower animals; but, however their symptoms may vary in other respects, in 
one point they all agree, — that of being strictly continued; — intermittence being 
never observed in the diseases of brutes. He then points to the mode in which 
the various actions of life are performed in man and the lower animals. During 
the whole of their existence, the lower animals preserve, in all the operations of 
life, the same horizontal position; and, consequently, the heart, abdominal viscera, 
and brain, retain the same relative position to each other; but man, on the contrary, 
changes from the vertical to the horizontal position; and consequently each nycthe' 
meron^ (period of one day and night) presents a succession of sanguineous conges- 
tions, which are felt according as he is in the erect or horizontal posture, and 
according as the viscera change their relative position. These varying congestions 
constitute the physiological condition of most healthy persons; but, argues M. 
Bailly, every pathological or morbid state is only the exaggeration of a physiologi- 
cal or natural one. The sanguineous congestion of the digestive organs, displays 
itself in a degree which may be considered morbid in females or other delicate 
persons; who are either sick on first assuming the erect posture in the morning, or 
feel a total inaptitude for any occupation till they have taken food; and is well illus- 
trated by that febricula, first described by Roederer and Wagler, which may be 
said to constitute the habitual state of many literary and other sedentary men. M. 
Bailly attributes this disorder to gastro-enteritic irritation, produced by the erect 
position acting on a delicate and sensitive frame; and considers that the horizontal 
posture diminishes it; — so that if the patient remain so long in tlws posture as to 
bring this irritation to the lowest point, the functions of the skin are then restored, 
and the indisposition is removed temporarily by a crisis. MM. Roederer and 
Wagler have observed, that nothing tends so much to the production of intermit- 
tent fever in this delicate class of persons, as the suppression of these morning 
perspirations. What has been described above, which is in some degree patho- 
logical, is but an excess of what exists in all individuals, and intermittent fever is 
but a further grade of such an excess; or, as Bailly expresses it, is the exaggera- 
tion of that assemblage of organic acts, which completes a nycthemeron; and which 
takes place in the following manner: — 1. Morning congestion of the stomach and 
intestines. 2. Augmentation of the different nervous influences which it produces 
throug^hout the system; and which, according to the particular disposition of the 
individual, gives rise to one set of nervous symptoms rather than another; or which 
excites that part of the nervous system which penetrates all our organs, accom- 
panied by blood-vessels, when intermittent fever takes place. 3. Cessation of 
this congestion by the horizontal posture. 

The chief objections to this very ingenious hypothesis are: — 1. It is based on 
the assumption that the cause of ague exists in the alimentary canal; which, in the 
present state of our knowledge, is doubtful. 2. While it provides an explanation 
for the occurrence of quotidian ague, tertians and quartans are still unexplained; 
which are considerable lacunae in the hypothesis.*'] 

* "Cyclopaedia of Anatomy and Phy<;iology;" Volume 1; Page 424. 

'' From vi;^, vuxTc?, night; and 'yfju^a. day. 

« "Cyclopaedia of Practical Medicine;" Volume 2; Pages 232 and 23.S. 



268 INTERMITTENT FEVER. 



SECTION IV.— DIAGNOSIS AND PROGNOSIS. 

The affections from which it is necessary to distinguish intermittent fever, are 
hectic, remillent fever, suppuration, stricture, and retention of urine. 

Hectic. — In the diagnosis, we sometimes have a little difficulty in distinguishing 
ague from hectic. Hectic is a disease Avhich continues for a length of time; and so 
may ague. It is called "hectic," from being placed in the habit (f|tj); — being a 
continued disease; that is to say, lasting for a length of time. It also resembles 
ague in another respect; — it is more or less intermittent. In hectic, however, the 
rigors are irregular. All the stages, too, are irregular; — one comes before the other, 
without any sort of order. After a time, in hectic, there are no rigors; — nothing 
but sweating, constant feverishness, and a quick pulse; and this feverishness is 
excited by taking food, and by the slightest quantity of nourishment. There is 
generally profuse sweating on dropping asleep; — the moment the patient drops 
asleep, some part of the body is in a sweat. In ague, when the sweating is over, 
the person is comparatively well; but in hectic, so far from being better, the patient 
feels weaker. In hectic, there is a red patch on the face, the palms of the hands, 
and the soles of the feet; the tongue is moist, and generally red. In the urine there 
is not the lateritious, red, brick-dust sediment of fever; but a pink deposit. In 
hectic, there is not the exposure to the cause of ague; and there is not the aguish 
face; — that peculiar cast of countenance, which is so often seen in ague. In hectic, 
there is frequently a local disease; — suppuration in some part of the body; and there 
is an exacerbation at night, and frequently at noon. No one of these symptoms 
alone, will enable us to distinguish the disease; because ague is sometimes irregu- 
lar, — recurs at no certain time; and is, perhaps, even almost remittent; so that we 
may have to make the distinction between intermittent and remittent fever. In 
ague, we may sometimes have profuse sweating, and little else. It is therefore 
necessary, in making a diagnosis, to take all these circumstances into consideration; 
and, by so doing, we shall (in ninety-nine cases out of a hundred) be correct. 

Ague and Hectic together. — Now and then, however, there may be a little dif- 
ficulty. Sometimes ague and hectic occur together. I have seen hectic in a person 
labouring under phthisis; — where there were rigors, increased heat, and sweating, 
from ague; and increased heat and sweating from the suppuration; so that really the 
case was one of difficulty. There was at the same time the aguish face; so that it 
would have been difficult to make the distinction between the diseases, had I not 
known there was suppuration in the lungs. The aguish face, and the circumstance 
of having been exposed to the cause of ague, showed that probably ague was present; 
but the suppuration also showed that hectic fever was present. If we take pains 
with our cases, we can rarely be deceived. Now and then there will be a difficulty; 
but that will occur in instances where the hectic fever is attended by great rigors; or 
where, on the other hand, ague is assuming a remittent, rather than an intermittent 
character; and the patient has a local affection. 

I^ervous Debility. — We must also remember that rigors will occur without ague 
or hectic. Many persons, from mere nervous debility, will experience rigorsj — 
they will not be able to do their business, and their teeth will chatter, merely from 
depression of mind. 

Stricture. — Again: persons with a stricture are subject to rigors. Some persons 
always have rigors when a bougie is passed; and without that, simply from a stric- 
ture m the urethra, many will experience the same. If we find the rigors come on 
suddenly, and there is a stricture in the urethra, we ought to doubt whether there 
is ague. When rigors occur from stricture, or some other disease of the urethra, 
there is generally no heat or sweating. Neither is there the aguish countenance; 
nor can we ascertain that the individual has been exposed to malaria. If, however, 
there should still be a doubt, after all our inquiries, it is best in all cases to give the 
remedies for ague. If they be properly managed, they can do no harm; — at any 
rate the sulphate of quinine can do none. 



INTERMITTENT FEVER. 269 

The diagnosis of intermittent from remittent fever, is an easy matter. It is a 
mere circumstance of degree. If there be a perfect intermission, we call it " ague;" 
if it be imperfect, we call it "remittent fever." 

Suppuration. — [The danger of an error in diagnosis is still greater, when deep- 
seated and undetected suppuration has taken place. The paroxysms of fever are 
such as, for a time, to impose on the most experienced. In cases of intermittent 
fever, therefore, it is well to examine for visceral disease, especially in districts little 
liable to ague; and to bear in mind that, even in the midst of endemic ague, we 
may have cases resembling intermittent fever, though, in fact, of a totally different 
nature.*] 

Prognosis. — The prognosis in ague, in this country, is almost always favour- 
able. We may almost always promise a speedy cure. If there be conjoined with 
the ague a local structural disease, of course that part of the prognosis must stand 
on its own foundation; but the ague itself we may generally cure. If its type be 
quartan, we cannot promise so speedy a cure, as if it be tertian or quotidian; and I 
believe we are placed under the same restrictions, if the disease be autumnal and 
not vernal. An autumnal ague does not yield so readily as a vernal ague; and, 
indeed, the latter usually yields so easily, that it often ceases spontaneously, after 
a few paroxysms; — some think after seven. It generally ceases when the warm 
weather comes in; and will frequendy do so on a person changing his residence. 
It is the ague of spring, and not of autumn, that is ♦' fit for a king.'"* There is a 
contrary proverb for autumnal ague:— 

" Febris aulumnalis 
Est longa aut lethalis."o 

In hot climates, and even in England, many intermitteyit fevers become remit- 
tent; and from being remittent they will become continued, unless vigorous mea- 
sures are adopted; and may prove rapidly fatal, by congestion of the head, thorax, or 
abdomen. It is in hot countries, and in hot weather in this country, that we have 
to give a guarded prognosis. In hot countries it is common for patients to die early 
in the attack; — in consequence of the enormous congestion which occurs in the 
head, chest, or abdomen. Now and then this may be the case here, from some 
peculiarity in an epidemic. We have always to consider, therefore, in giving a 
prognosis, whether there is any peculiar form of ague present; and if that be the 
case, and if it be a form that is sometimes fatal, our prognosis must be more or less 
guarded; although, without that, we should give the usual prognosis. We have 
no idea, in this country, of what aguish fever, remittent or intermittent, is in hot 
climates. In Italy, they are called *' pernicious fevers;" for as soon as a person is 
seized, he may fall into a comatose state, from which he never recovers; and, on 
inspection after death, the greatest degree of congestion is found in the lungs and 
head, and also in the abdominal viscera. In this country, however, we may almost 
always promise, not only a cure, but a speedy cure; and that by means not at all 
severe; — '*tuto, cito, etjucunde."* 



SECTION v.— TREATMENT. 

The means which we employ for the purpose of curing intermittent fever, may 
be divided into those which are had recourse to in the intermission of the disease, 
and those which are employed during the paroxysm. With regard to the latter, 
the greater number of them are adopted rather with a view to the temporary allevi- 

» "PrinciplesoflheTheory and Practice of Medicine; by Marshall Hall, M. D." Page 134. 

•> See Page 242. 

' "An auiumnal fever is either long continued or fatal." 

d Asclepiades oflicium esse medici dicit, ut tuto, ut celeriter, ut jucunde curet.— C^/.w^; 
Liber 3; Caput 1. ("Asclepiades lays it down, as the duty of a physician, that he should 
efiect a cure safely, speedily and pleasantly.") 



270 INTERMITTENT FEVER. 

ation, than to the cure of the affection; and I need not say that they must be very 
different, according to the stage in which they are employed. 

a. During the Paroxysm* 

Cold Stage. Warmth. — In the cold stage, common sense would point out that 
there should be plenty of covering, and warm drinks; and some have recourse to 
the warm-bath. It would, however, I conceive, be better to employ dry heal; for 
warm air may be easily and instantly conveyed to a patient when in bed, by hav- 
ing something under the clothes to raise them, and a tube continued from above a 
spirit-lamp. Thus we surround the patient with hot air, in any quantity we 
please, and of any temperature. Something like an inverted funnel is placed near 
the bed, with a spirit-lamp under it; a tube goes from the extremity of this funnel- 
shaped body, and is conveyed under the bed-clothes; so that the air is dispersed 
throughout the bed. The degree of heat may be regulated, by altering the prox- 
imity of the lamp to the funnel. This will be found to be by far the best mode of 
applying heat externally;^ and on this account, particularly; — that when we employ 
vapour, the patient, for the most part, must be in a sitting posture; or at any rate 
must be taken out of bed, and more or less exposed after the bath. But, in ex- 
treme exhaustion, it is a material thing to avoid all this, and to keep the person 
horizontal; and by using the contrivance 1 have mentioned, we need not take him 
out of bed, or remove him from the horizontal posture. Heat may thus be em- 
ployed, to an extent sufficient thoroughly to warm the surface; and friction, espe- 
cially to the extremities, may be had recourse to at the same time; — ^just as grooms 
rub shivering horses on the legs, and even on the ears. If it be right to apply 
heat, during the intensity of the cold stage of intermittent fever, I imagine that this 
contrivance will be found much better, than a bath either of hot water or of vapour. 

Warm Drinks. — Warm liquids, of course, appear to be indicated; but we should 
guard against administering real stimulants. It is very well to apply caloric by 
means of hot liquids; but by giving stimuli (such as brandy and wine) we incur 
the risk of doing more than was intended; — of increasing the subsequent hot stage; 
of inducing delirium, and causing congestion and inflammation of the head, and 
internal organs. I should therefore give hot diluents, or at the utmost hot spiced 
diluents, rather than alcohol, or things which are in themselves real and perma- 
nent stimulants. 

Bleeding in the Cold Stage.< — A remedy has lately been recommended, which 
one could not a priori imagine to be proper; but in favour of which there is very 
strong testimony. 1 allude to the abstraction of blood. The best information upon 
this subject, is to be found in Dr. Mackintosh's "Practice of Physic.'"* I believe 
he is the gentleman who first advised, and put in practice, this mode of treatment. 
In the cold stage of fever, the circulation is greatly deranged. The internal parts 
are in a state of congestion; the head, lungs, heart, and all the organs the veins of 
which go to form the "vena portae," as well as that vein itself, and its divisions, 
are in a state of extreme turgescence; and, by removing a certain quantity of blood, 
we unquestionably diminish this load. We give ease to nature; and it is found 
that the loss even of a small quantity of blood, relieves more or less the general 
uneasiness of the patient. I mentioned"^ that, in hot countries, — where they have 
what are called ^'pernicious fevers," — it is very common for those fevers to be- 
attended by such a degree of congestion, as we rarely see in this country; — con- 
gestion which speedily proves fatal, and it must therefore be a very great point, 

» In the Cholera-Hospital at Edinburgh, every bed was furnished with a hollow " tin mat- 
tress" (as il was called); which could, at any time, be filled with steam, bymeans of a pipe 
which communicated with a boiler. 

b " Principles of Pathology and Practice of Physic. By John Mackintosh, M. D." Fourth 
Edition. See also two papers published by him, in Volumes 27, Page 269, and 28, Page 
276, of the " Edinburgh Medical and SurgicalJournal." 

* See Page 269. 



INTERMITTENT FEVER. 271 

in hot countries, to bleed as early as possible. Dr. Mackintosh mentions, that the 
cold siaffe is shoriened by this practice; that the hot stage is either prevented, or 
diminished in violence and duration; and that many cases are entirely cured. A 
report on this subject by Dr. Stokes, will be found in the "Edinburgh Medical and 
Surgical Journal," for January, 1829.** It is not altogether favourable. He says 
that venesection is more or less useless, and more or less injurious, in different 
respects. He says it is beneficial in removing the local symptoms, — in removing 
the symptoms of congestion about the chest and abdomen; — which is just what we 
should imagine. But (he says) he was always compelled to exhibit quinine sooner 
or later; and he adds, — as a reason for limiting venesection to those cases where 
there is coma or inflammation, — that a friend has informed him of some patients, 
so treated, who never recovered. There can be no doubt, I think, that the practice 
is not so injurious as one would (perhaps) imagine beforehand; but that, on the 
contrary, it frequently does a great deal of good; for it removes the local symptoms, 
frequendy shortens the complaint, and sometimes cures it. As far as I can under- 
stand, it is, for the most part, rather a means of alleviation, than of cure^ but I 
have no doubt that, in many cases abroad, where the congestion is extreme, it is 
imperiously necessary. I have never myself had recourse to it; and therefore 
cannot speak of it, except as a matter of opinion. I put the testimony of others 
togetlier, atid infer for myself; but I have no facts to give. I have never seen a 
case of ague, which I thought required such treatment. I never saw a case which 
I could not cure by the sulphate of quinine; and knowing this, and not seeing any 
violent local symptoms during the cold stage, to make such treatment necessary, of 
course 1 have never employed it. 

Speaking of venesection in general, and not of the cold stage in particular, Dr. 
Lind says that he, and two others, had each three patients with ague. Each bled 
his three patients; and each lost one.'' This, however, is saying very little, unless 
we knew the particulars of the cases. Dr. Mackintosh says that it is always safe, 
often shortens, and sometimes cures; but, finding that I can always remedy the 
affection by the sulphate of quinine, in some quantity or other, I have not thought 
it right to take away blood, and thus impair the powers of the patient. There can 
be no doubt, however, that it is a remedy to which it is our duty to have recourse, 
if we find great symptoms of congestion; and if we fear that the next attack will 
prove fatal. 

Opium in the Cold Stage. — Opium is found both to shorten and to alleviate the 
cold stage. I have given it with very great success. The best authors tell us, 
that a full dose of opium certainly shortens this stage, and always alleviates it; but 
still, if I found great congestion of the head, or of other parts, I would certainly 
order bleeding, in preferc-nce to opium. A tourniquet'' has sometimes been applied 
to an extremity, for the purpose of producing early excitement. One would con- 
ceive that, by this means, internal congestion must be increased. If we compress 
the femoral** or brachial" artery, there must be a larger quantity of blood thrown 
upon other parts; and if such a remedy does good, it must be by producing such a 
load, as will stir up nature to attempt Us removal; — so that the body will be hurried 
out of the cold stage, more quickly than it would otherwise have been. 

Hot Stage. — When the hot staoe comes, we have to give cool drinks; to take off 
some of the clothes; and to employ, if it be necessary and advisable, the tepid- 
bath; or warm affusion, or warm ablution. There would, I should think, be no 
harm in cold alTusion, or cold ablution; neither should I hesitate to bleed in the 
hot stage, if there were any congestion, or any inflammation. A cure has now and 
then been effected in the hot stage, by a person jumping into a pond (which is a 

* Volume 31; Page 1. 

b " Essay on Diseases incidental to Europeans in Hot Climates; with an Appendix con- 
cerning Intermiiient Fevers." 

« From the French " lourner," to turn. 
d From " femur, femoris," the thigh. 
« From ^^AXiov, the arm. 



272 INTERMITTENT FEVER. 

cold-bath); but I believe this is rather a dangerous practice. Opium, in this stage, 
has likewise been found of use. Dr. Lind says that he found opiurn useful in the 
hot stage; both in shortening its duration, and mitigating its violence. It would 
appear, then, that venesection is admissible in the cold stage, as well as in the hot; 
and that opium does good in both stages. 

Sweating Stage. — When the sweating stage has arrived, all is going on well, 
and the paroxysm is nearly at an end; and then (if the patient chooses) we give 
him w;irm diluents; and put on more clothes than in the hot stage, because he is 
gradually cooling. We must not allow a draught to blow upon him; but we may 
attempt to lessen the duration of the sweating stage (which will sometimes rim on 
for many hours) by diminishing the quantity of clothes, and cooling him gradually. 
We must be very cautious, however. In the hot stage there is no danger, I pre- 
sume, from tepid ablution; but in the siveating stage we must be more on our 
guard. In this stage narcotics, and every thing that debilitates, would be wrong. 
Nature is now exhausted, and wants repose; and to lower her still more, must be 
not only injurious but unnecessary; because health is about to be restored, and 
things are now nearly at a conclusion. If the patient be exceedingly faint, stimu- 
lants may be given; but before we exhibit them, we must take care to observe 
whether local congestion, or inflammation, may not be present. 

b. During the Intermission, 

The great means, however, for curing the disease, (unless venesection be con- 
sidered a very important means,) are certainly to be employed in ihe intermission. 
By the term *^ intermission,^^ we mean the period between the paroxysms; while 
by ^^ interval t^^ we mean the period of the paroxysm and the period of intermis- 
sion together. The two chief remedies, in the cure of this disease, are bark and 
arsenic. 

History of Bark as a Remedy for Ague. — Nothing is more instructive, in 
pointing out the impropriety of hastily deciding against a medicine, than the his- 
tory of bark. Peruvian bark was first brought from South America in the year 
1632; but the mode in which its efficacy was discovered, has not been well ascer- 
tained. So highly, however, was it thought of at first, that in the year 1658, 
sixty florins^ were given for twenty doses. It was then made a nostrum of, as all 
good medicines are; till at length many regular practitioners wrote against it; and 
such was the prejudice excited, that, about thirty years afterwards, several hundred 
pounds' weight of it lay at Piura, unable to find a purchaser. An alderman died, 
while using it to cure his ague; and it was therefore immediately asserted, that he 
was killed by it. Oliver Cromwell, who (as I before stated") had an ague, was 
not allowed to take bark; and consequenUy died of the afli'ection. The prejudice 
against it continued to extend, and great violence w^as manifested. Sydenham, 
however, though at first opposed to it, gave it boldly; and warmly advocated its 
employment. Violent medical altercations took place; — far gieater than any which 
now occur; and those who employed it were called "murderers," and were stig- 
matized as being unfit to practise. Sydenham gave it in larger doses than his 
contemporaries; and exhibited it, not during the paroxysm, but in the intermission. 
Now there can be no doubt that it may do harm during the paroxysm; for it may 
overload the stomach, and increase congestion, if given in large quantities. Syden- 
ham, therefore, introduced a great improvement, by giving it in the intermission; 
and he improved its efficacy by giving it in large doses. The efficacy of many 
medicines is not properly ascertained, in consequence of their not being given in 
sufficiently large doses. Many persons will exhibit a medicine; and, if it does not 
appear to answer, relinquish it immediately; — without determining whether it will 
really do good or not. Sydenham — by giving larger doses than his contempo- 

» Presuming: that the Spanish florin is meant, this sura will amount to about thirteen 
pourids sterling. 
«> See Page 243. 



INTERMITTENT FEVER. 273 

raries, by exhibiting it between the paroxysms, and by gradually increasing the 
dose — found that it deserved all the praise which had been bestowed upon it. 

Dose of Bark, — When it does not cure the disease as rapidly as we could wish, 
it should be given in the largest dose that the patient will bear. A drachm or two 
drachms every two hours, is frequendy necessary to cure the afTeclion. Dr. Gre- 
gory* used to tell us he was informed by a practitioner, that a friend of his, in the 
delirium of ague, took from three to four ounces of bark; and not only did no ill 
effect ensue, but he was cured from that moment. It ought to be given finely 
powdered; because, if it be not, a very small quantity only will come in contact 
with the stomach and intestines; and its full virtue is not obtained. 

Varieties of Bark. — There are three kinds of Peruvian bark; — the yellow, the 
pale, and the red.** The latter is preferred by many, as being the most powerful; 
but although the most powerful, it is not so well borne by the stomach. Dr. Chap- 
man (of New York*"), Dr. Sanders (who practised at Guy's Hospital"^), Dr. Rigby 
(of Norwich^), and Dr. Skeete,^ all wrote on the red bark; and extolled it as being 
more efficacious than the others. 

Mode of administering Bark. — Milk is one of the best vehicles in which bark 
can be given. Some give the powder in decoction, and some give it as an electuary; 
and it may be given thoroughly mixed with any syrup or sweet substance, and 
then diffused in some liquid, — so as to be drunk. Sometimes it disagrees with the 
stomach; and therefore it is necessary to add something to it. Many persons, 
from pure bark, experience nausea, and perhaps vomiting; while, in some, it occa- 
sions purging. In all such cases, a few drops of tincture of opium, will frequendy 
enable the stomach and intestines to bear it. If it be only the stomach which is 
disturbed, an effervescing draught wdl answer the purpose; and so will prussicacid. 
A small quantity of prussic acid, given at intervals in the course of the day, will 
enable the stomach to bear bark, and many other things, very well. But if the in- 
testines be deranged at the same time, opium is probably one of the best things; 
because neither an effervescing draught, nor prussic acid, will lessen the purging. 
We may sometimes bring a patient to bear bark by degrees; — giving him small 
doses, and increasing them. In the case of children, it may be given in the form of 
clysters; and some persons have been cured, it is said, by its external application; 
— by having it tied, in fine muslin, or fine linen, on different parts of the body. I 
recollect hearing Sir Henry Halford say that, when he was a child, he had ague; 
of which he was cured by wearing a jacket of bark. A double jacket was filled with 
powdered bark, and put next his skin. 

Active Principles of Bark. — It is now ascertained that the power of Peruvian 
bark resides in two substances, called ^'quinina''' and ''cinc/ionina;^'^ and of 

* See Note to Page 239. 

^ Ascribed to "Cinchona Cordifolia,''^ "Cinchona Lancifolia,^' and "Cinchona Oblongi- 
folia''' respectivelJ^ But although the Phannacoposias of London, Edinburgh, and Dublin, 
all agree in this respect, Dr. Duncan observes that there is no satisfactory evidence of their 
being right; — " on the contrary, it is almost certain that, with regard to some of the species, 
they are wrong." Some highly instructive observations on this subject, distinguished by 
all his usual acumen, and never-tiring padence of investigation, will be found in his " Edin- 
burgh New Dispensatory;" Pages 373 to 387 (twelfth edition). A very complete account of 
the different kinds of Cinchona Bark, is given by Mr. Pereira; whose Lectures on Pharma- 
cology, unrivalled for extent and accuracy, were inserted in the "London Medical Gazette'* 
(Volumes 17 to 20); and were afterwards published in a separate form. Those who consult 
the interesting lectures of Dr. Sigmond, published in the "Lancet" for 1836-7 and 1837-8, 
will see what the graces of a polished style, and illustrations collected from every department 
of literature, can do for a subject usually coffsidered so dry and unattractive as Materia 
Medica, 
« "Discourses on the Elements of Therapeutics, and Materia Medica." 
d "Observations on the Superior Efficacy of the Red Peruvian Bark, in the cure of Agues 
and other fevers." 
« " Essay on the Use of the Red Peruvian Bark in the Cure of Intermiftenls." 
f "Experiments and Observations on auilled and Red Peruvian Bark." 
B All the additional alkaline bodies have so lately come to light, that their names are not 
yet settled. The French terminate their appellations in " ine;'' as, for example, " morphine," 
VOL. I. — 18 



274 INTERMITTENT FEVER. 

these two'the former is chiefly used; and tliat in the form of sulphate. It is found 
by chemists, that both these substances abound most in the red bark; and we 
therefore see how it is that the red bark was supposed, by many, to be the most 
efficacious of the three kinds. Quinina is said to abound most in the yellow bark, 
— the "cinchona cordifolia;^^ and the cinchonina in the pale bark, — the " cinchona 
lancifolia.^^ I have given the quinina, both simple and in the form of sulphate; 
and have cured ague with it very well; but I have never employed the cin- 
chonina.* 

"bracine," "strychnine," &c.; but, for the sake of uniformity with the names of the old 
alkalies, the termination should be "«;" and it seems to me most eligible to adopt the French 
appellations, with the change of the final e into a; — for example, '"morphina," " brucina," 
"sirychnina," &c. Some have proposed to designate "quinina," "quina," or "kina;" but 
the latter, at least, is too similar to the word *'kino" and would, besides, lead any one to 
suppose the substance it denotes must be the basis of kinic acid; — another instance, I may 
remark, of objectionable nomenclature; from the circumstance of a very ditferent article 
being termed " kino." " Cinchonina" is, by some, called "cinchonia;" but the word is evi- 
dently too similar to "cinchona;'' SLud the, same observation applies to the word " hyoscijama;^' 
which would easily be mistaken for " hyoscyamus;'" and the objection must be still stronger 
if the alkalies "cinchonina" and " hyoscyamina" should ever be prescribed. The uniform 
termination in "uta," would be very distinctive. — Dr.Elliotson, in the " Medico- Chirurgical 
Transactions;'^ Volume 12; Pages 546 and 547. 

* Among the energetic substances which the industry and sagacity of continental chemists 
have extracted from various articles of the Materia Medica, and upon which the peculiar 
properties of these articles appear to depend, none (I believe) have hitherto [1823] been turned 
to any medical purpose in their separate state, except hydrocyanic acid, iodine, morphina, 
emeiina, and some of those which are furnished by cinchona. An account of the proper- 
ties of strychnia, veratrina, hyoscyamina, and other alkaline substances procured from 
vegetable narcotics, is to be found, not in works upon the practice of medicine, but in Orfila*s 
treatise on poisons, or in similar writings of experimental physiologists. Hydrocyanic acid 
has been investigated (as a medicine) both here and abroad, and deserves a place in our 
PharmacopcBia; although destitute of the high pretensions which were at tirst injudiciously 
proclaimed. Of the powers of iodine in bronchocele, we have abundant testimony: I have 
seen sufficient to satisfy myself; and they would seem equally great in certain other struc- 
tural diseases. Very little has been written upon the medical virtues of morphina; but it is 
much employed, in combination with acetic acid, by some eminent physicians, instead of 
opium; and both it and emeiina, as well as hydrocyanic acid, have a place in the " Codex 
Medicamentarius" of Paris. The curative powers of quinina have been highly extolled in 
French publications; but I am not aware that any thing has yet [1823] appeared in this 
country upon the subject; and it is for the purpose of beginning to supply this deficiency, 
that 1 do myself the honour of offering the present communication to the [Medical and 
Chirurgical] Society. 

Of the three substances discovered in cinchona, — the alcali "quinina" (found in "cin- 
chona cordifolia," and more abundantly in the "oblongifolia"), the alcali "cinchonina" 
(found in "cinchona lancifolia," and also more abundantly in the "oblongifolia"), and kinic 
acid (found in combination with lime in all three species, and also with quinina in the "cord- 
ifolia," with cinchonina in the "lancifolia," and with both quinina and cinchonina in the 
"oblongifolia"), — the two alcalies only, if I mistake not, have been tried as remedies; and of 
them the cinchonina appears to have been but once exhibited. Dr. Chomel once prescribed 
the sulphate of cinchonina in intermittent fever. Six grains mitigated the paroxysms; 
twenty put a stop to them. 

The quinina, in the state of sulphate, is very extensively employed in France; and many 
relations of its efficacy have been published, in the journals of that country. 

In the common run of cases in which we prescribe cinchona, its efficacy is not particularly 
striking; as we generally employ at the same time nutritious food, perhaps wine and por- 
ter, and every thing calculated to strengthen. My general experience of simple quinina as 
a tonic, is the same as of the sulphate; but I have never observed derangement of the sto- 
mach induced by doses of the impure preparation I employed, so large as ten grains, given 
every six hours, I beg not to be misunderstood as recommending simple quinina, in pre- 
ference to the sulphate. My object is merely to illustrate the virtues of the substance, whe- 
ther simple or combined. I may here state, that although none of my friends have yet 
employed simple quinina, several have prescribed the sulphate; and all with the most satis- 
factory results. Every case of intermittent fever has presently yielded to it, and in some the 
bark had previously failed. • 

It has been apprehended, that the alcalies of cinchona may be analogous to those" of nar- 
cotics; and their exhibition, consequently, not altogether free from danger. But the fear is 
groundless. I have used many ounces of both quinina and its sulphate; have frequently given 
them every day for some weeks; and, even when the quantity of the sulphate or of the im- 
pure quinina was a scruple in the twenty-four hours, have never observed the slightest 



INTERMITTENT FEVER. 275 

Mode of Administering Qitinina. — Quinina is best given in a fluid state; and 
there should be a sli^rht addition of sulphuric acid; by means of which a super- 
sulphate is made. Sulphate of quinina is not very soluble; but, by adding one drop 
of sulphuric acid to every grain of sulphate of quinina, we have a super-sulphate, 
which is sufficiently soluble. It goes farther, I should imagine, when given in this 
form; but, on account of its taste, and for the comfort of the patient, we often give 
it in a solid form. If it be exhibited in a pill, its bitterness is not tasted. 

unpleasant effect. Yet there can be no question, that an excessive quantity of so intense a 
tonic and bitter may disturb. Accordingly, ten grains of the sulphate (at a dose) occasioned 
vomiting, in the three only instances in which i carried the medicine to that extent. An 
instance has been related to me of a gentleman experiencing nausea and headache from a 
dose often grains, taken without advice; and another in which five grains, repeated every 
three hours for six limes, caused a degree of uneasiness; and Dr. Magendie says, that when 
practitioners have gone considerably beyond ten grains, in the twenty-four hours, the patient 
has sometimes experienced a high degree of excitement, and of cerebral disturbance. But 
quantities that can disagree, are not required. Five grains of the sulphate, every six hours, 
is the largest dose that can be necessary; and many cases of intermittent fever have been 
cured with three, two, and even one grain, every six hours. 

I would always continue the medicine, whether using the sulphate or simple quinina, for 
about a week after the ague has ceased; because I have, heard of relapses, where it had 
been omitted immediately that the disease gave way. 

It is very true that quinina and cinchonina cannot strictly be called ^' nejo medicines;" 
because they exist (one or both) in cinchona, which we have all been prescribing. We are 
in the situation of M. Jourdain, in Moliere's ^'■Bourgeois Gentil/iomvie" (Act 2, Scene 6), 
who had been speaking prose all his life without knowing it; and we might address the 
chemists, to whose labours w-e are so deeply indebted, in language similar to that of the 
worthy man, on receiving the information from his Maitre de Philosophic. — "Par ma foi 
il y a plus de quarante ans que je dis la prose, sans que j'en susse rien; et je vous suis le 
plus oblige du monde, de m'avoir appris cela." (" By my faith, I have been speaking prose 
for more than forty years, without being aware of it; and I am under the greatest possible 
obligations to you, for having taught me the fact.") 

The powder of bark requires, generally, to be " thrown in" (according to (he apt expres- 
sion of old practitioners) in pretty large quantities, before the disease is removed; and not 
unfrequently it fails. But, with respect to quinina and its sulphate, a small quantity is suf- 
ficient. The patient has only to take a pill; and is spared the annoyance of swallowing any 
of the mass of inert powder, which remains after the extraction of quinina; and which fre- 
quently (whatever maybe the disease) so disgusts him, or so oppresses his stomach, and 
deranges his system at large, that bark cannot be borne in efficient quantity, or even borne 
at all; and (what is particularly interesting) we find, that they succeed when bark has failed; 
— that they cure cases of intermittent fever which have resisted bark, although perfectly 
well borne, and freely administered. — Di; Elliotson, in the ^' Medico-Chirurgical Tiansac- 
tions;" Volume 12; Pages 543 to 564:. 

Since the appearance [in the " Medico-Chirurgical Transactions"] of the paper upon 
quinina, [of which paper the preceding part of this note is the substance,] I have attended 
nearly a hundred and fifty cases of ague, and have treated them all with the sulphate. Many 
were combined with so much inflammation (in the abdomen, chest, or head), as to require 
venesection;— some being combined with dropsy; and some with a chronic disease of the 
lungs or liver; but all were cured. Having never seen it augment any inflammation that 
may be present, or interfere with antiphlogistic measures, I have always given it in all 
circumstances; and have simultaneously adopted any other measures, that might be de- 
manded by other symptoms. Some cases, and those were generally quartans, would not 
yield to less than five grains every four hours; but this quantity has never failed, after 
having been exhibited a week or ten days. Like mercury in syphilis, I have frequently 
seen its use followed by a relapse, when noVcontinued for a proper length of time after the 
disease. It cannot be a matter of surprise, that a fresh exposure to the causes of ague, will 
renew it after a cure; — precisely as happens with syphilis, after the successful exhibidon of 
mercury. In London, the disease may in general be arrested immediately, by the exhibition 
of ten grains at once, just before or after the paroxysm. 

Dr. Home found the bark much more successful after than before the paroxysm; and this 
is my experience with quinina. I am convinced, that the best practice is first to give ten 
grains as soon as the paroxysm is over. This almost always (the exceptions are generally 
quartans) prevents the paroxysm next expected; and, if repeated daily at the same hour, 
often cures the disease. But as ten grains, given in any number of doses in the twenty- 
four hours, are frequently insufficient to conquer it, and half a drachm may be required, it 
is sometimes necessary, in addition to these ten grains after the fit, to make the whole quan- 
tity in the twenty-four hours amount to a scruple or half a drachm;— by small doses also, 
every six or eight hours.— £)r, Elliotson, in the ''Medico-Chirurgical Transactions;'' Vo- 
lume 13; Pages 464 to 466. 



276 INTERMITTENT FEVER. 

Dose of Quinina. — A few grains, every eight hours, will generally cure the 
complaint. Some give a grain or two, every two hours; and say it answers very 
well; but others give a larger quantity, at more distant intervals. Either way is 
very good; but if the stomach reject it, certainly it would he better to give only a 
grain or two every two hours throughout the twenty-four, rather than a large quan- 
tity at once. I have found it the most efficacious mode, to give a large dose imme- 
diately after the paroxysm. It is very good to give it before the paroxysm; but I 
think, of the two, more effect is produced by giving it as soon as the paroxysm is 
over. For the moat part, we put a stop to it direcdy, by giving tenor twelve grains 
as soon as the paroxysm is over; but we do not usually cure ihe disease; — we only 
suspend it. To effect a cure, we must generally give a larger quantity in the course 
of the twenty-four hours; and for some time. When we first had sulphate of 
quinina, I was generally able to cure the disease with two or three grains, two or 
three times a-day; but that does not generally happen to me now; and therefore I 
cannot but believe, that this medicine is exceedingly adulterated. I continually have 
to give people twenty or thirty grains, in the twenty-four hours, before I can cure 
the complaint. 

Large Doses sometimes Necessary. — No general rule can be laid down respect- 
ing the quantity required. Some persons may be cured by a few grains; and some 
will require a very large quantity. In February, 1829, I had a patient labouring 
under quartan ague, which did not yield to less than forty-five grains, in the twenty- 
four hours. I thought that a very considerable quantity; but in the ensuing October, 
on my return from the Continent, I found a patient in my wards who, by direction 
of Dr. Roots, was taking a scruple every eight hours, together with ten minims of 
Liquor Potassae Arsenitis. This man, like the former, had a quartan ague; and 
was no better, notwithstanding he took this large quantity. However, as it did not 
disagree with him, and as I never failed in curing the complaint, I determined that 
if it could he cured it should; and I gave the remedy (as Dr. Roots would no doubt 
have done, had he continued to treat the case) every six hours, instead of eight; 
and he was then cured directly. That was the largest quantity that I have ever 
been obliged to give; but it was indispensable in this case. 

Time for administering Quinina. — I should certainly advise a large dose to be 
given (such as twelve or fifteen grains, in some cases; but eight or ten, in general) 
immediately after the fit, to suspend the disease at once; and then to give a small 
quantity repeated at intervals during the twenty-four hours, for the purpose of curing 
the disease. In the first case we knock it down at once, which is a material point; 
because every paroxysm shatters the patient, and is a period of great suffering; and 
therefore I would stop it immediately. But we shall not always stop \i permanently, 
unless we give a larger quantity in the twenty-four hours; and continue it for some 
time. I am in tlie habit of giving ten grains, as a medium dose, immediately after 
the paroxysm; and then five grains every six or eight hours, whether the disease 
comes back or not. 

Its Employment must not Cease too Soon. — It is necessary to continue the 
medicine for some time, after the disease appears to be cured; for if it be left off 
direcdy, the disease, in all probability, will return. It is just the same in the cure 
of syphilis; if we leave off mercury as soon as the sore is healed, or the pain has 
ceased, the symptoms will possibly return. Although ague, therefore, appears to 
be qifite arrested, it is necessary to continue the remedy for two or three weeks 
afterwards, in order to make sure of the cure. 

Administration of Quinina during the Paroxysm. — The remedy maybe given 
with perfect safety even during the paroxysm, when the pyrexia is present, and 
even though there may be local inflammation; but I should conceive that it is a 
waste of a good thing, to give it during the paroxysm. At that period the system 
is in such an unnatural slate, that all agents are resisted; and a dose of quinina, that 
produces a good effect during the intermission, will produce no effect during the 
paroxysm. Medicines are all resisted, more or less, when we are in an unnatural 
state. It is found to be more efficacious during the intermission; and sufficient may 



INTERMITTENT FEVER. 277 

then be given to cure the disease. I do not know that it is injurious to give it dur- 
ing the paroxysm; but it is certainly icasteful. 

Pflien attended by Local Inflammation. — I have frequently had occasion to give 
it, notwithstanding there was local inflaminalion. My object was to cure both 
diseases; and while I was curing the local affection by bleeding and other means, 
I stopped the ague with quinina; and never saw any harm done by it. When I 
first employed this remedy, many years ago, I had a patient with ague, who shivered 
every other day; and had then intense heat and sweating; but during the intermission 
he was always hot, always had a very quick pulse, and was always thirsty. He had 
continued fever, with the addition of a tertian ague; or he would have been said by 
some to have remittent fever. I did not then know a great deal about the remedy; 
but I gave it him at regular hours, day and night; and he became perfectly cured. 
Notwithstanding the great feverishness, no inconvenience arose. The case is pub- 
lished in the twelfth volume of the "Medico-Chirurgical Transactions;"* along with 
several others of which I made a report to the profession, before the remedy was 
much known in this country.'' I have continually seen quinina cure the disease, 

* A poor man, named Charles Hunt, was conveyed to me on the mornins: of Monday, 
September the first [1823]; and with difficulty was supported into the house. He said that he 
had laboured under ague at Cowes, in the Isle of Wight, twenty years ago; but was attacked, 
a fortnight since, with violent vomiting and pyrexia; for which, at the suggestion of some 
friend, he drank large quantities of cold water; — that in a few days, a severe tertian com- 
menced, without any alteration of the other symptoms; and that he had experienced four 
paroxysms, every successive one invading an hour earlier, and each of the three stages 
lasting nearly three hours. I found him excessively hot and thirsty; vomiting every thing 
he swallowed; with a feeble, rapid pulse; and so weak as to have fallen three times that 
morning, in walking through a yard belonging to his house. Five grains of the sulphate 
every six hours, in the form of pill, were ordered. The medicine was not procured that 
day; and, in the evening, he had a paroxysm an hour earlier than the preceding, and more 
violent than any. The next day (Tuesday), he began its use; and on Wednesday, to his 
great delight, he experienced no paroxysm, but merely a chilliness for about ten minutes, 
followed by neither heat nor sweating. "On Friday, I found him much stronger, much cooler, > 
with little thirst, with his pulse greatly reduced, and able to retain every sort of food; — not 
having vomited since the first dose of the remedy. I write this on Monday, September the 
eighth; and he tells me, to-day, that he has had not the slightest paroxysm, "and that he feels 
perfectly well. Indeed, he walked to my house, — a distance of three miles; and purposed 
walking home again. This case is particularly striking, not merely as an illustration of the 
cure of the disease, but from the circumstance of the violent vomiting and pyrexia— which 
were constantly present, and would have deterred any one from exhibiting bark in the first 
instance — yielding completely to the remedy. — Dr. Elliotson, in the '■'Medico-Chirurgical 
Transactions;'^ Volume 12; Pages 560 arvd 561. 

* As soon as the two alcalies of cinchona were discovered, M. Pelletier sent a quantity to 
Dr. Magendie; who administered them to dogs in large doses, without nausea, vomiting, or 
other apparent result. The indefatigable and acute physiologist then injected into the veins 
of these animals from two to ten grains of the sulphate and of the acetate of quinina and 
cinchonina, in solution; but with no more effect. Satisfied of the innocence of the substances, 
he ordered the sulphate of quinina to several scrofulous children affected with ulcers; and, 
in a fortnight, the most decided benefit was obtained. He mentions, in particular, one child, 
four years of age, who had scarcely been able to move for ten months, was constantly crying, 
and ate nothing; but, at the end of six weeks, after taking two grains of the sulphate daily, 
it acquired a good appetite, became cheerful, walked well, and would not readily have been 
recognised. In the same paper he states, that a phthisical patient derived considerable 
benefit from the medicine. 

M. Pelletier furnished Dr. Chomel, also of La Charite, with a large quantity of the sul- 
phates; and the following was the result of the exhibition of the sulphate of quinina, in 
thirteen cases of intermittent fever. Ten were cured; — five by the first doses, five by the 
second; in two the paroxysms were merely mitigated, and in one no sensible effect was pro- 
duced, la the three unsuccessful cases, the cinchona itself equally failed. The medicine 
was taken, dissolved in water, on an empty stomach, before the accession of the paroxysm; 
and the whole quantity was generally six or eight grains, but twice this amount when 
necessary. 

In September and October, 1820, M. Double tried the sulphate of quinina in six cases of 
intermiUent fever. In the first, the disease never returned after the exhibition of three grains 
three times in the interval; smaller doses were subsequently continued for some time. In 
the second, which occurred in a child, one grain night and mornina: retarded and deranged 
the course of the first paroxysm, and a second never took place. The medicine was given 
iiit some days, in gradually diminished doses; and the patient recovered her strength, and 



27S INTERMITTENT FEVER. 

when bark was given in as large a quantity as could be borne; and likewise arsenic,' 
and both had failed. I have also known it stop vomiting. When a person with 
ague has been exceedingly troubled with vomiting, — with great irritability of sto- 

a healthy state of her digestive organs. The third case occurred in a young female; and 
was cured with two grains night and morning. The fever, which was quotidian, instantly 
lost its intensity, and ceased after the third day; and the patient's health improved in a way 
! that could not have been expected. The fourth was a tertian; four grains were taken twice 

in the interval; the next paroxysm was of the slightest description, and no other was expe- 
rienced; the medicine was continued some time. The fifth and sixth cases were equally 
decisive. M. Double prescribed it in a variety of diseases, which are usually' treated with 
cinchona; and for the most part, he says, with satisfactory results. 

Instances of the equally successful exhibition of the sulphate of quinina, by MM. Villerme, 
Magendie, Talbot, and Dupre, are also recorded. 

M. Piedagnel has published a case of violent periodic pain of the supra-orbilar nerve, 

entirely cured by the administration often grains of the sulphate, during one of the daily 

intermissions, and a repetition of the same doses in the following twelve hours; with the 

view of greater security. M. Dupre relates a case of violent periodic pain of the infra-orbitar 

nerve, that subsided after the exhibition of twenty-four grains, in small doses, during two 

intermissions; and one of remittent sciatica, which yielded very speedily. Two instances 

I of periodic pain of the facial nerve, treated (with equal success) by M, Ribes, will be found 

I in the same pages. M. Dupre likewise gives us a case of typhus, in which a rapid move- 

i ment look place, after the use of the sulphate of quinina was commenced. 

I ordered it, largely and perse veringly, in one case of irregularly intermittent, and in one 

; of remittent, pain of the face; but without advantage. Like M. Dupre, I employed it in a 

; ease of typhus; and with eminent advantage. On the nineteenth of June [1823], a poor Irish- 

i woman, half starved and flooding, was brought into St. Thomas's Hospital, labouring under 

I severe typhus. She was supported by plenty of beef-tea and milk; the epigastrium, fore- 

i head, and occiput were blistered; and Hydrargyrum cum Greta was prescribed, in doses of 

I one scruple, and sometimes two scruples every six hours, till the mouth grew sore. The 

i delirium and stupor were entirely subdued, and the tongue became clear and moist; but the 

i debiUty increased hourly. The face became ghastly, and the body sunk lower in the bed. 

I ordered three, and soon five grains of sulphate of quinina, to be given every six hours; 

and the diet to remain as before. A striking amendment was observed the next day; and 

she speedily recovered. After being convalescent some time, the medicine was omitted; but, 

when 1 thought of discharging her, she suddenly relapsed into extreme prostration of strength, 

i passed her urine and faeces again involuntarily, and grew delirious; but the tongue remained 

clean and moist. The two blisters to the head were repealed, and the sulphate ordered as 

before; — milk and beef-tea, ad libitum, continuing to be her diet. The amendment was not 

so sudden; but, from the first day of recurring to the medicine, the debility ceased to increase. 

In a few days, she clearly gained strength; and was soon convalescent. After taking the 

full diet of the house, and a pint of porter daily, for two or three weeks, she was discharged, 

— perfectly strong and well. 

The three following are all the cases of intermittent fever in which I have yet [July 8, 
1823] prescribed it; and they corroborate the assertions of the French. They, as well as the 
rest which I shall detail, occurred in St. Thomas's Hospital. The medicine was given in 
the form of pills. 1. Elizabeth Taylor came under my care, as an out-patient, on the nine- 
teenth of September last [1822]. She had laboured under intermittent fever for nearly a 
twelvemonth, in Gloucestershire, when thirteen years of age; and had experienced a solitary 
paroxysm occasionally: and once so severe a return, as to confine her two months in St. 
Thomas's Hospital. The disease had now regularly recdrred, in the quartan type, for six 
months. I prescribed five grains of the sulphate of quinina every six hours. On the tenth 
day (September 28) 1 saw her again; and learnt that a paroxysm took place on the first regu- 
lar day, (namely, the twenty-first of the month,) but without any cold stage; that the hot 
stage was very mild; and that the disease had not subsequently returned. The same pre- 
scription was continued. On the eighteenth day (October 6) she informed me, that there 
still had been no return; and I continued the prescription. She never applied again;— re- 
maining, no doubt, perfectly well. 

2. The second case was that of an Irishman, named Hugh Kaney; who was admitted into 
the hospital on the twenty-seventh of March. He laboured under tertian for five days. I 
prescribed five grains of the sulphate of quinina every six hours. A paroxysm took place 
on the day after his admission; but, although he remained in the hospital until the eighth of 
May, he never experienced another. The medicine was continued, in the same quantity, 
till the twenty-second of April. 

3. The third case proved more refractory; but the disease was instantly influenced by the 
medicine, and removed in little more than a fortnight. Robert Tindall was admitted into 
the hospital on the twenty-seventh of March; having laboured under tertian for a month. I 
prescribed five grains of the sulphate of quinina every six hours. On the sixth day (April 
1), I found that the paroxysms had returned regularly, but less severely, and at a later hour; 
ou the tenth (April 5), that they were still milder, and on the thirteenth (April 8), that they 



INTERMITTENT FEVER. 279 

mach, I have known it put a stop to the irritability as well as to the ague. Still it 
is to be remembered, that now and then it disagrees with the stomach. Now and 

had become much milder. On the fifteenth (April 10), the paroxysm was severer than it had 
lately been; but on the nineteenth (April 14), it returned very mildly, and for the last time. 
The same quantity of medicine was continued till the twenty-sixth day (April 22); and he 
left the hospital on the forty-ninth (May 15), without the least return of the disorder. 1 have 
reason to believe, that the medicine which this man took was of inferior quality. 

1. I first prescribed the quinina itself, on the 29th of November [1822], for a woman named 
Martha Fallow, who had been affected with quotidian for a fortnight; the paroxysms always 
commencing at four o'clock in the morning. Five grains every six hours were ordered. 
She visited me again on the seventh of December (the next day for seeing out-patients); and 
said she had experienced no paroxysm since the seventh day (December 4). The medicine 
was continued in the same doses; but she never applied again: and probably, therefore, re- 
mained in good health. 

2. William Johnson was admitted into the hospital January 23 [1823];— having laboured 
imder tertian for ten weeks. He was ordered the same doses, at the same intervals. A 
paroxysm occurred on the day of his admission, but more mildly than before; and he had no 
other up to the eighth day (January 27); when he left the house of his own accord. 

3. Edward Cupon had tertian in Norfolk, twelve years ago; was now a surgical patient 
in the hospital, and desired my assistance on the fourth of February [1823], on account of a 
quotidian, which had existed three weeks. — The same prescription.— On the fifth day (Feb- 
ruary 8) I found that he had experienced no paroxysm, but merely a coldness of the loins, 
legs, and feet, at the customary time of the paroxysm. On the eighth day (February 11) he 
said, that even the coldness had ceased to take place; and, up to the first of May, he remained 
free from the disease. 

4. Francis Douglas had been afflicted with intermittent fever, irregularly, for eighteen 
months; — at first daily for six weeks, in the West Indies. Since that time he had made a 
voyage to China; and for five months had no paroxysm. One attacked him on the second 
of February last [1823], in the morning, one on the sixth in the evening; and one on the eighth, 
(the day on which I first prescribed for him,) at noon. He complained of a degree of shiver- 
ing every day. The same prescription was written for him. He had no paroxysm from 
the day he commenced the use of the medicine, till the eighth (February 15); and then none 
till the fourteenth (February 21). No other occurred during his residence in the hospital. 

5. Daniel Duff" was admitted on the thirteenth of February; — having laboured under quo- 
tidian a fortnight. — The same prescription. — A paroxysm took place on the two first days 
after his admission; but they were slight, and the second was sfighter than the first. Up to 
the twenty-seventh of the month he had no return, and was then discharged. 

6. Edward Perry, ill a twelvemonth with tertian, was admitted February 13 [1823], He 
had laboured under the disease in Wiltshire, thirty-six years ago; but never since that period 
till the present time. — The same prescription. — The paroxysms at once became slighter, and 
recurred but twice after the use of the medicine. 

7. John Ferguson, affected with tertian for three weeks, was admitted on the eighth of 
March. — The same prescription. — No paroxysm took place after the use of the medicine 
was begun. 

8. An old woman, of the name of Traylen, had laboured under quartan for ten weeks. 
She had been subject to it for many years; but always previously stopped the paroxysms, by 
a smaller quantity of cinchona than failed the last spring [1823]. The same doses of quinina 
were followed by an immediate cessation of the disease; and, though three months have 
elapsed, it has not recurred. 

9. Daniel Carthy was admitted on the twenty-ninth of May [1823], on account of tertian. 
He had the same prescription as the rest. The only paroxysm that took place, was the day 
after his admission; and he was discharged at his own desire, at the end of three weeks. 

10. Bryan Summers was admitted on the same day as Carthy, on account of a tertian, 
caught at Tilbury Fort. The same prescription was given to him. A paroxysm occurred 
immediately after his admission; but it was not succeeded by another. A chilliness of the 
legs came on every other day, for some little time; but this gradually decreased, and he was 
discharged at the end of three weeks. 

The following case, furnished me by my friend and colleague, Dr. Roots, is exceedingly 
worthy of detail; — as affording an instance of the immediate success of the sulphate, afief 
the failure of both bark and arsenic:— "Mrs. Sullivan was admitted into St. Pancras Infirm- 
ary on the seventh of May [1823]; after having sufl^ered under tertian for nearly a month. 
She took the Liquor Arsenicalis [Liquor Arsenitis Potassae] from the eighth of May to the 
twenty-third; and every two or three days rhubarb and calomel, without any advantage. 
From the twenty-third of May to the sixth of June, she took cinchona in drachm doses, every 
six hours, with the decoction and tincture; — containing, at limes, the rhubarb and calo- 
mel. As the paroxysms still returned at the regular period, the cinchona was discontinued, 
and the Liquor Arsenicalis resumed, in doses of nine minims every six hours; which she 
took from the sixth of June to the twentieth. On the thirtieth, finding the paroxysmsslill return 
at the usual period, I ordered her five grains of the sulphate of quinina, in a pill, every six 



280 INTERMITTENT FEVER. 

then it produces vomiting and gastrodynia;" — just as bark will do; and, more fre- 
quently still, it will also purge. When the stomach is disordered by it, — whether 
it be thrown into spasmodic pain, or vomiting be occasioned,— -we may give aro- 
matics, or opium, or (which is far the best) prussic acid. If there be mere pain, 
an effervescing draught will not be of any use; though it might be servicable if 
there were nausea and vomiting. 

Failure of Quininafrom Gastric Irritation. — The power of quinina is one of 
the most extraordinary facts in medicine; and always reminds me of the lines in 
Virgil,- 

*' Hasc certamina tanta 
Pulveris exigui jactu compressa quiescunt,"'' 

It is said to have failed sometimes; and that bark has then cured the affection; — 
just as, in many cases, I have seen it successful^ when bark \v3id failed. When 
this has happened, it has been (I imagine) from its disagreeing with the stomach; 
so that a sufficient quantity could not be taken. Cases have occurred to me, in 
which the stomach became so irritated, from the intensity of the medicine, that the 
patient rejected it; and could not take it in sufficient quantity; whereas bark, being 
far less intense, could be borne; and was taken in such a quantity as cured the dis- 
'[ ease. I had a case exactly of this description, in the lady who caught an ague 

i. from walking on the ramparts of the Tower.*" A very small dose of sulphate of 

quinina produced most excruciating pain at the stomach; and she could not persevere 
with the medicine. Bark was substituted for it; was borne very well; and cured 
the disease. Whether, if she had taken tincture of opium, or prussic acid (in 
proper quantity) the quinina could then have been borne, I do not know; but I 
il think it probable that it might; and that it would then have cured her. T think 

I Andral mentions the circumstance of quinina having failed, and of bark subse- 

quendy curing the disease. I do not know the particulars of his cases; but I 
imagine that such a circumstance as this, could only arise from the medicine irri- 
tating the stomach, — so that it was not taken in a sufficiently large quantity; because 
it has all the virtue of the bark, and in far greater intensity. 

Other Barks in Ague. — Many oiher barks, however, cure the disease. The 
bark of willow, the alcaloid principle of the willow-bark (salicina*^), swietenia,* all 
astringents of the vegetable kingdom, and more especially a combination of both 
(such as calumba^ with galls) will cure the affection. A combination of these, is 
found to be more powerful tlian either of them taken separately; and those barks 
which contain both a natural bitter and an astringent, are those which answer best. 
It is said, with respect to these, that they have sometimes cured the disease, after 
Peruvian bark has failed; and various other combinations of bitters and astringents, 
have done the same. Piperine will cure ague. 

Arsenite of Potassa. — Next to sulphate of quinina or bark, however, certainly 
comes arsenic. The solution of arsenite of potassa, is what is commonly used; in 
doses of from two to ten, or twelve drops, or more, two or three times a day. It 
is best to give this remedy in a very gradual mode; and I never begin with more 
than two or three drops, three limes a day; gradually increasing it. I have seen 

hours. She took twelve doses; — never having any return of the paroxysm after the first dose; 
and was discharged on the second of July." It is right to mention that, the day prior to the 
sulphate of quinina beingordered, she was allowed a pint of porter daily. Dr. Roots, I may 
add, has hitherto [July 8, 18231 employed the medicine but once since; and says, in his letter 
to me, — " In another case of quartan, the sulphate was given in doses of two grains every 
six hours; a.r\d Wcia equally successful'— Dr. Elliatson, in the '' Medico- Chirurgical Trans- 
actions" Volume 12; Pages 546 to 561. 

a From ytttf-Txj, the stomach; and oSuvx, pain. 

b "On a light powder being thrown, the contests (though violent) cease.'*— ^^ Georgia;" 
Book 4; Li7ies 86 and 87. 

The allusion is to the effect of a little dust, thrown on bees engaged in battle. 

«: See Page 251. ^ From " salix, salicis," the willow, 

« So named from Van Swieten. 

f So named from Colomba, in CeyloHj whence it is obtained. 



INTERMITTENT FEVER. 281 

iague cease Irom the first day it was given, although tlie disease had continued for 
a length of time; but frequently a longer period is required, for its successful ex- 
hibition. The largest dose required, I believe, is from twelve to fifteen drops, three 
times a day; or as frequendy as is necessary. I never had occasion to go beyond 
that; nor should I like to do so. I need not say that, on account of its virtues in 
this disease, it has been made a nostrum of; — exacUy as was the case with bark. 
What is called " Tasteless Ague-Drop," is a preparation of arsenic. 

3Iode of Jidministerins^ .Arsenic. — It is always best not to give this medicine 
on an empty stomach. When giving an acrid matter, — such as iodine, the bichlo- 
ride of mercury, or antimony, — with a view, not to nauseaie, but merely to pro- 
duce diaphoresis, it is by far the best practice to exhibit it after food has been taken. 
It is evident that any thing acrid, coming into direct contact with the mucous mem- 
brane of the stomach, is more likely to irritate it, than if food had been first taken; 
—so as to cause it to be applied to the stomach partially and gradually. When- 
ever Peruvian bark or sulphate of quinina irritates the stomach, it is best to try 
whether it will not be borne when given after meals. But in the case of arse- 
nic, we should make it a rule never to give it before breakfast. Persons are con- 
tinually nauseated, and will even vomit if they take it before breakfast; whereas 
after breakfast they may bear it very well. When it produces nausea or vomiting, 
a little tincture of opium is indispensable; indeed it is well, in general, to combine 
a little tincture of opium with every dose of arsenic. 

/// Effects of Arsenic. — The ill effects of arsenic are symptoms of gastritis. 
The slightest symptom is nausea; the next is vomiting; then pain of the stomach, 
and heal there; tenderness on pressure; and heat extending up the throat. Arsenic 
has a tendency to excite gastritis, even when not taken into the stomach, I knew an 
instance of a person being seized with gastritis, and thrown into the greatest danger, 
simply from having arsenic applied to a sore of the leg. One of the first effects of 
arsenic, is to irritate the stomach; and the irritation soon arises to the pitch of in- 
flammation; but it will also produce other effects. Singularly enough, it occasions 
soreness and redness of the tarsi; redness and heat of the fingers; soreness of the 
throat; and oedema of some part of the body. Very frequently, when patients 
liave been taking arsenic, I have seen the face swell; and sometimes the lower ex- 
tremities. Sometimes it is one part, and sometimes another; but most frequently 
it is the face. Frequently, too, there is heat of the system. When this local in- 
flammation of the stomach, throat, or face, takes place, the whole body will become 
more or less excited; — so that we have general pyrexia. In this case, it is necessary 
to omit the medicine immediately; — not to lower the dose, but to omit the medicine 
altogether; and the symptoms generally decline; though it may be necessary to apply 
leeches freely at the pit of the stomach, or to bleed. I never, but once, saw any 
harm ensue; and in that case the remedy had been carried on very injudiciously. 
If, while giving arsenic, we look carefully at the patient's face, and ask about his 
throat, and also respecting the state of the stomach, — as to whether there is pain, 
tenderness, nausea, heat, or vomiting, — I believe no harm can arise. 

Arsenious Acid. — It is asserted, but I cannot say from experience whether it is 
correct, that when Liquor Potassae Arsenitis has failed, pure arsenic has succeeded; 
— that is to say, what is called "arsenic" in commerce, has succeeded; when its 
combination with potassa, according to the directions in the Pharmacopceia,* has 
failed. It is said that about the sixteenth of a grain may be given, three or four 
times a day; that the eighth of a grain can seldom be borne; but that the sixteenth 

» The mention of the Pharmacopoeia, gives us an opportunity of recommending to the 
attention of our readers — " Diagrams, explanatory of the Chemical Decompositions of the 
London Pharmacoposia, and of the various Processes used in Medical Chemistry; by Tho- 
mas Harper Whitaker." The plan adopted in these Diagrams, is that invented by Dr. David 
Boswell Reid (see his " Elements of Practical Chemistry"); and is far superior to any other 
in perspicuity. We may also mention a kindred work, the title of which is of too unpro- 
fessional a character to accord with our taste:—" Sparks from the Wheel of a Man wot 
Grinds. A Light on the Pharmacopoeia." Both these works are published by Butler, Me- 
dical Bookseller, St. Thomas's Street, Southwark. ^ 



282 INTERMITTENT FEVER. 

of a grain succeeds very well. This is stated by Dr. Macculloch, in his first volume 
on "Marsh Fever;"* JDut I never exhibited it. Many other minerals, which are 
astringents, wmU cure cases of this disease; — sulphate of zinc, oxide of zinc, sul- 
phate of copper, and alum. Muriate of ammonia is likewise said to have a power 
over the thsease; and it is thought by many, at least abroad, that it heightens the 
power of bark. Carbonate of potass is supposed to possess some virtue. A com- 
bination of some of these things is thought to be best; but no doubt sulphate of zinc, 
and sulphate of copper, will frequently cure the disease. 

Opium, Sudorifics, and Emetics, — As a full dose of sulphate of quinina, or a 
full dose of bark, is found more useful immediately before the paroxysm, than at 
other periods of intermission (except immediately after it is over), so various other 
remedies have been employed at this periods These have been of various kinds; 
— sometimes medicinal; and sometimes calculated only to make an impression on 
the mind. Immediately before the beginning of a paroxysm, a large dose of opium 
has sometimes prevented it from coming on violently. Sudorifics and emetics 
have been employed for the same purpose. Mental emotion has been excited at 
the moment with a similar view; so that a child has been flogged out of his ague, 
or frightened out of it by threats. He has been threatened with a good thrashing, 
if his ague came on; and there can be no doubt that this has cured his complaint. 
Sometimes by exciting disgust, — by insisting that a person should swallow spiders 
and cobwebs, the paroxysm has been prevented. Some persons, however, imagine 
that the latter really possess a power in preventing the disease. I have no personal 
knowledge of the virtue of spiders and cobwebs; but Dr. Chapman's work on Ma- 
teria Medica,'' contains a very strong testimony in favour of the soothing eflfects of 
cobweb. He mentions that it will procure sleep in fever, and tranquillize the system, 
when all other things have failed. I know that many persons declare that it has a sort 
of sedative quality; and there is no reason why it should not; but, in the cure of ague, 
it has been employed merely with a view of exciting disgust; and has succeeded. 
These effects might be produced at any time during the intermission; but it is 
immediately before the paroxysm that disgust, or fright, or violent emotion of 
mind, is most likely to be of use. 

Great Value of Bark and Quinina. — The great remedies for the disease, how- 
ever, are quinina and arsenic, — all other means being more or less uncertain, except 
perhaps salicine. I never think now of employing any thing but quinina; though, 
in particular circumstances, I might be induced to order venesection. These two 
medicines (quinina and arsenic) are equally good in other complaints of an inter- 
mittent, though not aguish, character. In intermittent rheumatism and neuralgia, 
they are among the best remedies. It is a singular circumstance; but, even in in- 
termittent vomiting, arsenic has been known to effect a cure, In the volume of the 
^♦Transactions of the London Medical Society" for 1817,'' there is a paper by Dr. 
Adams, on periodical vomiting, coming on at certain intervals; which was cured by 
what would, in many cases, have /}roc/wce(/ vomiting; — a small quantity of arsenic. 

a In as far as it does fail, there is reason to think that the fault is very often in the remedy 
itself; and I cannot concede that the well-known combinaiion of this sulDstaTice (or, rather of 
its primary acid), with potash,— commonly called " Fowler's Solution,"— is the proper mode 
of using it. It is certain, at least, that when this has failed, the same substance (or the com- 
mon arsenic of the shops) in powder, has often succeeded, and even immediately. Of this 
the sixteenth part of a grain is equivalent to the common dose of the solution, and is capa- 
ble of being repeated three or four times in the day; while it is conveniently divided by 
means of white sugar; which also aids in reducing it to that fineness of powder, which can- 
not be too perfect. With respect to the superiority of arsenic in substance to its neutral salt, 
[arsenite of potash,] I may quote the experience of a friend, who — residing in a district 
where "tic douloureux" is extremely common, and where the solution seldom succeeded— 
now reports to me; that he finds the powder almost infallible;— giving it without the least 
inconvenience to the extent of one-twelfth of a grain for a dose, and finding that its utmost 
limit is one-eighth; which, however, can seldom be endured; though he has administered 
one-sixth, without further evil consequences than griping.— "-E55«7/07i Remittent and Inter- 
mittent Diseases; includins^ {generically) Marsh- Fever and Neuralgia. By John Maccul- 
loch, M. or Volume 1; Pages 452 and 453. 

* See Note to Page 273. <= Volume 1; Part 2; Page 89, 



INTERMITTENT FEVER. 283 

Whenever complaints assume an intermittent form, whether they be aguish or not, 
the sulphate of quinina, and arsenic, are among the best remedies. If either of 
these failed separately, I should not hesitate to give them both together. I have 
failed with arsenic, but not with quinina. Whenever a case was obstinate, I in- 
creased the dose to the largest quantity the stomach would bear. 
• Is it Dangerous to Stop an jJgue? — It was formerly imagined that ague was 
too good a thing to be cured; — that it was very wrong to slop it. At any rate, 
many contended that it ought not to be stopped, till the patient had gone tlirough a 
certain preparation. I have astonished many persons (who, when abroad, were 
accustomed to see'some preparation employed before the remedies for ague were 
given) by stopping the disease immediately. I never saw any harm done by it; 
though if there be any local affection of the head, chest, or abdomen, we must take 
care to attend to that at the same time. If there be any congestion of the head, 
lungs, or abdomen, it may be necessary to bleed, to purge, and to use all the reme- 
dies for such a state as that; for if we do not, it is possible that the circumstance 
of stopping the ague at once, may be useless. If we do every thing indicated by 
the local affection, I am quite satisfied there will be no danger in stopping the ague, 
I never did harm by it in a single case. I never lost a patient from ague; notwith- 
standing that I gave sulphate of quinina when local inflammation was present. 
Arsenic, 1 need not say, may be very proper when the inflammation which is pre- 
sent affects the stomach; and in the case of gastritis, possibly neither arsenic nor 
quinina can be borne; and we do not remedy the morbid condition, till we adopt 
either local or general bleeding. 

So far from the stoppage of the ague doing any harm, I have found any local 
disease that might be present, removed the more easily; for every attack of ague 
of course disturbs the circulation, renders it more irregular, and is likely to throw 
a greater load of blood upon those organs which are already in a state of conges- 
tion. At any rate, ague always makes bad worse. I have always considered that 
I have treated local complaints more successfully, by having stopped the ague. 
Sydenham says — "Cure the ague first, and then you will easily cure the dropsy; 
which otherwise might be impossible." I never saw any chronic complaints ensue, 
on stopping ague. I believe they do not arise from the ague; but are, like ague itself, 
the result of malaria; and I know that, for many of them, one of the best remedies 
is sulphate of quinina, bark, or arsenic. I have seen many cases of dropsy 
vanish, on the exhibition of sulphate of quinina, without any thing being conjoined 
with it. If we stop the ague, all those effects which are ascribed to it, whether 
they be acute or chronic, are cured more safely. Still it is possible that ague 
sometimes may not give way, till we have remedied the local mischief. It is said 
that, now and then, ague will not yield to any thing, till we make use of local 
bleeding. Many say they have met with cases, where bark would not cure the 
disease, till they made the patient's mouth sore. I never met with a case of that 
description; but still it is so asserted. If what is said be correct, such a practice 
must be adopted; but I should, nevertheless, in such a case, go on with the quinina, 
while I was giving the mercury, or making use of local means. 

Prevention of Ague. — With regard to the prevention of ague, the great point 
is to drain the country, and to prevent all accumulations of dead vegetable sub- 
stance; — in order to prevent, as much as possible, exhalations from putrefied 
vegetable matter. When land cannot be drained, occasional inundations may be 
necessary; — in order to throw more water upon it than is compatible with vegeta- 
ble decomposition. With regard to individuals who must be exposed to ague, the 
best mode of preventing it is to live as well as possible; to have good food; a cer- 
tain portion of wine or beer; and never to expose themselves to malaria with 
empty stomachs. Persons so situated, ought always to take something before 
they go out of doors; and where malaria is very intense, spirits may be found 
necessary. Smoking is an excellent preventive, in damp places. I mentioned'^ 

• See Page 259. 



284 CONTINUED FEVER. 

that when Napoleon was in Italy, he found the advantage of keeping up good fires, 
in preventing disease. When persons are obliged to live in a house wliere there is 
malaria around, it is best to sleep as high as possible; — raiher to condescend to 
sleep in a garret, than to aspire at sleeping in the best apartments; and it is of 
great importance to avoid going out at night, or very early in the morning. It is 
said that a gauze-veil around the head, when persons must be exposed, is likewise 
of use. It might be highly beneficial for a person exposed to malaria, to take 
gulphate of quinina. 



CHAPTER V. 

CONTINUED FEVER. 



Definition. — The same constitutional symptoms which occur in any intense 
local inflammation, are those which, generally speaking, characterize continued 
fever. There is quickness of pulse, increased heat, and diminution of the secre- 
tions. From the latter circumstance we have thirst, dryness of the skin, scanty 
and high-coloured urine, and costiveness. There is usually restlessness and 
watchfulness. At first, as at the beginning of inflammation, and as in intermittent 
fever, there are the opposite symptoms of chilliness (even amounting to rigors), 
coldness, paleness, and smallness of the pulse; but these, in general, last only for 
a time. Andral, according to some observations which he made at Paris, in 1822, 
on two hundred. and twenty-nine cases of fever, says that chilliness rarely occurs 
on the first two or three days. However, I have been attentive to this circum- 
stance; and I know that people in London, at the very beginning of continued 
fever, do frequently complain — more frequently than not — of chilliness; and of 
those symptoms which are analogous to the first stage of intermittent fever. If, 
however, these symptoms do take place, — rigors, chilliness, and smallness of the 
pulse, — they usually last but for a short time. 'J'hey soon yield to symptoms of 
excitement; and these symptoms continue throughout the disease; though per- 
haps, after a time, they are united with symptoms of great debility; — just as is 
frequently the case in inflammation. 

When those symptoms, which I have now mentioned, occur quickly and acutely, 
they show the existence of continued fever; more especially if the morbid appear- 
ance of the tongue, the heat, the quick pulse, and the thirst, be out of all propor- 
tion to any signs of local inflammation that may exist. In these circumstances we 
consider that the patient has fever, in the proper sense of the wonVj—idiopathic 
fever; — fever as distinguished from mere pyrexia. Local inflammation frequently 
exists at the same time; but whether local inflammation is always present or not, 
is a theoretical question upon which I will not now enter. These symptoms, 
however, very frequently occur without any evidence of local inflammation; and 
are as frequently out of proportion to any' that we may observe; and it is this 
circumstance that makes us consider the person as labouring under fever, pro- 
perly so called. 



SECTION I.— SYMPTOMS AND PROGRESS. 

The general symptoms of continued fever vary; — from those which characterize 
an active inflammation, down to those which accompany an atonic or a passive 
inflammation, or even those which denote mortification; — so that we have symptoms 
of activity and strength, and all the intermediate shades and degrees, down to symp- 



CONTINUED FEVER. 285 

toms of extreme prostration of strength; and even a disposition to putrescency in the 
fluids of the body. 

Early Symptoms. — In an attack of fever, there is (from the first) more affection 
of the head, than when the constitutional symptoms of mere inflammation occur. 
There is generally (at first) more or less confusion, giddiness, and drowsiness; 
perhaps even stupor or watchfidness. There is generally, from the first, pain of 
the loins; with a complete loss of appetite, and a general sense of debility. The 
countenance, too, in fever, is almost always expressive of heaviness and anxiety. 
The countenance of continued fever, is exceedingly characteristic; the patient is 
both very heavy in his look, and is evidenUy, at the same time, labouring under a 
degree of uneasiness. Sometimes, in these circumstances, the face is pale; but 
still there is the heaviness and the anxiety. Sometimes the face is flushed, and the 
eyes look red; and there is frequently great heat of the head. The vessels feel to 
the patient to throb; and they feel so likewise to the medical attendant. There is 
then great pain usually felt in the forehead. The tongue is generally tremulous;— 
whatever may be its appearance as to dryness or colour. The extrem.e feeling of 
weakness, and the aching of the loins, in the beginning of this disease, are no less 
characteristic than the countenance. 

Heat of the Surface. — As to the particular symptoms to which I have just now 
alluded, the heat is sometimes intense. The temperature of the body will some- 
times rise to 104°, 108°, or 110°; and sometimes it is of that peculiar character 
which authors have denominated mordant; — a pungent, or biting heat. Galen, Sir 
John Pringle, and Sir Gilbert Blane, all speak of " mordant heat." Galen, when 
treating of autumnal remittent fever, says, that the great mark of it is the mordacity 
and acrimony of the heat; which erodes the touch, just as smoke does the nose and 
eyes. (" Maximum indicium est mordacitas et acrimonia caloris; quae, perinde ac 
fumus nares et oculos, sic ipsa erodere tactum videtnr.") This peculiarity of heat 
is not felt, he says, the moment the hand is applied; but is perceived on continuing 
the hand upon the patient for a certain time. Sir Gilbert says, that in ship-fever, 
there is a peculiar heat of the skin; — a glow of heat imposed upon the palm of the 
hand of the practitioner, who has grasped the wrist of the patient; and which lasts 
some hours, if the hand he not washed sooner. He adds, that he never saw this 
in the sporadic fevers of England; though he has been informed of its occurrence. 
Andral also mentions the same circumstance. He says that, in the continued fever 
of Paris, the heat of the skin was in one case very high, acrid, and mordant; — 
leaving a sense of heat for some time upon the hand of the practitioner; — a sensa- 
tion, he says, very nearly allied to pain. ("La chaleur de la peau etoit devenue 
tres elevee, acre, et mordicante. En Laissant quelque terns le doigt en contact avee 
elle, on eprouvoit une sorte de sensation penible, voisine de la douleur.") Some- 
times, however, the heat is not increased in fever; or if it be increased, it is only 
partially; and it varies in degree at different times. Occasionally, the temperature 
in fever is below what it ought to be; and, in the last stage, there is sometimes 
absolute coldness. 

The Pulse. — The pulse, like the temperature, is generall}^ increased. The pulse 
in continued fever may be full or hard, soft, small, or weak. Like the temperature, 
it may be of all degrees. As the temperature may be from 110°, down to far 
below the natural standard, so the pulse may he quick, full, hard, and strong; or it 
may be more or less slow. It may be so feeble, as to be easily extinguished; — to 
be what is called a " fluttering," or a " vermicular" pidse. It varies in this way, 
according to the tonic or atonic character of the disease; and according to the stage 
of the affection. In examining the pulse, if there be signs of debiliiy, and the 
pulse be strong, we ought to examine the actual state of the circulation at the heart 
itself. We ought, if we be in any doubt, to resort to that method; for occasionally 
Ihere may be the extreme debility of fever, with rather a strong pulse. The heart 
may be in a slate of disease; which, in consequence of not having seen the patient 
before his present illness, we may not be aware of. The heart may be gready 
thickened; and, although it may be acting less forcibly than it did before the attack 



286 CONTINUED FEVER. 

of fever, yel it may act (from its thickness) so as to produce a full pulse; — such a 
pulse as might incline us to adopt active measures. * 

The quickness of the pulse in fever may amount to about 200. Such a pulse as 
that cannot be counted at the wrist; but we may count it, with perfect ease, at the 
heart itself. The usual range of the pulse, however, in continued fever, is from 90 
to 160. Occasionally it is not quick; — just as the heat occasionally is not increased; 
nay, it is sometimes even slower than it should be. This takes place chiefly when 
the head is very much oppressed. It occurs sporadically from the state of the 
head, or from some peculiarity in the individual's constitution. It has, however, 
occurred epidemically. There have occurred epidemical fevers, in which one of 
the characters was slowness of pulse. De Haen mentions a sporadic case of very 
severe fever, in which the pulse was only 44. Sarconi, in his account of an 
epidemic which prevailed at Naples, states that the pulse was hardly more than 40 
in a minute, in some cases. 

Occasionally in fever the pulse is regular; while in health it is intermittent. 
Many such instances are upon record. Andral mentions a case of fatal fever, 
where the pulse at first was intermittent; but as the symptoms grew worse and 
worse, the pulse became more and more regular; till at last it was perfecdy so. 
Rasori, the celebrated Italian physician, mentions the case of an individual, in whom 
the pulse was regular till the fever was over; and then it became intermittent. He 
therefore inferred that his pulse, in health, was naturally intermittent. De Haen also 
mentions the case of a man, who had an intermittent pulse at all times, except when 
he was labouring under fever. Monro and Shenkius mention such cases; and Dr. 
Heberden himself saw two persons, whose pulse was always intermittent, except 
during illness. Dr. Heberden knew a female, who had intermittent pulse all her 
life; and who at last died of cancer of the womb; but in whose circulating system 
an able anatomist could discover nothing unhealthy. 

State of the Skin. — The skin in fever is usually dry; but, as a favourable change 
takes place, it becomes more soft; and the moisture is for the most part general. 
Sometimes, however, in fever there are partial sweats, which are by no means 
favourable; and when death is near at hand, then the sweats are generally both cold 
and clammy. Sometimes the sweats are offensive; especially if there be great 
debility. IFpon the skin are not unfrequently seen spots; — discolorations of 
various sizes. If they be exceedingly small, they are called petechise; if larger, 
they are termed vibices;"" if still larger, they are denominated ecchymoses. These 
spots are of various shades; from a tolerable bright redness, down to a purple hue. 
They occur particularly in the last stage of the disease; where there is extreme de- 
bility; but sometimes they occur where there is not great debility. At particular 
periods, continued fever is characterized by them; and I once saw a greater 
number of instances of that description within three months, than I had ever seen 
before during many years. 

State of the Tongue. — The tongue is usually dry in fever. With respect to colour, 
it may be white, or yellow, and loaded; it may be of a whitish brown, or really- 
brown; or it may be absolutely black. Occasionally it is brown down the middle; 
and has a broad white band on each side; — the edges, perhaps, being red. It is 
sometimes of a reddish brown. Occasionally it is red, glazed, smooth, and dry; and 
not unfrequently, in these circumstances, it is cracked also. It is very common to 
see it more or less while or brown on the back; with redness at the tip, or redness 
at the edges. Occasionally it is extremely pale. When the tongue is of a reddish 
brown, or really brown, or absolutely black, we usually have likewise collections 
of black matter about the teeth and lips; — "sordes,'"* as they are called. They are 
the result, no doubt, of vitiated secretion; and sometimes they are partly the result 
of a little effusion of blood, which coagulates; and, uniting with the secretion, con- 
tributes to their formation. The tongue is generally tremulous; and frequently the 
extremities are in a similar state; — so that, when the patient attempts to move, his 

a From " vibex, vibicis," a mark of a blow. ^ Filth. 



r 



CONTINUED FEVER. 287 

hands or his legs tremble; but even when they do not, we may generally observe 
a tremor of the tongue. From the dryness of the tongue, and perhaps of the fauces, 
the patient necessarily suffers thirst. The breath is frequently offensive; — much 
more so ihan the perspiration. 

The Urine.— 'The urine is scanty and high-coloured; — containing an excess of 
tlie lithales, and the purpurates (chiefly the purpurate of ammonia, but also the 
purpurate of soda); together with the yellow colouring matter, which naturally 
exists in the urine. As the fever declines, the lithates become super-lithates, 
and are precipitated; so that we have a red sediment. The urine has a strong 
animal smell; and not unfrequently it has a strong ammoniacal smell; and almost 
as soon as it is discharged, it rushes into a state of putrefaction. Occasionally the 
urine is very dark-coloured; and sometimes it is bloody. 

The Stomach. — With respect to the stomach, the appetite, for the most part, is 
lost; but — ^just as there are extraordinary instances, from time to time, with regard 
to the pnlse, (such as its being regular in fever, while it is intermittent in health,) 
— so, with respect to the appetite, there are upon record cases in which, so far 
from its being lost in fever, it was much increased. In the fifth volume of the 
"Transactions of the College of Physicians,"* Dr. Satterly mentions the case of a 
boy who laboured under typhus-fever, attended by marked inflammation of the 
head. Tlie exacerbations of the fever were always attended by a voracious 
appetite; — so that, in the midst of the fever, he would eat four meals a day; and 
each meal would have been sufficient for a stout labourer.'' Besides these four 
meals of meat and vegetables, he daily ate many pounds of dry bread, biscuit, and 
fruit.'' He had no sooner eaten a meal, than he denied that he had eaten any thing; 
so that the more he ate the more he desired: — 

" Cibus omnis, in illo, 
Causa cibi est; semperque locus fit inanis edendo."** 

If he was not fed the moment he requested it, he sucked the bed-clothes and bit 
his fingers; — in this, also, bringing to one's mind Ovid's account of Erisichthon: — 

" Ipse sues artus lacera divellere morsu 
CcEpit; et infelix minuenda corpus alebat."e 

This boy discharged several very copious stools a day; and he recovered perfectly. 
The appetite, however, usually returns as the disease declines; and when the disease 
is first gone, the appetite is for the most part voracious. Persons say there is 
nothing the matter with them; but that they are hungry. The stomach, however, 
is frequently much more affected than with mere loss of appetite. Even from the 
very first there is nausea; and, in many cases, vomiting. Sometimes the vomiting 
does not occur from the beginning; — does not make its appearance, till the disease 
has existed for a length of time. The stuff which is vomited may be mere mucus; 
or it may be bile; or it may be like coffee-grounds; and sometimes the quantity is 
very considerable 

The Intestines. — The intestines likewise suffer in this disease. There is often 
more or less costiveness: but very often tliere is diarrhoea. Sometimes the diarrhoea 
begins with the disease; and sometimes it will not come on, till the latter has 
existed for a certain period. The character of the stools is as various, as the 
character of the matters vomited. They may be very watery; or they may be 

a Page 350. 

b The boy would eat, at a meal, a pound and ahalf of beef-steaks, a large fowl, or a couple 
of rabbits; without, apparently, satisfying his appetite. — "Medical Transactions, 'published 
by the College of Physicians, in London.^' Volume 5; Page 353. 

= " Exclusively oif several basons of sago and other slops." (See the Volume and Page 
mentioned in the last note.) 

^ "Food, in his case, is a provocative to food; and his appetite is always increased by 
eating."— Ouvi's ''Metamorphoses" Book 8; Fable 11; Li7ies \QAa7id 105. 

e " He began cruelly to mangle his flesh with his teeth; and, with the view of nourishing 
his body, diminished ii."— Ovid's ^'Metamorphoses;'^ Book 8; Fable 11; Lines 1^0 and 141. 



288 CONTINUED FEVER. 

mucous, or (as the common people say) slimy. They may be (in colour) yellow, 
greenish, or white. They may be exceedingly offensive; and perhaps bloody. 

The Brain. — The functions of the brain are almost always affected. Pain, 
vertig"o, and tinnitus aurium, are very common; and sometimes there are con- 
vulsions, duhiess, or stupor; there is usually great depression of spirits; and there 
may be delirmm at night, terrific dreams, and watchfulness. 

The Breathing. — It is said, with regard to respiration, that more oxygen is con- 
sumed in the hot stage of fever (as well as during digestion and exercise) than in 
health; and that more carbonic acid is -formed; whereas, in the cold stage (as, 
indeed, after bleeding, and in dyspnoea) l^ss oxygen is consumed, and less carbonic 
acid formed. 

Excitement. — The disease, such as I have described it, may have all the symp- 
toms of mere excitement, with no remarkable debility. There is always a feeling of 
more or less debility; but there may be sometimes chiefly excitement; and only 
that debility which is inseparable from fever. The fever may be subdued; the 
morbid changes which occur in the secretions and functions, may decline; nothing 
but weakness and a degree of emaciation may remain; and recovery from these 
may speedily take place. The emaciation, I may observe, is proportionately greater 
after fever, than after any other acute disease. 

Debility. — However, this may not be the progress of the case. Signs of debility 
may appear; the breath may become very fcelid; as may also the perspiration, and 
all the dischargees; whether from the stomach, the intestines, or the urinary bladder. 
What is vomited may be like coffee-grounds; the urine may be bloody; and so may 
the faeces. Even blood may be found in the mouth; or may be poured forth under 
the skin. There may be extreme blackness of the tongue; and a great quantity 
of sordes upon the teeth, lips, and every part of the mouth. All the fluids may be 
secreted in so vitiated a manner, that they may putrefy as soon as they are dis- 
charged; and the body may become putrid direcdy after death. One cannot con- 
ceive the possibility of putrefaction of parts still alive, or of the secretions at the 
moment of their formation; but they are often as near putridity as is compatible 
with life. The secretions putrefy, the moment they are separated from the body; 
and the body itself, as soon as it is dead, will frequently rush into great putridity. 
The discharges are sometimes so offensive, that perhaps the very house is intoler- 
able. In these circumstances, the pulse is very rapid and very weak; there is 
extreme prostration of strength; and a death-like faintness is complained of by the 
patient. The face becomes ghastly; — in fact, we have the " facies hippocratica.'* 
The intellect is greatly disturbed; there is an inability to attend to any thing; a 
troublesome hiccup; catching and working of the fingers (called ^^subsultus ten- 
dinum''^^); perhaps convulsions; at any rate, cold clammy sweats; and an in- 
voluntary discharge of the urine and fieces. Still, the debility and putrescency 
may decline; and a high degree of these symptoms be recovered from. 

Varieties. — If the symptoms be purely inflammatory, — purely those of excite- 
ment, with good strength at first, and do not afterwards degenerate into debility, 
or at least not into considerable debility, the disease is called " synocha." If they 
degenerate into great debility, it is called "synochus." If, from the very first, 
great symptoms of debility appear, it has been called ^^ typhus. ^''^ Thpse are arbi- 
trary names; — the two first having the same etymology;'' but they do very well to 
express different characters of the same disease, in different individuals. When 
it is called "/y/j/iws," it is the same fever as many authors write of under the name 
"s/iip-fever," " /ios;}i7«/-fever," '^ gaolAtvex,'''' ''putrid-ieveY,^^ or ''adynamic^ 
fever." If the symptoms be very severe indeed, then it is called "typhus 
gravior;^'' but if they be mild, though it even prove fatal, it is then called " typhus 
mitior;^^ — typhus being divided into two varieties. There is every variety in con- 
tinued fever; both as to the degree of excitement and the degree of strength;-^ — from 

* " Leaping of the tendons." ^ From tv^u, to smoulder. 

« They are derived from (tuve;)^*), to continue. 

^ From a (privative), without; and ivvafAiq, power. 



CONTINUED FEVER. 289 

the very highest excitement, and a high degree of strength, down to the most 
absolute prostration that can be present; and from no puirescency, up to a high 
degree of it. 

Duration. — The duration of tlie disease, — whether active and inflammatory, or 
of great debility and even putrescency, — may exist from one or a few days, to 
several weeks; but it rarely extends beyond eight or ten weeks. Occasionally the 
disease will end with a discharge of blood, either from the nose, the intestines, or 
other parts; or with purging or sweating. Dr. Gregory* said that he once knew a 
fever terminate by a great discharge of healthy urine. Andral says that he once 
saw a fever terminate with a profuse expectoration; and once with an alternation 
of sweating and expectoration. Suppuration after the disease, a general crop of 
petechias, and even the emaciation which follows the disease, are mentioned by 
authors as happy terminations; — as critical circumstances, which were closely con- 
nected with the happy result of the affection. 

Critical Days. — These discharges, when they occur, are called "critical;" and 
the amendment is called "a crisis.''^^ The ancients imagined that a crisis occur- 
red particularly on certain days: and hence those days were called "critical." 
During the first eleven days of fever, these critical days were of a tertian character; 
so that the third, fifth, seventh, ninth, and eleventh days, were critical days; and 
were supposed to be those, on which the disease was supposed to terminate well. 
After the eleventh day, the type was supposed to be quartan^ so that the four- 
teenth, the seventeenth, and twentieth days, were then supposed to be critical. If a 
change took place, it was supposed to be most favourable and most complete when 
it occurred on those days. It might happen on other days; but it was then sup- 
posed to be less favourable. Some are of opinion that the testimony of Hipj)o- 
crates and Galen, among the ancients, and of Dr. Fordyce,'' Dr. Stoker, and Dr. 
Percival,*^ among the moderns, in favour of these critical days, is too great to be 
withstood; but others imagine that it was a mere hypothesis, founded upon the 
Pythagorean doctrine of numbers; or that it was taken from the types of intermit- 
tent fever, which the ancients supposed continued fever must very much resemble. 
De Haen says, that of one hundred and sixty-three terminations of fever mentioned 
by Hippocrates, one hundred and seven (that is, two-thirds) took place on the critical 
days; — namely, on the third, fifth, seventh, ninth, eleventh, fourteenth, seventeenth, 
and twentieth; that none took place on the second or thirtieth; and only eighteen 
(that is, one-ninth) on the other non-critical days; — namely, the eighth, tenth, 
twelfth, fifteenth, sixteenth, eighteenth, and nineteenth. The only types of fever 
now talked of here, ^ are those of fourteen and twenty-one days; — so that the com- 
mon people will say, that a patient has a fourteen, or a twenty-one day fever. Perhaps 
the vulgar only retain notions which formerly prevailed among physicians. Phy- 
sicians may have inherited these notions from the ancients; and so they may have 
come down to us, and still linger among the vulgar. The notion may be correct. 
Some persons say they do observe these things; but I cannot say that I have ever 
noticed the disease tp terminate on one day, in preference to another. The reason 
that we do not observe what the ancients did, is said to be, that we are more active 
in practice than they were. We do not let nature take her course, but endeavour to 
knock a morbid process on the head; and we cure far more cases of fever than they 
did. "We allow diseases to run on a much shorter period, than they were accus- 
tomed to do; and some ascribe the want of critical days to our active practice. To 
show the inefficacy of the practice of tlie ancients, Broussais mentions that Hippo- 
crates, in the first and third sections of his work on Epidemics, gives an account 
of thirty cases of acute disease; in which cases sixteen of the patients died, and 
the other fourteen suffered much afterwards. It must have been bad practice to 

« See Note to Page 239. 

b From x^ia-tf, the separation of something from the body. 
c See his " Dissertations on Fever." 

d " Praciical Observaiions on Typhus Fever; by Edward Percival, M. B." 
e In Lnndon, 
v< '.—10 



290 CONTINUED FEVER. 

lose sixteen acute rases out of thirty, unless in particular circumstances; — such as 
in the eastern epidemic, improperly called " cholera-morbus." Sir Gilbert Blane 
says, that, in the first and third sections of Hippocrates, forty-two cases of acute 
disease are mentioned; thirty-seven of which were continued fever without local 
affection, and five with local affection. Of these twenty-five died; — twenty-one 
out of the ihirty-seven, and four out of tl^e five. If nature had an inclination to 
perform her cures on certain days, she had there a fine opportunity; but at the 
present day we so interrupt her course, that I have never observed critical days. 



SECTION IL— LOCAL COMPLICATIONS. 

The parts most dangerously disturbed in fever, are the head, the chest, and the 
abdomen. Tiie relative proportion of disturbance, in these different regions, is 
exceedingly various; but the head and abdomen suffer most of the three; except 
where there is a particular epidemic character; or an individual predisposition to, 
or a local cause of excitement in the chest. With these exceptions, the head and 
the abdomen suffer far more, in continued fever, than the thorax. It is in hot cli- 
mates, and in hoi seasons, that the abdomen is most affected. The local disturb- 
ance, when very great, is usually of an inflammatory kind; — at least it is usually 
inflammatory at first. But as there are all degrees of the general affection, from 
tonie to atonic, so the local affections may be of all degrees of violence; — varying 
from active tonic inflammation, down to mere irritation, or extreme loss of power. 

Cerebral Complications. — To begin with the head. The local affection there, 
when very great, may give rise (as I have said before*) to drowsiness, headache, 
convulsions, vertigo, wt^tch fulness, and tinnitus aurium. But it may amount to a 
higher degree tlian this; so that we have violent headache, — such as distracts the 
patient; violent throbbing, which is visible wlien you look at the temples; intole- 
rance of light; redness of the eyes; and violent delirium. The delirium may be 
constant; and it maybe such as to require corporeal restraint. There may be loud, 
incessant, incoherent ravings; and ignorance of persons and things, which before 
were perfectly familiar to llie individual; and yet, in the midst of this, a person 
may be rational and sensible for a single moment; — he may be momentarily re- 
called by some circumstance, but is instantly off again. At the same time, there 
is a picking of the bed-clothes, and tremor. Delirium of this description, is called 
'''•delirium fer ox ''^ On the other hand, the delirium is sometimes not of this fero- 
cious character. The patient mutters to himself; there are altogether slighter symp- 
toms ofdisturbanceof the head; and it is tfien called "{/e;Vrmmm27e."'' Occasionally, 
where there is great debility, there are no symptoms of vascular excitement in the 
head; — no headache, no intolerance of light, no redness of the eyes, or throbbing of 
the temples; but merely muttering delirium. Sometimes there is great stupor, and 
a comatose stale; with or without symptoms of an inflammatory disposition in the 
head. 

Jlbdominal Complications. — As to the stomach, there is almost always ano- 
rexia," vomiting, purging, or costiveness, but these symptoms are sometimes ex- 
treme. There may be copious and intense vomiting of every thing that is taken, 
and of fluids of all descriptions. There may be violent diarrhoea, — of all kinds of 
characters. The abdomen may be excessively tender to the touch, and painful on 
the slightest pressure. It may be ext^eedingly distended; and may be especially 
painful at the epigastrium, or in the hepatic region. There may be a sense of 
burning in the abdomen, more particularly at the epigastrium; it may be felt like- 
wise up the throat, and be attended by extreme thirst. When the symptoms in 
the abdomen run high, they are extreme vomiting, extreme purging, extreme ten- 
derness, and perhaps violent pain, even when compression is not employed. 

The state of the tongue has been supposed to correspond with that of the ali- 

* See Paj2:e 288. «> '• Fierce delirium." 

« "Gentle delirium." <i Fr ova ay, without; and o^f^n:, appetit?. 



CONTINUED FEVER. 291 

mentary canal. When the internal coat of the stomach is inflamed, the tongue is 
often, perhaps crenerally, red; — either throughout, at the edges, or at the tip; but 
the agreement in the two organs is not constant. The tongue may be red in fever, 
and in other diseases, wiliiout any corresponding state of the stomach; — at least, 
without any evidence of it; and therefore the alleged universal correspondence is 
a mere assumption. A blackness of the tongue is rather indicative of the general 
debility of fever, than of a gastric affection. Thirst may be commensurate with a 
gastric affection; but it may arise simply from the intensity of fever drying the 
fauces. Again: ulceration and inflammation of the stomach or intestines have been 
found, where the tongue had not been red during life; and it is said that sometimes 
neither they, nor any abdominal inflammation, could be discovered, where there 
had been much pain of the abdomen experienced on pressure. Purging may be 
very violent wiihout inflammation of the mucous membrane; which may be found 
healthy in consistence, and even pale; — ^just as we have profuse sweating in vari- 
ous circumstances, wiihout any inflammation of the skin. It is not a necessary 
circumstance that the tongue should indicate the state of the stomach or the intes- 
tines. There is a certain correspondence between them; but it is by no means 
invariable. "Neither is it a necessary consequence that, when we see great irrita- 
tion of the stomach, and great irritation of the intestines, there should be inflam- 
mation. FreqtienUy, after such circumstances have occurred, inspections have not 
shown that inflammation existed. 

Thoracic Complications. — As to the chest, it is commonly a litde affected. In 
general, we have the breathing more or less quickened; and there is a little cough; 
and generally, if the ear or the stethoscope be employed, we find some degree of 
sonorous, or sibilous, or mucous rattle in the linigs. The symptoms may not be 
such as to attract the attention of the patient, or the practitioner, or to demand any 
measures; but if we listen with tlie stethoscope, I believe we shall generally find 
the mucous membrane of the bronchia more or less affected. Sometimes, however, 
the respiration is very i7iuch affected. It becomes very rapid; and there is violent 
cough; pain in the side, or at the front of the chest; great rattle; copious expect- 
oration; and all the decided signs of bronchitic, pleuritic, or peripneumonic affec- 
tion; — so that, at last, there is blueness of the lips and cheek, — from congestion of 
the lungs. I believe that, throughout the disease, there is more congestion in the 
lungs than actual inflammation. The affection of the chest, though it generally 
exists, is far less frequently of an inflammatory nature, than the afieclion either of 
the head, or the abdomen; and, of these two, the abdomen suffers most. 

The Blood. — If we examine the blood, we may find it buffed, and perhaps 
cupped; but frequently it is quite natural. Sometimes the coagulum is exceedingly 
loose, — corresponding with the debility; and frequendy it soon putrefies. In the 
typhoid stage of exhaustion and debility, it has been found that the chemical cha- 
racters of the blood are very depraved; — that it abounds more and more in serura, 
and less in its other constituents. As the disease is more and more characterized 
by debility, the blood at last resembles mere fibrin and serum. Litde or no chyle 
is formed; and the blood is deficient in carbonic acid, and in saline materials. Dr. 
Clanny, of Sunderland, pointed out this circumstance; and Dr. Stevens made 
similar observations. He made them in a distant locality,-'' without knowing what 
Dr. Clanny had done; — so that we have the unbiassed observations of two physi- 
cians, unknown to each other. 

[The modifications of the blood in fever and many odier diseases have lately 
been investigated by Andral and Gavaret, whose conclusions are highly interesting. 
These gentlemen found that the composition of this fluid in fevers was very 
different from what is met with in inflammations. In the latter the proportion 
of fibrin is increased, whilst the globules retain their normal standard, or are 
diminished in amount, but rarely augmented. In fevers, on the other hand, which 
do not depend upon local inflammation, such as continued fever and the exanthe- 

» London. 



292 CONTINUED FEVER. 

niata, the fibrin either retains its normal proportion or its diminished, whilst the 
quantity of the red globules remains the same or is augmented. In typlioid fever, 
(the common continued fever of Paris,) at whatever stage the blood was examined, 
the fibrin was never found to be augmented; sometimes its proportion was natural, 
whilst at others it was diminished, thus presenting conditions exactly the reverse 
of those which belong to inflammation. In the latter, too, the fibrin augments in 
exact proportion to the intensity of the disease, whilst in typhoid fever, on the 
other hand, the fibrin diminishes in the same proportion. Its quantity may fall as 
low as 0.9. Again, contrary to what occurs in inflammation, there is in typhoid 
fever, a tendency to increase of the red globules, and the earlier tlie stage at which 
the blood is examined, the more often are cases met with, in which not only are 
the globules not diminished, but very decidedly augmented in proportion. These 
alterations in the composition of the blood in fever, assist in explaining its imper- 
fect coagulation and t!ie softness of the clot. It is reasonable also to conclude that 
the frequent congestions of the spleen and other parenchymatous organs in fever, 
as well as the tendency to haemorrhages and gangrene, are largely dependent upon 
the altered condition of the blood, for M. Magendie has found that in animals, hee- 
inorrhages and congestions occur in proportion to the degree in which the quantity 
of fibrin is diminished. — T. S.] 

Other Complications. — Besides those particular parts that I have now mention- 
ed, others are sometimes very much affected. Sometimes the eyes will become 
inflamed; and sometimes the throat, bladder, or skin. Sometimes we have an 
eruption of minute vesicles, of the size of millet-seeds; sometimes we have large 
patches of inflammation; sometimes we have irregular pimples, — papulae. Occa- 
sionally we have a great discharge of blood from the intestines, and urinary pas- 
sages; a!id perhaps all this without any correspondent severity of the general 
symptoms. Sometimes we have inflammation of the parotid glands; — ending in 
abscess. Occasionally abscesses will form in different parts; and sometimes a 
great crop of boils will appear. Now and then mortification of some part occurs; 
— not general mortification within the head, chest, or abdomen (the parts which 
are aflected with inflammation in these cases); but mortification of the extremities, 
or of the loins. 'J'he debility is such, in this disease, that from a patient's lying 
long on his back, the loins are much disposed to mortify; and so may one or both 
hips. There being universal debility, the efiect of pressure is not resisted, as it is 
when we are in health. If we lie upon a part, for any length of time, in health, 
it will not produce mortification; whereas persons in the debility occasioned by- 
fever, from lying on their back, will soon have the circulation sufficiently impeded 
by the pressure to cause mortification. After fever, the mind will sometimes 
remain dull, or even imbecile, for a length of time; — sometimes for several months; 
and sometimes there is a great depression of spirits; which the patient, although 
in other respects pretty well, cannot shake off. Sometimes a hand or a foot, or 
both hands and both feet, or a whole extremity, will remain for a longer or shorter 
time bent, and little influenced by volition; — so that, indeed, a person is perhaps a 
cripple for life. I have seen several persons, wliose hands or feet have been bent 
uj) in this way, after fever; and where this state ceased after a time; but I know 
others, in whom this state of parts continued many years, and continues still. 



SECTION III.— MORBID APPEARANCES. 

The appearances after death will vary exceedingly. They are chiefly situated 
in the head, chest, and abdomen; — occasionally in one of these p:irts, occasionally 
in tivo, and occasionally in all; and, in all these parts, they will sometimes vary, 
both in their positive degree, and their relative proportion. The appearances vary: 
— from those of active inflammation, down to very slight marks of inflammation 
indeed; — where the case has been one rather of irritation than of nflammation; 
and they are sometimes those, not merely of ulceration, but of gangrene, or an 



CONTINUED FEVER. 293 

extreme degree of softening". The morbid appearances are chiefly found in the 
head and abdomen; — just as the local symptoms during life are principally situated 
there; and occasionally we find degeneration of the structure of parts, without 
much inflammation; — exactly as (I remarked'') is often the case independently of 
fever. We have softening, and various other changes, without any marks of in- 
flammation at all proportionate to those changes. 

^Appearances in the Brain. — We will begin with the head. We sometimes 
find, in the brain, more red points than usual. We sometimes find the arachnoid 
injected; — both as to its superficial portion, and as to that portion which lines the 
ventricles. The veins and sinuses are frequendy found turgid; and frequently 
there is too much serous fluid upon the brain, and in its cavities. But it must be 
remembered that, in all this, there is great room for fanciful opinion. On opening 
the brain, some will maintain that it is very healthy; and others will contend that 
there are more bloody points than there ought to be; — that the veins and sinuses 
are too full; or that there is more serous fluid than natural. We must take care, 
therefore, to be quite sure we are right, when we assert that any thing preterna- 
tural is found in the cavity of the head. It will continually happen in fever, that 
there shall be rather more bloody points than usual; without the patient, during 
life, having shown particidar symptoms of an afl'ection of the head. These ap- 
pearances will vary in diff'erent individuals, even in health; — exactly as appearances 
do in other parts of the body. To enable us to say that there are decided inflam- 
matory marks about the head, we ought to see appearances respecting which no 
one would entertain a doubt. When two or three persons difl"er in opinion, we 
ought to be much upon our guard in supposing that there is really any morbid ap- 
pearance. I know there is so much fancy in all these things, that it is absolutely 
necessary to exercise the greatest caution in drawing a conclusion. But sometimes 
we do find, in fever, more bloody points than natural in the substance of the brain. 
The vessels of the pia mater are sometimes really in a state of congestion; some- 
times the sinuses; and sometimes we find more fluid, indisputably, than ought to 
be there. This fluid is various in its appearance; — as in all other cases of aflfection 
of the head. Sometimes H is clear; sometimes turbid; sometimes fragments of 
lymph may be seen floating in it; now and then there is even eff*usion of blood, or 
(St any rate) the serum is bloody. But very often in fever, after there has been 
strong phrenitis, or strong marks of excitement of the head, we find nothing. I 
have repeatedly opened patients, w^ho have died with marks of affection of the 
head, in whom the appearances after death have been quite disproportionate to the 
symptoms which occurred during life; and others in which I doubt whether any 
one, unprepared to expect any thing in the head, would have found any thing. 
Indeed, it is said by Andral, that the morbid appearances in the head, are less than 
those in the abdomen; and I believe this to be the case. 

.Appearances in the Thorax. — If the chest happen to be the part very much 
affected, (which is rarely the case,) then we have far more morbid appearances in 
the chest than in the head; notwithstanding that many have said, that the disease 
is situated in the head. If the thorax happen to show marks of disease, we may 
find the lungs soft; — we may find them filled with a frothy red fluid; and some- 
times they will crepitate as in health, and sometimes not. Sometimes they will be 
soft, and quite impervious to the air, — especially if there have been extreme de- 
bility; and sometimes, but very rarely, they are in a state of gangrene. It is very 
rare to find them in a state of solidification, or what is strangely called " hepatiza- 
tion.'"' Now and then we find them solid and gray in different parts; — spots of 
gray solidification; and it is common to find an abundance of red frothy fluid in 
them. One of the most frequent appearances in the chest, is redness and thicken- 
ing of the bronchial tubes, because a slight degree of bronchitis is very common in 
fever. Now and then the pleura is affected. An etTusion is observed in the pleura; 
perhaps redness of the membrane; perhaps adhesions; — at any rate an effusion of 

* See Page 179. b From hita^, the liver. 



294 CONTINUED FEVER. 

lymph. Now and then even blood is found. The appearances, in fact, bear an 
analogy to those wliich are found in the head. The blood which is found in the 
heart and large vessels, is generally fluid, and of a very dark colour. As to the 
coats of the arteries being inflamed, that we shall not necessarily find to be the 
case; though some have said that in fever they are always inflamed. The inner 
coats of the arteries may be inflamed now and then, like other parts; but we may 
open scores of bodies, and find no such thing. In one case, the coronary arteries 
were ossified; and yet the patient had no symptoms of angina pectoris; which is 
said to occur when the coronary arteries are ossified. 

Jippearances in the Mdomen. — If we come to the abdomen, we shall some- 
times find marks of inflammation of the peritonaeum, or at least of the sub perito- 
naeal cellular membrane; — or we may find inflammation within the stomach and 
intestines. The intestines are in general contracted, whether inflamed or not; but 
inflammation in the intestines is very common as well as in the stomach; and is 
situated in the cellular membrane under the muscular coat, or in the mucous mem- 
brane itself. It has been long known that, in fever, the intestines are very fre- 
quently inflamed. Theophilus Bonetus, an old writer, says that inspections of 
those who died of intermittent fever, showed that the stomach and intestines 
were inflamed. (" Anatome eorum qui febre maligna extincti sunt, docet ventri- 
culum cum intestinis inflammari."*) Bartholini bore testimony to the same fact: 
— "In omni febri acuta, imminet vent^riculi inflammatio."" Sydenham says that 
the intestines are frequently ulcerated in continued fever." The knowledge of in- 
flammation existing in the intestines, and also other affections, is not altogether 
new; though the fact was neglected. When the intestines are opened, we fre- 
quently find very extensive redness; and the redness wdl sometimes end suddenly, 
as inflammation of the skin will do; and sometimes it is lost insensibly in the sur- 
rounding parts. Occasionally we find the redness extensive, — running the length 
of a foot or so; but generally it is found merely in patches. Occasionally this red- 
ness is arborescent, and has little red spots around it. The redness varies in hue, 
from a bright red to a brown, or even a purple shade, — according to the degree of 
congestion; and sometimes it is a very dark red. In continued fever, the mucous 
coat is often thickened, and it may be thickened to a great extent, or only in 
patches. Sometimes it is softened; and, indeed, all the (;oats of the intestines are 
sometimes in the same condition, — softened. On the inner surface of the intes- 
tines, — the mucous membrane, — there are frequently small, red, conical elevations, 
— pimples; like the fringes below the tongue; or little white projections, either 
conical, or with a central depression. These last appearances are observed much 
more in the inferior two-fifths of the small intestines, than elsewhere; indeed, it is 
in this situation that we find the chief morbid appearances. In the colon they are 
generally pointed. Occasionally, these white conical elevations are real pustules; 
or, at least, small follicles containing real pus; — so that we have what may be con- 
sidered pustules. 

The secretion of the intestines is diseased. The mucus is of a thicker quality 
than it should be; — sometimes almost as thick as fibrin; and sometimes it is bloody. 
The mucous membrane will frequently peel olf; not from any affection of its own, 
but from the cellular membrane which attaches it to the next coat being so brittle, 
as no longer to form a medium of union. Very frequently a quantity of blood is 
efliused into the cellular membrane, under the mucous coat. Nothing is more com- 
mon than to find ecchymosis;** — an eflfusion of blood into the cellular membrane, 
under the mucous coat. 

Ulceration of the Intestines. — Ulcerations are continually found in the lowest 
third of the ileum, nearest to the coocum; and the nearer to the co9cum, the greater 
is the degree of ulceration. I just now mentioned the frequent occurrence of red 

* " Sepulcretum, sive An'fltomia Practical' 

b " In every acute fever, the stomach is in imminent danger of inflammation." 
c See his "Opera Medica." This work has been translated by Dr. G. Wallis. 
d From tK)(v[Ji'!»y-a-i derived from ex;^ww, to pour out. 



CONTINUED FEVER. 295 

patches. In the midst of these, there is frequently ulcerntion; anil then, ag-ain, the 
surface beyond the patches is frequently pale. It would seem that supeificial in- 
flammation had taken place locally, with great severity; and in the centre had pro- 
ceeded to ulceration. But these ulcers frequently occur, also, in the little pimples 
or pustules of the glands; so that we have, in the intestines, two kinds of ulcera- 
tion; — the one superficial, givinij the idea of an abrasion (such as occurs in the 
mouth, throat, or on the organs of generation); and the other occuring in the glands. 
These ulcerations are of all sizes, and of all shapes. A portion is sometimes 
ulcerated to a very great extent; and sometimes these ulcerations are slougliy; or, 
at least, we may detach a sloughy layer of something; — perhaps sometimes a 
diseased secretion; and underneath we find an ulcer. Surrounding the glandular 
ulceration, we frequently see the mucous membrane more or less detached; and the 
ulcer, of course, extends to various depths. 

Perforation. — Sometimes it extends so deeply, as to go through all the coats, 
and perforate the peritonseum. When this occurs, there is generally sudden 
peritonitis induced. Pain is felt at a particular spot, and darts from it in all direc- 
tions; and speedy death generally ensues. Nature, however, sometimes prevents 
this (as I formerly said^) by producing adhesion; or perhaps the perforation is 
blocked up by a piece of omentum, or something else; but if this do not occur, 
violent peritonitis takes place, though not always. Occasionally the inflammation 
which is produced, is of a slow, chronic form. The patient recovers from the 
fever, but continues to labour under peritonitis, in a chronic form. Occasionally 
there is no pain; but this is rare. Generally, when a perforation occurs in the 
peritonaeum, violent peritonitis is induced; and the })atient sinks. Now and then, 
we have an abscess in the substance of the intestines; — in their cellular membrane, 
I presume. It occurs there as it does in the cellular membrane anywhere else. 
The peritoneeal and the mucous coats being sound, the matter is produced between 
them; and is contained in the cellular coal. With respect to inflammation of the 
muscular coat of the intestines, I do not believe that such a thing occurs. Mucous, 
cellular, and serous membranes, are far more frequently inflamed than muscles. It 
is rare for muscles to be inflamed; and there is sufficient of the former structures in 
the intestines to become inflamed, without supposing that the muscular coat is 
the seat of inflammation. 

The period at which these ulcerations may take place, is very various. It 
would appear that, occasionally, they will take place rapidly; because persons have 
shown them who have only had fever a couple of days; but generallv they occur 
slowly. They are more frequently observed in persons who die of fever, than in 
those who fall victims to other complaints. The large intestines are seldom 
affected; — at least, far less so than the stomach or the small intestines; and of the 
latter, it is in that portion nearest the coecum, — the lowest third of the ileum, or at 
the utmost the lowest two-fifths, — that we chiefly find these appearances,'' 

Splenic Disease. — I have in my possession a curious specimen of diseased 
spleen; — showing intense ossification. The peritoneeal coal is exceedingly thick- 
ened; — so much so that it has become absolutely while. It is not only thickened, 
so as to have become almost cartilaginous; but there is a rare occurrence within. 
The blood-vessels (I presume, the arteries) are ossified. On passing the fingers 
over any of these vessels, the coats of the vessels are fell to be bony. There is 
anodier curious circumstance. Ulceration has taken place in the peritoneal coat 
of the sjjieen; which is rather a rare thing; though sometimes we see ulceration 
beginning in a serous membrane, and going inwards. In general, ulceration pro- 
ceeds outwards (as is the case in ulceration of the intestines), till at last the 
peritoneEal coat is ulcerated; but here the external coat of the spleen is alone ulce- 
rated; — there being no ulceration beneath it. 

Stale of the Muscles. — In fever attended with extreme exhaustion, the muscles 

» See Page 71. 

*» The various morbid appearances here described, as occurring in the intestines, are well 
represented iu Dr. Carswell's plates. 



296 CONTINUED FEVER. 

(I believe) are generally soft and livid. The blood, I mentioned,* is generally fluid 
and black in the larg'e vessels; and the muscles are generally soft and livid; — a fact 
altogether corresponding with the state of the blood. I mentioned'' that if, in a case 
of typhus-fever, where there is great prostration of strength, the blood be analyzed, 
it will be found to contain less saline matter than should be there; and it is said to 
contain less carbonic acid than natural; — in fact, it is more like lymph than blood. 
The liver and spleen are rarely affected. The bile is often abundant, and some- 
times very dark and thick; but in other cases it is just the reverse; — pale and thin. 
Sometimes it is acrid, and sometimes not. The liver or spleen may exhibit marks 
of inflammation; or, if not inflamed at the time, the results of inflammation may 
be seen; — in the form of a little suppuration, &c. The organs in question may be 
softened. But all these things are very uncertain. 



SECTION IV.— DIAGNOSIS AND PROGNOSIS. 

Diagnosis. — "VVe form our diagnosis, and determine that the case is one of 
fever, in a great measure, by observing that the constitutional symptoms are dis- 
proportionate to any local affection which may exist. The constitutional symptoms 
are, of course, influenced by a local affection; but they are out of all proportion to 
it; and frequently they are altogether of a diff'erent nature. For example: there is 
often to be discovered no local sign of inflammation, or of any local disorgani- 
zation; but there is extreme debility from the very first; — a sense of debility, 
indeed, which is not observed in any mere inflammation. The countenance, too, 
is peculiar; — expressive of both anxiety and oppression. There is almost always, 
from the first, pain of the loins; and, nearly throughout the disease, tremor of the 
tongue. All these circumstances are very difl^erent from those which we see, in 
mere inflammation of the brain, or of the chest. Sometimes there is a local in- 
flammation of the liver, or of the stomach; but we have also a disproportionate loss 
of strength; perhaps a feeble pulse; perhaps a putrescent state of the body; — 
symptoms, in fact, of a character diff'erent to those which arise from mere local 
inflammation. The countenance, and the sense of debility, are very characteristic 
from the very first. 

Prognosis. — The prognosis must be taken, in the first place, from the severity 
of the disease; but we need not give an unfavourable prognosis, because the con- 
stitutional symptoms of excitement are very violent. Here general excitement is 
by no means dangerous; but when it is accompanied by extreme local excitement, 
— by marks of severe local inflammation, then there is reason to apprehend danger. 
As long as we can discover no great maiks of inflammation in the head, chest, or 
abdomen, the general excitement, however violent, is not in itself dangerous. But 
although we have no right to infer danger from extreme excitement, when there is 
no great local aflfection, yet symptoms of an opposite description are always dan- 
gerous. In proportion to the intensity of the signs of debility, is the degree of 
danger. Intensity of general excitement, is not alarming in proportion to the ex- 
citement; but the danger is proportionate to the marks of real debility. 

The marks of debility, in fever, are great rapidity and weakness of pulse. An- 
dral says that he never knew a person recover from fever, whose pulse exceeded 
140; but I believe it is well known that recovery will take place after a pulse even 
of 160, — however dnngerous such a pulse may be. Dr. Heberden mentions re- 
covery from fever, after a pulse of 180. If rapidity of pulse be accompanied by 
weakness, then of course the danger is so much the greater. Involuntary dis- 
charges of the urine and f2eces, likewise, show great danger; because they prove 
extreme debility; or extreme local affection (of the head or abdomen, for instance). 
They will arise from the patient being unconscious of what he is about, — from 
being in .a state of stupor; and they will also arise from the patient being too feeble 

• See Page 294. 



CONTINUED FEVER. 297 

to make an effort to restrain them; either of which conditions is extremely dan- 
gerous. We learn much, too, from the position of ihe patient. When a patient 
lies on his back, there is more danger than when he lies on his side; — a greater 
effort being required to maintain the latter posture; but if the patient sink in his 
bed, the danger is greater still; for it then shows that he has very little power at 
all. A person can exert the muscles of deglutition, long after he has lost control 
over those of the trunk; and an inability to swallow, therefore, is one of the most 
dangerous symptoms. The countenance, I have already intimated, is a good in- 
dex to the degree of danger. Blackness of the tongue, and of the teeth, is also 
more or less dangerous. We see patients recover every day, whose teeth have 
been covered with sordes, and whose tongue has been black; but still it is a bad 
sign. Abundance of the discharges, too, is generally dangerous, unless the symp- 
toms remit; and the danger increases in proportion to their depraved nature. An- 
other very unfavourable symptom is the discharge of blood, or its effusion under 
the skin; — forming petechiae, vibices, and ecchymoses. The larger these spots, 
the greater the danger; — vibices being more dangerous than petechiae; and ecchy- 
moses more dangerous than vibices. Still, however, the presence of petechiae in 
itself is not dangerous; for some epidemics are characterized by it; but if it be 
very considerable, and accompanied by other marks of exhaustion, then it is dan- 
gerous. Hiccup, loo, is a dangerous symptom; on account of its usually coming 
on towards the fatal termination of the disease; but, now and then, fever may 
attack dyspeptic persons; and we may have hiccup, not so much from fever, as 
from the disposition to it occasioned by the habitually weak stomach. Early de- 
bility is a very unfavourable sign. Debility, after the disease has existed for a 
fortnight or three weeks, would not be so dangerous as the same degree of debility 
at the beginning of the disease; because, if the affection be to last for a fortnight, 
and there is at the beginning the same debility which, in otiier cases, we have at 
the end of a fortnight, the debility may be such when the latter period arrives, that 
life maybe extinguished. The more intense the debility, in the early stage of the 
disease, the greater is the degree of danger to be apprehended. 

When a person has violent pleuritis, peripneumonia, enteritis, peritonitis, or any 
other local inflammation, the danger is aggravated; and the danger frequently rests 
solely upon this local affection. The age and constitution of the patient, are im 
portant considerations. Individuals of bad constitutions, who have been badly fed, 
or addicted to the vice of drinking, or have suffered from the want of proper rest, 
are very liable to fall victims to the disease. We must always consider the cha- 
racter of the epidemic; for if we know it to be of a dangerous nature, we should 
always give an unfavourable prognosis even at the outset, before dangerous symp- 
toms have come on. We are sometimes obliged to give an unfavourable prognosis, 
from the state of the patient's mind. I have often seen patients die of fever solely 
because their mind was uneasy. I have seen two or three patients, within the last 
six months, who in all probability would have recovered from fever, had it not 
been for an unfortunate state of mind. If a patient has made up his mind that he 
shall die, or some real calamity presses upon him, then the medical man has a far 
less chance of success, than if his mind be in a st^ite of happiness and tranquillity. 
If we know this to be the state of the patient's mind, we should speak with more 
caution, even thous^h things are going on favourably, than we otherwise should; 
for we have an additional enemy to contend with. We must also, in giving a 
prognosis, have reference to the power which we possess of doing our duty. 
Sometimes — through the whims of friends, or the unwillingness of the patient— 
we are not allowed to do what we desire; and sometimes we are prevented, by 
another practitioner, from being quite as active in the use of means as we wish. 
These things are all to be taken into the account. 

Favourable Prognosis.— The grounds of a favourable prognosis, are furnished 
by the decline of all the symptoms. But we must be on our guard, when the 
symptoms are declining generally; and ascertain whether all is well throughout 
the body;— -whether there may not be still existing some local circumstance, from 



298 CONTINUED FEVER. 

which danger may be apprehended. For example: fever will sometimes decline 
when the loins slough; and the patient may then die of exhaustion. A return of 
strength is one of the best signs. When a patient no lonaer sinks in bed, but is 
able to lie on his side, tlien the prognosis is favourable. We judge much from the 
countenance, and from the feeliiigs of the patient himself. It has been thought 
that deafness is a favourable sign; — at any rate, it is not an unfavourable sign. 
Many authors have thought it favourable; but why it should be so, I do not know. 
In many cases of fever, patients become very deaf; and they recover, just as though 
liiis circumstance had not occurred. The return of all the feelings of the patient to 
a state of health, must contribute to a favourable prognosis. 



SECTION v.— CAUSES. 
a. Remote Causes. 

Predisposing Causes. — T will not enter upon the exciting causes of fever now; 
but will speedily run over the predisposing causes; and the first I shall mention is 
mental depression. Many persons do not become the subjects of fever (though 
exposed to all the exciting causes) till their mind is depressed. I have known many 
persons go, year after year, to spots where fever prevailed (from some local circum- 
stance) with perfect impunity, till some calamity happened which greatly depressed 
their minds, and then they became the subjects of fever. It has been observed, 
with regard to the plague, that persons have not fallen victims to the disease, till 
they have lost a relative, or been cast down in spirits; and then they have sickened 
immediately. Diemerbroeck mentions an instance of this kind. A person escaped 
the plague, till he saw a funeral pass by; and, on inquiring who it \\*as,' he found 
that it was one of his dearest friends. He went home, sickened of the plague, and 
died. The same circumstance occurs with regard to fever, and all other complaints. 
Anxiety of mind will have the same effect; — downright grief, or anxiety lest mis- 
fortune should occur. Corporeal depression, and over-exertion of mind, will have 
the same injurious tendency. Too much muscular exertion, excess of venery, and 
debilitating circumstances of all descriptions, whether of mind or body, will lay 
the foundation for fever. The ruant of food, and bad f )od, are both predisposing 
causes. Famine and fever generally go together; and hence, perhaps, we pray in 
the same breath against "plague, pestilence, and famine."* Want of fresh air also 
predisposes to it. Adult age (or, at least, the vigorous period of it) appears the 
most inclined to it; for infants, and very aged persons, have fever less frequently 
than others. It is in adults, and not in the aged, that we most frequently see fever. 
Besides this, there appears to be a peculiar susceptibility to it in some persons: 
they will, with no evident reason, become the victims of fever, when placed in the 
same circumstances in which others escape. 

Exciting Causes. — Some o[ the predisposing causes of fever may, by their con- 
tinuance, become exciting onuses. It is possible that the continuance of debauchery 
may, without any additional exciting cause, increase the disposition so much, that 
at least the disease itself begins; — requiring nothing at all, in addition to the de- 
bauchery, to produce it. One cause, certainly, of continued fever, is exposure to 
cold; especially when the body is over-heated. Many cases of fever appear to have 
nothing to do with any other exciting cause than exposure to cold, especially when 
this is united with wet; and more particularly when the body is over-heated and 
fatigued. Besides these very common causes of continued fever, there is generally 
allowed to be one of a peculiar description; — contagion.'* Before considering this 
point, however, it will be necessary to make some remarks on the subject of con- 
tagion in general. 

* See the Litany of the Church of England. '' From " contingo," to touch. 



CONTINUED FEVER. 299 



h. Con fashion. 



Definition. — By "contagion" is generally meant, I believe, either a peculiar 
matter generated m, or a depraved secretion of, a living system under disease; 
capable of producing the same disease in others, when there is no indisposition to 
it; and more especially ifihere be a 'predisposition. 

Mature of the Contagious Matter. — I have said — "either a peculiar matter or 
a depraved secretion f because, in the greater number of instances of contagion, it 
is a depraved secretion. Very frequently it is pus; as in the case of small-pox, 
syphilis, glanders, and a variety of other diseases. In the case of hydrophobia, it 
is either mucus or saliva; and in other instances it is apparently mucus. In the 
case of the skin, it sometimes appears to be sweat; but, for what we know, it may 
be sometimes separated from the body, unconnected with the real natural secretions 
of the latter. It is possible that an emanation of some kind may take place from 
the surface of the body, or the lungs, and infect the air, independently of the aque- 
ous fluid which is separated from those organs; but whether such is the case I do 
not know. To avoid, however, the objections of those who admit such a thing, I 
think it better to say that it is '^either a peculiar matter, or a depraved secretion.*' 
I have said — ^'living system," instead of ''''animal system," in order to avoid the 
objections of those who might urge, that contagion occurs in vegetables, as well as 
in animals; and of course it is the characteristic, — the necessary attribute of a con- 
tagion, that it should be able to produce the very same disease in others. Not that 
it can produce it in a// others; because there are some that will not take a particular 
contagion; but it is able to produce it in others, who have a predisposition to it; 
or rather, I should say, who have no indisposition to it. I said — "others" (refer- 
ring to the antecedent phrase — "living system"), because contagions produced by 
one species of animals have, in many instances, affected other species; for there are 
several diseases of the inferior animals ("brutes," as they are called), which may 
be communicated to the human body. It is necessary to say, therefore, — " pro- 
duced in a living system; and capable of exciting the same disease in another 
living system;" — not of the same species merely; but "another living system,"— 
speaking at large. 

Nature of the Diseases produced by Contagion. — When diseases are so produced, 
they may be (in the first place) either a(:?^/e or chronic. What are called " the ex- 
anthemata," are acute diseases; such as scarlet-fever, measles, small-pox, chicken- 
pox, cow-pock, and the plague; and so are hydrophobia and typhus (if the latter 
be a contagious disease); whereas the itch, syphilis, porrigo elephantiasis, the yaws, 
the sibbens, and a disease (peculiar to Africa) called " laander," always become 
chronic if not checked; and are not more active at first than afterwards. Some 
contagious diseases may be considered both acute and chronic. The hooping- 
cough (if it be a contagious disease) comes on, usually, as an active disease, — with 
all the activity of the most acute diseases; and yet it may run on for a length of time; 
so that it may be either acute or chronic; whereas scarlet-fever, measles, small-pox, 
chicken-pox, hydrophobia, and typhus-fever, cannot be chronic; — they are always 
acute. Syphilis, which I mentioned as being a chronic afTection, cannot indeed be 
so considered when it first begins; but it rarely has, comparatively, the activity 
which characterizes acute diseases. Hooping-cough, however, is generally active 
at the onset; and frequently it has the activity of small-pox or measles; but it may 
run on for many weeks, — perhaps even months. Contagious diseases, both acute 
and chronic, are sometimes /e^ri'/f, and sometimes non-febrile; and therefore it is 
belter to divide them into " acute" and "chronic." Hydrophobia is an instance of 
an acute disease of a contagious kind; but it is not in the least febrile. 

Now, although we may put each of these diseases into one class or other of 
those 1 have been enumerating, yet it does not follow that a disease which is 
placed with another in one class, will be side by side with it in another class. 
These classes are all distinct;— the characteristics of each have no relation to those 
of another, The diseases which meet in one class, will not meet in another; and 



300 CONTINUED FEVER. 

the affections which are of different classes in one respect, will meet in another 
class with others. For example: hydrophobia is of the class of acute contagious 
diseases, together witii small-pox; — both are acute diseases. But small-pox is in 
the class of those which may be communicated either by the atmosphere or by 
contact; whereas hydrophobia is in the class of those that can be communicated 
only by contact, — by the application of palpable matter. Itch and syphilis meet 
in the class of those that can be communicated by contact only; yet there is no 
reason to believe that the latter occurs de novo; while, I think, we have some 
reason to believe that the former does. The cow-pock is in the class of those 
which can be communicated by contact only; and so is itch; yet cow-pock is in 
the class, also, of those which occur but once; whereas the itch is in the class of 
those which recur indefinitely. Hence we see that the classes have no relation 
whatever to each other. 

Mode of Communication. — Some of these diseases must be communicated by 
contact, either with the patient, or something that he has touched; or some pal- 
pable matter that has proceeded from him. Of this kind are itch, syphilis, cow- 
pock, hydrophobia, elephantiasis, yaws, sibbens, laander, — the three latter of which 
I have never seen, — and the glanders of horses; together, in all probability, with 
the plague, and porrigo or scald-head. Some, again, may be communicated both by 
contact, and merely by the atmosphere surrounding the patient. In the latter case, 
there must be the contact of something which has emanated from the patient; but 
then that something has not emanated in a palpable form. It is not the contact of 
any solid, or any liquid, that is to be seen; but the contact of something znmsift/e. 
Still, that something must have proceeded from the patient. The diseases which 
may be communicated both by contact with the patient, and by contact with 
something he has touched, or something palpable which has proceeded from hira; 
or which may be commnnicated by merely being exposed to his atmosphere, — are 
the small-pox, the chicken-pox, scarlatina, and the measles. The latter have cer- 
tainly been communicated by inoculation; — just like small-pox. It is probable that, 
by means of something in the atmosphere which is not palpable, but which has 
emanated from the patient, we may become the subjects of typhus, — if it be a con- 
tagious disease, — and of hooping-cough. Even if an individual touch another 
labouring under these diseases, still it is probably not the mere contact, but an im- 
palpable emanation from the patient, that gives the disease. 

Difference between Infection and Contagion. — The adjective ^^ contagions'^ em- 
braces all the diseases we have enumerated; but it is also employed, in a restricted 
signification, to distinguish those which are communicated solely by contact with 
the patient, or with something that he has touched, or with something that has 
proceeded from hira palpably; whereas the word ^^infections'''' is given to those 
diseases, which may be commnnicated by merely being exposed to the patient's 
atmosphere. The word " contagious^^ is used in the same way as the term 
''^horse.'" The latter is used to include both a horse and a mare; but it is fre- 
quently applied to the male only; and so these diseases are all continually spoken 
of as ^' contagious;^' but the word ^^contagions'' is also employed in a limited 
sense, to signify those diseases which are communicated by actual contact; or by 
touching something which the patient has touched; or something which has pal- 
pably proceeded from him. "We sometimes hear quibbles on this subject; but it 
appears to me that the word ^^ contagious" is used as I have now stated; — that we 
may separately have a contagious and an infectious disease; but that we may ex- 
press them both, according to established custom, by the word ^^ contagious." 

Diseases are Communicated more Rapidly by Contagion. — Some diseases are 
both contagious and infectious; — may be communicated either by contact (as I have 
already said), or by merely being in the neighbourhood of the patient. Now it is 
observed, that when a disease may be communicated in both ways, it is communi- 
cable more quickly by contagion, than by infection. If two persons be exposed to 
an atmosphere infected with small-pox, and we inoculate one with the virus, the 
disease will appear in him much sooner than in the other. It is a well-ascertained 



CONTINUED FEVER. 301 

fact, I think, that contagion (in the limited sense of the word) excites the disease 
sooner tlian infection, when the disease n^ay be produced in both ways. Hence, 
when a person is exposed to tlie infection of small-pox, it is the practice to inocu- 
late him as quickly as possible; — in order to bring the disease on in the artificial 
manner, before it can arise by infection. 

Diseases occasionally Contagions. — Again: some diseases are thouglit to be 
only occasionally contagious; — I use the word " contagious" generically. Catarrh 
is supposed, by many, to be sometimes infectious; but I do not know whether it is 
so. Ophtlialmia certainly appears to be sometimes contagious. In the greater 
number of casps it is not; but it would appear, undoubtedly, to be contagious in cer- 
tain cases. Erysipelas is not considered to be a contagious disease; but Dr. Wells, 
in a paper published in the "Transactions of a Society for the Improvement of 
Medical and Chirurgical Knowledge,"* furnishes very strong reasons for suspecting 
that certain instances which he details, were instances of erysipelas by contagion. 
Continued fever may be an instance of the same kind. It arises, certainly, very 
often, without contagion; but I am very much disposed to think that, in other cases, 
it is contagious. 

Contagion Limited in Time. — Some diseases, again, are contagious only^br a 
time. This is the case with gonorrhcea, and with hooping-cough. There is no 
doubt that, after a certain time, the discharge from the urethra (whether called 
"gonorrhcea" or "gleet") is perfecdy innocuous, — can communicate no disease. 
It is the same with hooping-cough. Children will continue to hoop, long after 
there remains any chance of communicating the disease to others. It is said that 
some diseases are only partially contagious. The instance of this which is 
usually alleged, is syphilis. The matter from the primary sores of syphilis, will 
communicate the disease. It is contagious enough; but it is said that the matter of 
secondary sores is not contagious. It is impossible to make experiments on this 
subject; and, therefore, I cannot tell whether those who hold this opinion are cor- 
rect or not. 

Contagions generated afresh, — Some contagions appear to be occasionally 
generated afresh. Some of those diseases which will give rise to a something 
capable of producing the disease in others, do appear to be produced denovo. The 
itch, at any rate, will sometimes occur in patients after continued fever, where it is 
not possible to trace it to any other persons. Hydrophobia, there is every reason 
to believe, will sometimes spring up in the same way. Dogs become the subjects 
of the disease, without its being in our power to trace it to any other animal; — 
where there is no probability of their having been exposed to contagion. The 
same is true of the glanders in horses. This is also said to be the case with regard 
to typhus; — that a patient has become the subject of it, from a mere common ex- 
citing cause; and that he has been known to give it to others. Of this I cannot 
speak; because I never saw typhus fever contagious. With regard to all these 
diseases, — itch, hydrophobia, and typhus (granting the latter to be contagious), 
whether or not they ever now occur de novo, still they must have had that origin 
at some time or oilier; and it is not more wonderful for them to occur de novo 
now, than that they were originally produced. There must have been a person 
who fitst had measles, small-pox, scarlet-fever, and so on; and who could not have 
derived it from any other person. If we even go to brutes, still the difficulty is 
the same; for some of them must have had the disease first of all. It must have 
occurred de novo, in some one instance or other. Indeed, it is not certain that 
small-pox, chicken-pox, hooping-cough, scarlet-fever, and measles, do not occur, 
from time to time, without contagion. We frequently see these diseases in 
chihiren who have been shut up in the country; without havintr had communication, 
directly or indiret-lly, with any others who could have had them; or having been 
near persons who had visited others sufi'ering the afi'ection; — at least, so fiu- as we 

• Volume 2; Page 213. 



302 CONTINUED FEVER. 

can trace it. It is possible, however, that an error may exist on this point; and 
that there has been communication; but, certainly, the ascertainable absence of all 
communication, direct or indirect, occurs so often, that I do not think we have a 
right to assert, that the diseases in question never occur denovo. I give no opinion 
on the subject; but I would not be positive on the negative side. 

Recurrence of Contagious Diseases. — Some contajjious diseases occur rarely 
more than once. Among them we may mention cow-pof.k, chicken-pox, small- 
pox, measles, hooping-couo^h (by which T mean the real disease, — not a spasmodic 
hoop), and scarlet-fever. We must all have seen instances of a second occurrence 
of these affections, and sometimes perhaps of a third; but the general rule is for 
them to take place but once; wliile the rest may occur more than once; and, indeed, 
some of them an indefinite number of times. Some persons contract syphilis and 
gonorrhcBa over and over again; — as long as they expose themselves. It would 
not answer the moral end of these complaints, were they (like small-pox and 
measles) to be had but once. With regard to hydrophobia, it is not known whether 
it may be had twice or not. So far as I am acquainted with the subject, both 
human beings and dogs have always died of the disease when seized with it; and, 
therefore, we cannot tell whether it may be had a second time. 

One Contagious Disease renders the Body insusccpiible of Another. — Another 
circumstance 1 may mention is, that we have an instance (or, at least, we gene- 
rally have an instance) of one contagious disease preventing another. The cow- 
pock is supposed to prevent the small-pox; and, for the most [)art, it certainly does; 
but it is to be considered, that it is not by any means proved, that cow-pock and 
small-pox are not the same disease; — the former being modified. If they be but 
one disease, the fact of cow-pock preventing small-pox merely resolves itself into 
the fact, that some contagious diseases do not usually occur more than once; but if 
they be distinct diseases, then it is an instance of one contagious disease prevent- 
ing another. 

Period of Incubation. — When a contagion has been applied, there is for the 
most part an interval before it operates; — there is usually an interval, between the 
application of the poison and the appearance of the disease. This interval is vari- 
ous in different diseases; and it is va ious in different cases of the same disease;-^ 
depending upon whether it is applied by means of the atmosphere, or in a palpa- 
ble form by inoculation. The interval of small-pox is very short, compared with 
the interval of hydrophobia; and then, again, the interval of the latter is by no 
means always the same. It will vary, from a few weeks to a few months. 

Infection prevented by Dilution. — Some of these contagious diseases which are 
infectious, — using the word '■'■ contagious'''' in a generic sense, to comprise both, 
are very easily prevented by dilution of the atmosphere. We find a great dif- 
ference in diseases, in this respect. 'J'he contagiousness of diseases which are 
infectious, or the infection of some diseases, is very easily annihilated by dilution; 
whereas great dilution has comparatively little effect on others. The infection of 
small-pox, and of measles, will sometimes operate in a very free ventilation. It is 
thought, by some, that their infection will not extend to a very great distance in 
pure air. But, at any rate, in the purest air, we see these diseases caught by 
children, in the neiglibourhood of those that labour under them; whereas other 
diseases cannot be caught, if any pains at all be taken to dilute the air. As a re- 
markable example of this, I may mention that the contagion of continued fever (if 
continued fever be allowed to be contagious) may be dissipated with the greatest 
ease. A comparatively trifling dilution of the atmosphere annind the patient, will 
prevent it from being communicated to any one; whereas a great dilution will fre- 
quently not prevent the small-pox or the measles. So easily is i!ie contagion of 
continued fever (supposing it to be contagious) dissipated, that if there be a very 
free ventilation around the patient, there is little or no danger of any one catching 
the disease; and it is asserted that, in small-pox, tlie contagion, in the worst cases, 
will not extend beyond half a yard, in the open air. Dr. Haygarth, in his cele- 



CONTINUED PEVER. 303 

brated letter to Dr. Percival,^ says that the infection of small-pox will not extend 
beyond {he distance of half a yard; and that of continued fever much less; and 
this is one reason why the contagious property of the latter has been denied alto- 
gether. 

Coiitai^ious Diseases commimicahle to Brutes. — Some contagions diseases are 
communicated from brutes to man. Hydrophobia, cow-pock, and (it would appear) 
small-pox, are of this description. Every one knows that the cow-pf)ck may be 
given to the human subject; but it is said that some experiments have lately been 
made, with success, to give the small-pox from the human subject to the cow; and 
these have been adduced as proofs that the two diseases are the same; because the 
disease produced in the cow by the small-pox matter, was the cotv-pock. The 
itch is a disease communicable from brutes to man; at least, it is said that a kind of 
itch is produced from mangy dogs. There is a peculiar disease in Germany, men- 
tioned under the name of '^ milzbrand,^^ — "inflammation of the meli." It is a 
disease of brutes, analogous to what has been called "malignant pustule;" and is 
communicable to the human subject. Many persons have had malignant pustules 
produced in them, by merely touching the blood of animals labouring under a cer- 
tain disease; or, perhaps, by merely putting into their mouth a knife wetted with 
the blood. The glanders of the horse is another disease, which may be unques- 
tionably communicated to the human subject. It is possible that all those diseases, 
which may be so communicated from brutes to man, may be given back from man 
to brutes. M. Magendie has made experiments with regard to hydrophobia. He 
inoculated dogs with the saliva of a man labouring under hydrophobia; and, he 
says, they became the subjects of the disease. The cow-pock, I believe, may be 
given from the human subject to brutes; and so, unquestionably, may the glanders. 
Whether any other contagious diseases than those I have enumerated, may be given 
from brutes to tlie human subject, I do not know; but I should think all these may 
be given back. It is said that there are some other diseases, which may be com- 
municated from .man to brutes. The plague, it is said, has affected brutes; sheep 
have been seen to catch the measles; and the disease called "trichoma" may also 
be communicated to brutes. 

Bad Health sometimes prevents Contagion. — There are some contagious dis- 
eases, to which persons are very much disposed by being out of health; — typhus- 
fever for example; whereas, other contagions act as well upon persons in heahh as 
out of it. But it would appear that sometimes bad health will prevent a contagious 
disease. It is well known, I believe, amon^ vaccinators, that they frequently 
cannot give a child the cow-pock, when it is labouring under any cutaneous affec- 
tion. It is found by many who vaccinate to a great extent, that they cannot give a 
child the cow-pock, when it is labouring under any disease, such as scald-head, or 
any chronic eruption. This may simply arise from the body being indisposed to 
take on two diseases at once; — not that the body is out of health altogether; for, a 
cutaneous disease is but a slight affection. Habit lessens the susceptibiHty to some 
contagions; at any rate, persons who are continually exposed to the infection of 
typhus-fever, in its most concentrated form, generally escape; and so with respect 
to the plague. A new comer into some situations, will sometimes suffer imme- 
diately; wdiile those who have been accustomed to it will go on witli impunity, and 
never suffer. Habit appears to have a great influence upon contagion; — ^just as it 
has with regard to the agnish effect of marsli-miasmata. 

Insusceptibility of different Persons and JJges to Contagion. — Some persons 
have an unaccountable indisposition to contagions. Some children will not take 
llie small-pox, though they sleep in the same room, and even in the same bed, with 
others labo'.ring under it. The same has been observed with regard to the measles; 
and (what is very si igular) after a lapse of time, — s )metimes a year or two, and 
sometimes longer, — the least exposure will produce the disease in the same i idi- 

» "Letter to Dr. Percival, on the Prevention of Infectious Fevers; by John Haygarlh, 
M. D." 



304 CONTINUED FEVER. 

vidual. It is well known that some persons run into the greatest risks, with 
respect to syphilis and gonorrlioea, without using any precaution; and invariably 
escape, thougli as bad as their neighbours. In fact, I have known persons of that 
description; and yet, after a time, they began to catch the disease whenever they 
ran the chance of so doing. It is the same with respect to small-pox and measles 
in young persons, as it is with regard to syphilis and gonorrhoea in adults. The 
extremes of atje are very insusceptible of many infections. Some persons, again, 
without any indisposition (so far as can be observed) escape, without our knowing 
why. A person shall be exposed, for example, to the poison of syphilis to-day, — 
the existence of morbid secretion being proved by the fact that others, yesterday 
or to-morrow, suffer from the same source, — and catch nothing; and yet, a fortnight 
afterwards, the same source may give the disease to him. Persons without any 
indisposition sometimes do escape, without our knowing why. 

Existence of Contagion Denied. — Some persons deny there is any such a thing 
as contagion. Some deny the contagiousness of one disease, and some of another; 
but there are some who maintain, that contagion was unknown in ancient times, 
and is altogether a modern invention. There is (or was) one person so convinced 
of this (in the case of hydrophobia), that he has written a pamphlet to prove it. 
He contends that it is a mere imaginary disease; that, at any rale, the symptoms 
which have occurred, have never taken place through hydrophobia. He says that 
he has inoculated himself, again and again, with the saliva of a rabid animal; and 
has escaped. His escape, however, is no proof of the non-existence of contagion; 
because many persons escape all sorts of contagions, every day. Two medical 
students, at Paris, went so far as to deny that syphilis was contagious; and, in the 
year 1823, they inoculated themselves with some syphilitic matter. They laughed 
at contagion; and gloried in having some syphilitic matter under the skin. How- 
ever, the consequence of tiiis experiment was a very bad suppuration in, and a partial 
destruction of, the axilla of one young man; — he having inoculated himself on the 
hand: while the other had a bad ulcer somewhere else; and became so distracted 
at what had happened, that he actually committed suicide, by opening the crural 
artery. Others have done exacUy the same in the case of the plague; and they 
have suffered exactly in the same way. A Dr. Whyte was convinced that the 
plague was not a contagious disease; and, therefore, in the pest-house of the Indian 
army at El Hammel, he rubbed some pus, taken from the pestilential bubo of one 
of his patients, inside his own thigh; and, not contented with this, he inoculated 
his wrist from another pestilential bubo. Four days had hardly passed, before 
rigors began; with all the symptoms of violent fever; and he died of plaaue before 
the end of the third day. It is mentioned, in the "Journal de Medecine" for May, 
1811, that an Italian doctor (called Dr. Valli), was so convinced of the non-con- 
tagiousness of the plague, that he mixed the matter from some pestilential buboes 
with a number of other things, and formed it into an ointment, which he called 
his "pomade." He rubbed this mixture on the eyelids of people who came to 
him with sore eyes; on the abdomen of others, &,c.; and thereby communicated the 
plague to thirty individuals. He was quite sure that he was doing no harm what- 
ever. The Turks, however, thought differently; for, disapproving his practice, 
they cut off his head. 

There are on record some other singular instances, of the denial of what it would 
appear almost impossible that any one would think of denying. Dr. Maclean, for 
instance, denied that plague was contagious: and went so far as to explain why it, 
or any other disease, was ever supposed to be contagious. He says that the idea 
of contagion is merely an invention comparatively modern; — that it was neither 
more nor less than a popish trick of 1.547. He would have us believe, that one of 
the popes, Paul the Third, in 1547, (after the death of our King Henry the Eighth, 
of blessed memory,) when the holy fathers were assembled at Trent, finding he 
could not manage them, — tliat he could not get them to vote his own way, broke 
up the conned by setting forth the idea of contagion: — that he stated there was a 
contagious disease in the town; — a disease that might be caught from those affected 



I 



CONTINUED FEVER. 305 

with it; and thus excited so much fear among the members of the Council, that all 
withdrew to Bologna. Thus was the celebrated Council of Trent dissolved. The 
holy men were so frightened at this invention of his popeship, that away they all 
went scampering to Bologna. 

The introductory part of Boccaccio's " Decamerone," contains a description of 
the plague at Florence.* He says, that the disease spread from the diseased to the 

» In the year of our Lord, 1348, there happened at Florence, the finest city in all Italy, a 
most terrible plague; which — whether owing to the influence of the planets, or that it was 
sent from God as a just punishment for our sins — had broken out some years before in the 
Levant; and — after passing from place to place, and making incredible havoc all the way 
— had now reached the west; where — spite of all the means that art and human foresight 
could suggest (such as keeping the city clear from filth, and excluding all suspected per- 
sons); notwithstanding frequent consultations what else was to be done; nor omitting prayers 
to God in frequent processions — in the spring of the foregoing year [1347J,it began to show 
itself in a sad and wonderful manner; and — different from what it had been in the east, 
where bleeding from the nose is the fatal prognostic — here there appeared certain tumours 
in the groin, or under the arm-pits; some as big as a small apple, others as an egg- and after- 
wards purple spots in most parts of the body; in some cases large and but few in number, in 
others less and more numerous;— both sorts ihe usual messengers of death. To the cure of 
this malady, neither medical knowledge, nor the power of drugs, was of any effect;— whether 
because the disease was in its own nature mortal, or that the physicians (the number of 
whom, taking quacks and women-pretenders into the account, was grow^n very great) could 
form no just idea of the cause, nor (consequently) ground a true method of cure. Which- 
ever was the reason, few or none escaped; but they generally died the third day from the 
first appearance of the symptoms; without a fever, or other bad circumstance attending. 
And the disease, by being communicated from the sick to the well, seemed daily to get 
ahead, and to rage the more; — as fire will do, by laying on fresh combustibles. Nor was it 
given by conversing with only or coming near the sick; but even by touching their clothes, 
or any thing that they had before touched. It is wonderful, what I am going to mention; 
which, had I not seen it with my own eyes, and were there not many witnesses to attest it 
besides myself, I should not venture to relate, — however credibly I might have been informed 
about it. Such, I say, was the quality of the pestilential matter, as to pass not only from 
man to man, but (what is more strange, and has been often known) that any thing belonging 
to the infected, if touched by any other creature, would certainly infect, and even kill that 
creature in a short space of time; and one instance of this kind I took particular notice of- 
— namely, that the rags of a poor man just dead, being thrown into the street, and two hogs 
— coming by at the same time, and rooting amongst them, and shaking them about in their 
mouths— in less than an hour turned round, and died on the spot. These accidents and 
others of the like sort, occasioned various fears and devices amongst those people that sur- 
vived; — all tending to the same uncharitable and cruel end; which was, to avoid the sick 
and every thing that had been near them; — expecting, by that means, to save themselves! 
And some — holding it best to live temperately, and to avoid excesses of all kinds— made 
parties, and shut themselves up from the rest of the world; — eating and drinking moderately 
of the best, and diverting themselves with music, and such other entertainments as thev 
might have within doors; — never listening to any thing that was without, to make them un- 
easy. Others maintained free living to be a better preservative; and would balk no appetite 
or passion they wished lo gratify; — drinking and revelling incessantly from tavern to tavern, 
or in private houses; which were frequently found deserted by the owners, and therefore 
common to every one; — yet avoiding, with all this irregularity, to come near the infected. 
And such, at that time, was the public distress, that the laws, human and divine, were not 
regarded; for the officers to put them in force being either dead, sick, or in want of persons 
to assist them, every one did just as he pleased. A third sort of people chose a method be- 
tween these iw^o; —not confining themselves to rules of diet like the former, and yet avoidino- 
the intemperance of the latter; but, eating and drinking what their appetites required, they 
walked everywhere with odours and nosegays lo smell to; — as holding it best to corroborate 
the brain: for they supposed the whole atmosphere to be tainted with the stink of dead bodies; 
arising partly from the distemper itself, and partly from the fermenting of the medicines 
within them. Others, of a more cruel disposition, — as perhaps the more safe to themselves, 
— declared, that the only remedy was to avoid it. Persuaded, therefore, of this, and taking 
care for themselves only, men and women (in great numbers) left the city, their houses, 
relations, and effects; and fled into the country;— as if the wrath of God hadbeen restrained 
to visit those only within the walls of the city; or else concluding, that none ought to slay in 
a place doonied lo destruction. Divided as they were, neither did all die, nor all escape; 
but, falling sick indifferently,— as well those of one as of another opinion,— they who first 
set the example by forsaking others, languished themselves without mercy. I pass over ihe 
little regard that citizens and relations showed to each other, for their terror was such, that 
a brother even fled from his brother, a wife from her husband, and (what is more uncom- 
mon) a parent from its own child; on which account, numbers that fell sick could have no 
VOL. I.--20 



306 CONTINUED FEVER. 

healthy, as flames spread to an unctuous substance. Not only speaking and asso- 
ciating with each other produced it, but the clothes or any thing else that belonged 
to persons who laboured under the plague, communicated it. Even brutes got the 
disease, by touching the clothes of those who died of the plague. He says: — " I 

help, but what the charity of friends (who were very few), or the avarice of servants sup- 
plied; and even these were scarce, and at extravagant wages; and so little used to the busi- 
ness, that they were fit only to reach what was called for, and observe when they died; and 
this desire of getung money often cost them their lives. From this desertion of friends and 
scarcity of servants, an unheard of custom prevailed. No lady, however young or hand- 
some, would disdain being attended by a man-servant (whether young or old it mattered not); 
and to expose herself (naked) to him,— the necessity of the distemper requiringit,— as though 
it was to a woman; which might make those who recovered less modest for the time to 
come. Many lost their lives, who might have escaped, had they been looked after at all; 
so that — between the scarcity of servants, and the violence of the distemper — such numbers 
were continually dying, as made it terrible to hear, as well as to behold. Whence, from 
mere necessity, many customs were introduced, different from what had been before known 
in the city. It had been usual, as it now is, for the women who were friends and neigh- 
bours to the deceased, to meet together at his house, and to lament with his relations; at the 
same time, the men M^ould get together at his door, with a number of clergy, — according to 
the person's circumstances; and the corpse was carried by people of his own rank, with the 
solemnity of tapers and singing, to that church where the person had desired to be buried; 
which custom was now laid aside; and— so far from having a crowd of women to lament 
over them — great numbers passed out of the world without a single person; and few had the 
tears of their friends at their depariure; but those friends would laugh and make themselves 
merry; for even the women had learned to postpone every other concern to that of their 
lives. Nor w^as a corpse attended by more than ten, or a dozen; nor those citizens of credit, 
but fellows hired for the purpose; who would put themselves under the bier, and carry it 
with all possible haste to the nearest church; and the corpse was interred, without any great 
ceremony, where they could find room. 

With regard to the lower sort, and many of a middling rank, the scene was still more 
affecting; for they, staying at home,— either through poverty, or hopes of succour in distress, 
— fell sick daily by thousands; and, having nobody to attend them, generally died. Some 
breathed their last in the streets, and others shut up in their own houses; when the stench 
that came from them made the first discovery of their deaths to the neighbourhood. And, 
indeed, every place was filled with the dead. A method now was taken (as well out of 
regard to the living, as pity for the dead) for the neighbours, assisted by what porters they 
could meet wiih, to clear all the houses, and lay the bodies at the doors; and, every morn- 
ing, great numbers might be seen brought out in this manner; from whence they were carried 
away on biers, or tables, two or three at a time; and sometimes it has happened, that a wife 
and her husband, two or three brothers, and a father and a son, have been laid on together. 
It has been observed, also, whilst two or three priests have walked before a corpse with their 
crucifix, that two or three sets of porters have fallen in with them; and where they knew of 
but one, they have buried six, eight, or more. Nor was there any to follow and shed a few 
tears over them; for things were come to that pass, that men's lives were no more regarded 
than the lives of so many beasts. Hence it plainly appeared, that what the wisest in the 
ordinary course of things, and by a common train of calamity, could never be taught, — 
namely, to- bear them patiently, —this, by the excess of those calamines, was now grown a 
familiar lesson to the most simple and unthinking. The consecrated ground no longer con- 
taining the numbers which were continually brought thither, — especially as they were 
desirous of laying every one in the parts allotted to their families, — they were forced to dig 
trenches, and to put them in by hundreds; — piling them up in rows, as goods are stored in a 
ship; and throwing in little earth, till they were filled to the top. Not to rake any further 
into the particulars of our misery, I shall observe, that it fared no beUer with the adjacent 
country; for — to omit the different castles about us, which presented the same view (in 
miniature) with the city — you might see the poor distressed labourers, with their families, 
— without either the plague, or physicians, or help of servants, — languishing on the high- 
ways, in the fields, and in their own houses, and dying rather like cattle than human crea- 
tures; and, growing dissolute in their manners (like the citizens), and careless of every thing 
(as supposing every day to be their last), their thoughts were not so much employed how to 
improve their substance, as to make use of it for their present support: whence it happened, 
that the flocks, herds, &c., and the dogs themselves (ever faiihful to their masters), being driven 
from their own homes, would wander — no regard being had to them — among the forsaken 
harvest; and many times, after they had filled themselves in the day, would return of their 
own accord, like rational creatures, at night. What can I say more, if I return to the city?— 
unless that it is supposed, and made pretty certain, that, between March and July following, 
upwards of' a hundred thousand souls perished in the city only; whereas, before that calamity, 
it was not supposed to contain so many inhabitants. What magnificentdwellings, what noble 
palaces, were then depopulated to the last person! What families extinct! What riches 
and vast possessions left, and no known heir to inherit! What numbers, of both sexes, in 



( 



CONTINUED FEVER. 307 

saw two pigs grubbing about the. clothes of a man who died of the plague; they 
then staggered and fell down dead." ('* Amendui sopra gli mal tirati stracci raorii 
caddero in terra.'"') This was actually published in 1348; and yet a man would 
seriously have us believe, that the idea of contagion was invented in 1547. 

However, some are more hardy than this. They will deny almost all sorts of 
contagion. There is a M. Lassis, of Paris, who denies all infections and conta- 
gions, except those of measles and lues venerea. But this is by no means a 
modern folly. 1 imagine that some of these persons have hoped to signalize them- 
selves by advancing something original, when they denied this or the other con- 
tagion; and particularly that those who deny many contagions, or nearly all, must 
have thirsted for fame indeed. But they are too late. They are merely dull imi- 
tators; for many persons among the older writers have denied, sometimes one 
contagion, and sometimes another. Gadbury, the astrologer, says that the plague 
is not more infectious than the small-pox, scurvy, pleuritis, ague, and gout. He 
published in 1665; and his book is called *' London's Delivery Predicted." 

There can be no doubt, that great mistakes have been committed on the oppo- 
site side, as to the contagiousness of particular diseases. We have seen"* that Dr. 
Fordyce and Dr. Cleghorn, both able men, believed that ague was contagious; 
and, when speaking of scurvy, I mentioned'' that some contended, formerly, that 
that disease was contagious. We know now, to a certainty, that neither ague nor 
scurvy is contagious. Again: some diseases, on the other hand, which we now 
certainly know to be contagious, were not supposed to be so. It is by no means 
certain, from the writings of Sydenham, that he was aware that small-pox or scar- 
latina was contagious, or perhaps even measles. He may occasionally write as if 
they were, but he attributes them to other causes than contagion; and it is by no 
means clear that he was much impressed with the fact. But other writers refer 
small-pox, and other diseases just mentioned, to causes of all kinds instead of to 
contagion; such as the faults of parents, before their children were born or pro- 
created; — any thing, in short, rather than contagion. Mistakes, it must be allowed, 
have been committed on both sides of the question. Diseases not contagious were 
formerly supposed to be so; and diseases known now to be contagious beyond all 
doubt, were formerly, at different periods, not imagined to be of that nature; and 
therefore we ought to listen, with some degree of patience, to those who deny 
that any particular disease is contagious. 

Is Typhus Contagious? — Typhus-fever is a disease, which some deny to be 
contagious; and I willingly confess, that I never saw an instance in which it 
shovi'ed that character. Nevertheless, I cannot but believe that it is frequently a 
contagious disease. Such it has proved itself at the Fever-Hospital, at Battle 
Bridge. I do not recollect an instance of its spreading; notwithstanding the expe- 
rience of many years, as physician to St. Thomas's Hospital; where, of course, 
there is always a great deal of fever. But it is to be remembered, that the ma- 
jority of cases of fever which are met with there, are generally by no means vio- 
lent, compared with what (I am told) they are at such an institution as the Fever- 
Hospital. An exceedingly small number of cases of fever are lost at St. Thomas's; 
— either because persons are admitted in the early stage, when the disease is easily 
treated and cured; or because they are not desperate cases that, in general, people 
think of taking there. I hear, however, that to the Fever-Hospital (which is a re- 
ceptacle for this disease only) patients are taken, as a matter of course, when they 
have fever, whether moderately or desperately; and therefore many are so taken, 
of whom there is no hope that the disease will be cured. The greater success at 

the prime and vigour of youth,— whom in the morning neither Galen, Hippocrates, nor 
^sculapius himself, but would have declared in perfect health— after dining heartily with 
their friends here, have supped with their departed friends in the other world. But" I am 
weary of recounting our late miseries.— Translation of Boccaccio's Iritroduction to his "Dc- 
camerone.'''' 

a " Both fell down dead upon the clothes about which they had grubbed." 

«> At Page 260. c See Page 260. 



308 CONTINUED TEVER. 

St. Thomas's, therefore, is owing (in a great measure) to the comparative mildness 
of the disease treated there. This may be one reason why the disease does -not 
appear contagious there; — the emanations from the body are not of that extremely 
powerful kind, which they frequently are at the Fever-Hospital; and it is not all 
our patients, but a very small number, who labour under the disease. In the next 
place, we have extreme ventilation, — extreme cleanliness; and this is another rea- 
son why a mild disease, at any rate, will not spread. I have no doubt there is 
the same cleanliness and ventilation at the Fever-Hospital; but they must be in- 
finitely less efficient there; because all the patients have fever; whereas with us 
generally but one or two, and rarely more than three patients with fever, are in 
the same ward; — large as our wards are. There can be no doubt that, if typhus- 
fever be very bad indeed, persons standing near the patient, even if there be good 
ventilation, may now and then contract the disease. 

Arguments for the Non-Contagion of Typhus, — But with regard to the argu- 
ments in favour of typhus-fever not being contagious, it is to be remembered that 
it is a disease, the contagion of which may be most easily rendered quite inert, by 
the dilution of ventilation; unless in some very very bad instances, on the one 
hand; or where tftere is a great predisposition to it, on the other. In the next 
place it is a contagion, which is allowed by those who stand up for its contagious- 
ness, to be resisted exceedingly, if the body be in good health, and the person be 
in good spirits. But it appears to me, that there are instances, without end, of a 
person catching typhus-fever from others. It is true, I have never met with one 
of these cases; but instances innumerable are mentioned, by those who see far 
more of the disease than I do; though I see quite as much as I wish; — perhaps 
about fifty cases in a year. There will also be found, recorded in books, cases 
without end; — such as I cannot pretend to controvert. I understand, with regard 
to the Fever-Hospital at Battle-Bridge, that every medical ofl[icer there, — physi- 
cians, surgeons, and apothecary, — have had the typhus-fever; and some more than 
once; — that every nurse, every matron, every laundress, every housemaid, and (in 
short) every body that ever had any thing to do with the place, have all had it; 
and many officers have died. Yet nothing of this kind has happened at the Small- 
Pox-Hospital, which is on the very same spot. This is very important; — as clear- 
ing up the point, whether all these persons have had it from the emanations of the 
patients there, or from the situation of the hospital. I used to see, every day, per- 
sons taken to St. Thomas's with typhus-fever, from the midst of others who have 
the disease; but I never considered that any proof of contagion. The disease 
may have arisen, in those cases, from contagion; but the fact is noi proved; for it 
may have been the situation which gave rise to it. Some fault in the house — 
some drain, or other external cause — may have caused the disease, first in one 
patient, and then in another. For infection to be proved, the individual who com- 
municates the disease must go from the place where he resides, to the spot where 
the healthy person is, and there give it to the latter. If the healthy person go to 
the sick person, and the sick person be still in the place where he was living when 
attacked, then no one can say that the disease, which the former contracts, has not 
been produced from the situation, and not from the patient. The disease may 
have arisen from contagion, — from the emanations of the patient; but this is not 
proved. If the patient go to a healthy spot, especially from an unhealthy one, 
and the disease then occurs there in others; or if any thing which the patient has 
touched, be taken from the place where the patient resides, to a healthy place, and 
there the disease takes place; — then it proves, if there be a sufficient number of 
these instances, that the disease is contagious. Many persons who have caught 
the fever at the hospital, have carried it home and given it to others, who had not 
gone near the hospital. Whether, however, this were the case or not, there are 
instances (without end) of persons having visited patients with the disease, and 
then given the disease to others where they have gone. 

Fomites. — Inanimate substances have become impregnated with the secretions 
or emanations from a person labouring under a disease; and have communicated 



CONTINUED FEVER. 309 

the disease to other persons. All such substances are called " foraites."* Amonff 
these, woollen substances are by far the most influential. All woollen substances 
imbibe secretions and emanations, and convey infectious and contagious diseases, 
far more than any other description of substance. It will be recollected that, even 
in the case of malaria, some assert that bushes will entangle it; and, on cutting 
them down, persons have been seized with intermittent and remittent fevers;'' — 
arising, in all probability, from the disengagement of a considerable quantity of 
malaria, which had been collected. Even the cutting down of woods,^ will have 
the same effect; and therefore there is something analogous to fomites, in the case 
of malaria; but it is in cases of contagion that, to inanimate substances, the term 
^^fomites^^ is applied. There are instances, without end, of the plague having 
been conveyed by old clothes. It is even said, that the plague of London was 
conveyed to Derby by that means. There is scarcely any point in medicine, of 
which there are more numerous instances, than of plague and ty pus-fever having 
been conveyed by left-off clothes. The exanthemata are frequently so communi- 
cated; and when I come to speak particularly of yellow-fever, I shall be able to 
lay some instances before you, in which this has unquestionably been the case; 
although it would appear, from the testimony of one whom I have the pleasure to 
call my friend," that yellow-fever is of different kinds; — that there are two kinds; 
one which is not contagious, and one that undoubtedly is so. I dare not say how 
long fomites will retain contagion. I know that a person who has been about 
another labouring under measles, will communicate the disease at the end of even 
a month; and that a room once infected with scarlatina, will give the disease for a 
twelvemonth. The contagiousness of fomites is best destroyed by heating them 
well.* Articles may be exposed to a high temperature; and large fires, M^ith plenty 
of smoke, best disinfect apartments. 

Sudden Cessation of Typhus. — Whenever such a thing occurs, as disease being 
produced in a healthy spot, by the approach of an unhealthy person to a healthy 
one, or the application of fomites to a healthy person, it is a proof of contagion; — 
provided the instances be sufficiently numerous; for one or two cases may be quite 
accidental. But an argument against the contagion of typhus-fever, is adduced 
from this circumstance; — that it will sometimes disappear during an extreme tem- 
perature; and will sometimes disappear altogether, without any obvious reason; 
whereas, if it were contagious (it is argued), it would spread from one to another; 
till all, or the greater part, suffered from it. It is said, that it is only a disease 
which depends upon a particular state of the atmosphere, and not upon an emana- 
tion from a diseased person; and that therefore it is suspended by the extremes of 
temperature, or will suddenly cease without any obvious reason. It is indeed true, 
that non-contagious yellow fever, and intermittent and remittent fevers, and other 
diseases decidedly not contagious, will be aggravated or repressed by extremes of 
temperature; and by causes not discoverable. But this is exactly the case, not 
only with typhus-fever, but with diseases which all people of common sense allow 
to be contagious. Epidemic small-pox is frequently checked by extreme cold. 
The plague, which (I believe) almost every body allows to be a contagious disease, 
in the strict sense of the word, (not infectious, but contagious,) is also stopped by 
extreme heat or cold. Small-pox is frequently so stopped; and also by the wind 
called '^harmattan,^^^ which also arrests the plague; and (what is curious) this 
wind will prevent persons from talcing the small-pox, even if they be inoculated. 
When that wind prevails, inoculation is commonly found to be fruitless. We have, 
therefore, the same fact with respect to diseases undoubtedly contagious, or 
infectious, or both, that we have with respect to such diseases as our remittent or 
intermittent fever; or others which depend upon something in the atmosphere, not 
proceeding from diseased persons. This objection, therefore, has no force. Hoop- 

a From '' foxnes'' fuel ^ See Page250. = Dr. Stevens, 

d The experiments of the late Dr. Henry, of Manchester, have placed this fact in a very 
strong light. 
" See Note to Page 255. 



310 CONTINUED FEVER. 

ing-cough and measles, which most persons allow to be contagions, are generally 
checked at the height of summer; and Sydenham says that scarlatina is most pre- 
valent when the summer is over. 

But there are still more remarkable facts, with respect to the stopping of dis- 
eases known to be contagious; — nay, of some diseases which are, not infectious^ 
but contagious (in the true sense of the word). Cow-pock, which can only be 
communicated by contact, will sometimes decline so much that, at one period, Dr. 
Jenner could not prosecute his inquiries into the disease, for want of matter. 
Although there was apparendy no reason for the disease not spreading as usual, — 
"in the natural way," as it is said, — from the teat of a cow to the hand of the 
human subject, it was sometimes so checked, that Dr. Jenner coidd not obtain a 
case of it. When he was publishing his work on the subject,* the very same thing 
happened; and Dr. Woodville says, that the disease did not reappear till the fol- 
lowing spring, at which time it chiefly prevails. Sometimes, without our knowing 
why, small-pox (an unquestionably contagious disease) will not affect a place quite 
contiguous to another; although it is prevailing in the one, and free intercourse is 
being carried on between them. Van Swietert mentions this; and Sir John Pringle 
says, that he saw small-pox carried by recruits into the camp; and yet it did not 
spread. Dr. Odier, of Geneva, inoculated children when the disease was not epi- 
demic; and though they were going about the streets, every day, during the eruption 
of the disease, and although there was the freest communication between the chil- 
dren who had been inoculated and others, yet not a single instance was seen of the 
disease spreading. There was something (whatever its nature might be) in the 
atmosphere, that prevented it. Sir James M'Grigor says, that the small-pox was 
raging in houses at Bombay, contiguous to the barracks; and yet no child or adult 
in the latter place imbibed the disease. There was something in the situation 
which prevented it. In Burckhardt's "Travels," there is something equally curi- 
ous on this point. This author says, — "It is a curious fact, but one which has 
been attested to me by many persons, that small-pox has never been known to visit 
the Wadykenous; which is a narrow shore, from the Cataract up to Korosko. 
But," he adds, " this disease is well known at Derr; which is close by, and where 
it is much dreaded." It was never known to pass a certain point, notwithstanding 
there was free intercourse. 

If such singularities will occur in the case of diseases known to be contagious, 
there is no reason to doubt that typhus-fever is contagious, merely because it wUl 
suddenly cease in a neighbourhood, or in a district, without our knowing why; or 
because it may be apparently arrested by extremes of temperature. Not only will 
undoubtedly contagious diseases sometimes not spread in the natural way (to use 
common language) at certain seasons; but sometimes we cannot produce a disease, 
although we inoculate for it. It would appear to be the same in the case of hy- 
drophobia. We sometimes hear of nothing but mad dogs. A mad dog is killed 
every day, sometimes, for a month; and then we never hear any more of the disease 
for a twelvemonth. Now one would suppose that the disease would be communi- 
cated from one to another easily enough; but it is impossible not to imagine that, 
at one period, there must be a far greater susceptibility to disease, than at another. 
There is no a priori objection, therefore, to the possibility of typhus-fever being 
contagious. The only question would be — "Is it a fact, or is it not?" I think 
there are sufficient instances — instances without end — of persons having communi- 
cated the disease to others. Provided there is plenty of dirt, bad living, unhealthy 
circumstances, and a want of free ventilation, I think there can be no question as 
to the disease frequently proving contagious. There is certainly a great difference 
of opinion on the subject; and it undoubtedly is not contagious to the extent that 
many believe; and great cleanliness, with plenty of ventilation, will so dissipate the 
disease, that no practitioner, if in good health and spirits, and well fed, need be 

* "An Inquiry into the Causes and Effects of the Variolse Vaccinae; a Disease discovered 
in some of the Western Counties of England, particularly Gloucestershire, and known by 
the name of ' The Cow- Pox.' By Edward Jenner, M. D.'* 



CONTINUED FEVER. 311 

afraid of it; — unless it exists in great intensity, and the emanations are applied to 
him in a concentrated state. In order to imbibe the disease, if the practitioner be 
in good health, and there is free ventdation, he must go so near to the patient, as 
to inhale his exhalations in full concentration; but if he be out of health, the disease 
intense, and ventilation indifferent, he may easily catch it. This must nriake a 
great difference in determining whether the disease is contagious or not; for there 
are very numerous instances, in which the disease does not appear to be contagious; 
yet it is to be considered that, in these cases, if the bystanders had been predis- 
posed by debility, &;c., and there had been no ventilation, it might then have proved 
contagious. The question, however, must be determined by a great number of 
cases. 

An objection to the contagiousness of typhus-fever has been raised, not only from 
the irregularity of the period at which it begins, but from the irregularity of the 
duration of the disease; yet scarlatina, although undoubtedly a contagious disease, 
is very uncertain as to its course. Scarlatina will, in different instances, show the 
eruption at very different days. Sometimes the eruption will appear on the first 
day; — the very day on which the patient is taken ill; and sometimes it will appear 
before there is the least redness or soreness of the throat. Then, — when the erup 
tion does appear, it wdl sometimes last only a day, or a day and a half, or two days; 
and sometimes it will continue ten days. No valid objection can be raised to the 
fact of typhus-fever being a contagious disease, merely because it is very various, 
not only as to the period at which it takes place, but also as to its duration; for scarlet- 
fever likewise exhibits these very same varieties. Nay, the same would also appear 
to be the case with regard to small-pox; for Sydenham speaks of an epidemic small- 
pox, in which the eruption took place on the fourth day; which is not the usual 
period at which it occurs. 

Causes which Facilitate or Retard the Contagion of Typhus. — Granting, how- 
ever, that it is contagious, there are various reasons for explaining the circumstance 
of its frequently not spreading far; — it may not be always contagious, but only 
occasionally so; like erysipelas, perhaps. Another reason is, that persons (for the 
most part) escape the influence of the contagion, if they be in good health and 
spirits while exposed to it. I presume that neither good health, nor good spirits, 
nor good nourishment, nor any other good thing, however favourable to health, will 
render a person less disposed to catch the small-pox, or to catch syphilis; but it is 
a fact, that if a person be in excellent health and spirits, — if he have every means 
of promoting health in his power, — if all be healthful in and about him, he may be 
exposed to the emanations of a person labouring under the most virulent typhus, 
and yet (for the most part) escape. If, however, his mind becomes depressed, or 
if his body become debilitated in any way, then we see the same person become 
the victim of the complaint, when exposed to the emanations of a typhous patient 
in so slight a degree, that we could hardly suppose it possible for the disease to be 
communicated. Many persons are exposed, with impunity, to the emanations from 
patients labouring under typhus, till their mind desponds, or (by some chance) they 
are thrown out of health; and then the contagion, — if typhus be contagious, — acts 
as a predisposing cause; and the depression of the mind, or the accidental depres- 
sion of the bodily powers, acts as an exciting cause. We have seen* that, in the 
case of ague, a person may be exposed to malaria, and not contract the disease, till 
he gets cold and wet through; — the common original cause of the disease (the mal- 
aria) being the predisposing^ and "catching cold" the e:rci7ing* cause. Exactly 
so, in typhus, the peculiar contagion is often the predisposing^ and depression the 
exciting cause. I mentioned'' that, in the instance of the plague, persons have been 
known not to experience the disease, till they have lost some of their most intimate 
friends; and have thereby become depressed. Diemerbroeck, I stated," mentions 
an instance of this kind; and there are hundreds similar. 

These things are all to be considered, when we question whether continued fever 

a At Page 266. " At Page 298. 



312 CONTINUED FEVER. 

is contagious or not. It is allowed by those who contend for its contagiousness, 
that the contagion is one which is most easily dissipated by ventilation. In the 
next place, it is allowed by them, that if a person be in good health, and with every 
means of health in full play, he will generally escape; and if it be a fact that the 
disease is sometimes contagious, and sometimes not, and sometimes arises de novo, 
then we see another reason why some people have denied the contagion of the 
disease altogether. However, I am quite sure that much of the difference of opinion, 
on this subject, must have arisen from this circumstance; — that many diseases have 
been called "typhus," which were no such thing. There can be no doubt that 
many of the cases of continued fever which we see, are really cases of remittent 
fever,/ dependent upon malaria; — having nothing at all to do with contagion. We 
every day see cases of remittent fever, mistaken for typhus, but easily distinguished 
from it by nice observers; and persons may be exposed to such cases, without suf- 
fering the disease; and therefore typhus is continually said not to be contagious; 
"whereas the patient really labours under remittent fever, which is not a contagious 
complaint. 

Period of Incubation of Typhus. — The interval which occurs between the ap- 
plication of the poison of typhus-fever, and the appearance of the disease, is ex- 
ceedingly various; — exactly as occurs in other diseases. Dr. Haygarth says, that 
of seventy-two persons who were exposed to the contagion of typhus-fever, five 
were seized with the disease within ten days after exposure; thirteen were seized 
between the tenth and the seventeenth days; forty-one were seized between the 
seventeenth and the thirty-second day; and one so late as the seventy-second. 
This variation of interval, is the same as is observed with respect to all diseases 
acknowledged to be contagious. How long the poison may lie dormant, I cannot 
say; but to take a case from another poison, — malaria, we must remember that 
many months frequently elapse before ague is produced; so that the malaria be- 
comes the predisposing, instead of the exciting cause; and the same may be the 
case, sometimes, with respect to typhus-fever. It may exist dormant for a length 
of time; but what is the utmost period it will do so, I cannot pretend to say. It 
must have a limit, of course; but we know not what that limit is. 

Confinement and Filth. — But although the contagion of typhus-fever is ren- 
dered much more active by concentration, and both that and filth are injurious to a 
patient, and must render him more liable to be affected by the contagion, yet it fre- 
quently happens, that the utmost filth and the greatest closeness will not produce 
the disease. Some have ascribed the disease to confinement of air and to filth; 
and both these will unquestionably be injurious to the health at large; and con- 
tribute to render a person exposed to the contagion of typhus, the victim of the 
disease; yet persons are continually exposed to mere filth and confinement, with- 
out sufl?ering. In Kamschatka, the people live (seven months in the year) in 
" yourts;" which are cavities dug seven or eight feet under ground, and covered 
with a thatched roof; and which have only one small apartment, for three families 
perhaps; with a stock of provisions, consisting chiefly of dried putrid fish. In 
these pits they eat, sleep, and do every thing promiscuously; so that there is the 
most intolerable stench; which, though not perceived by themselves, is but too 
evident to travellers. Yet they have no fever. On the contrary, they are all 
healthy; wiih the exception of being liable to scurvy, which arises from the 
want of fresh provisions. The Greenlanders and Esquimaux crowd themselves 
together, and exclude the air. They have no chimneys in their huts; but an inner 
apartment, the fog and smell of which are quite suffocating to strangers. Yet they 
very rarely have fever. In general, they only experience scurvy. The habitations 
of the Russian boors, are equally intolerable to strangers; and yet it is said, they 
never have putrid diseases. Dr. Lind says, that in the slave-ships crossing the 
Atlantic, although the poor creatures are crowded below deck as much as possible, 
and at night are shut up under close hatches; and, although they sufl^er from a 
change, and some are suffocated; yet (in general) they have no infection: and if 
an accidental infectious disease enters among them, it is of a much milder charac- 



CONTINUED FEVER. , 313 

ter, than when it occurs in felons who had been transported in an opposite direc- 
tion; — owing, probably, to the opposition of a high temperature to the contagion 
of typhus. It is said (but I do not know with what degree of truth) that contagious 
fever never occurs in these slave-ships. At the black-hole in Calcutta, — an apart- 
ment forming about a cube of eighteen feet; and only opening to the west, by two 
windows strongly barred, — one hundred and forty-six persons were confined (in 
the month of June, 1756) from seven or eight o'clock in the evening, till dawn the 
next day. One hundred and twenty-three individuals were suffocated; and the 
rest were, of course, made ill. It is said, however, that the survivors afterwards 
felt only heat and extreme exhaustion; that a great many had boils; but that no 
fever was produced. Howard (the philanthropist) says, that there was no fever in 
the prisons at Venice; though they were the closest possible. He also says, that 
the prisons at Naples were close and offensive; that the people were ill; but that 
no fever was produced. He adds, that we must look for an additional cause of 
fever, than mere filth and confinement. Dr. Mounsey says exactly the same of 
the prisons at Moscow and Petersburgh; though the prisoners were crowded 
together, and had but little ventilation. But it is to be remembered that, when 
fever is introduced into such situations, it rages with the most dreadful violence; 
and it is also found that new comers into such filthy places, when contagion is 
present, suffer much more than those who have been habituated to them; — that 
contagion acts the more, on account of the bad state into which this filthy confine- 
ment throws the constitution. Those that were habituated to these situations, 
before the contagion was introduced, became gradually accustomed to it. People 
constantly live in confinement and stench, which would half poison us; but when 
strangers go into this filth, after having been in pure air, they are much more liable 
to experience the disease; and, if they suffer, it is worse in them than in others. 
Still, although, till certain contagions are introduced among people who live in 
close, dirty, and bad situations, they consider themselves as well as others differ- 
ently situated; yet those contagions, when introduced, at once act as a test of the 
tendency of the previous mode of life; and these people suffer in an infinitely 
higher degree than others; — provided there be not present any accidental counter- 
acting cause; such as great heat, in the case of typhous contagion. A' mere surgi- 
cal accident will test the previous mode of life, in two people who might have 
appeared equally healthy. 

Persons have been crowded together in the most filthy prisons, where the dis- 
cipline was frightful; where they were treated like beasts; — in a way that ice 
should not think of treating beasts; and yet no fever was produced. Various 
authors give an account of a disease which broke out at Oxford, in the year 1577, 
in the reign of Queen Elizabeth; at what was called " the black assizes," Some 
prisoners were brought out of prison, where they had been in a state of great con- 
finement, with very little ventilation, and exceedingly dirty. A strong stench 
arose, and was supposed to proceed from the prisoners. Some of the judges and 
magistrates, the sheriff, and most of the jury, were taken ill; and died in a day or 
two. Six hundred persons sickened the same night; in the next three days, three 
hundred more sickened; and before five weeks had elapsed, five hundred and ten 
had died. The symptoms are said to have been violent pain of the head and ab- 
domen, with delirium. Many contended that this was a disease produced by the 
confinement of these prisoners; — that a contagion was generated from them; — that 
although they did not suffer themselves, a contagion passed from them, and pro- 
duced this disease. But others, of equal judgment, are of a different opinion; 
and urge, on the other hand, that the disease was not contagious. It is said that 
the court was held in the yard of the casde, that was only a small distance from 
the river Isis, the banks of which were low; and it is actually recorded that a great 
damp arose; that "a breath,'^ as it is called, or ^ fog, arose among the people; 
and that, at the same time, an intolerable stench was perceived; and some seemed 
smothered. The weather was intensely hot. The disease was not tiie plague; 
and the physicians would not name it. From all these circumstances, some writers 



314 CONTINUED FEVER. 

contend that the disease had nothing to do with the prisoners; but that it was an 
exhalation, owing to the dampness of the earth; — some peculiar kind of exhalation; 
that we have no proof of its contagiousness; and that typhous contagion rarely 
affects so instantaneously. Women, children, and poor people, are said to have 
escaped. How this may be I do not know; but, to show the bigotry of the times, 
I may mention that others took up a very different opinion; and alleged that it was 
neither contagion nor exhalation; but entirely owing to the poor Roman Catholics, 
who used the art of magic. They stated that it arose from diabolical and papistical 
arts; — that it was produced by popish blasts, which emanated from the lowest 
depths of hell. This is particularly mentioned in Wood's "History of Oxford:' 
— " Some have thought, and do think, that it was devised by the Roman Catho- 
lics, who used art-magic in the design; and that also, as a certain note witnesseth, 
(Register of Merton College,) it sprung ex artificiosis, diabolicis, et plane papis- 
ticis flat'ihus; e Lovanensi barathro excitatis; et ad nos scelestissime, et clam 
emissis.''^^ This absurd opinion seemed favoured by the circumstance of a damp or 
fog having arisen in the court, as soon as sentence of loss of ears was passed upon 
a book-binder, who had continually spoken against Elizabeth's government, and the 
reformed religion. 

Another singular instance occurred at the Old Bailey, in 1750; where several 
persons were taken ill, after the prisoners had been brought into court, subse 
quenlly to close confinement. This has been supposed to be exactly a similar in- 
stance, but it appears that there are objections to it; and many contend that it arose 
from a window being open, and a draught of air coming on those who suffered. 
How this might be, I do not pretend to say; because there are many circumstances 
that might alter our opinion, if we had an opportunity of making minute inquiry. 
I can only state my belief, that typhus-fever is sometimes contagious; that it may- 
be made so in very unfavourable circumstances; — that it is, perhaps, always con- 
tagious in one sense; only that the contagion is so mild and diluted, that it comes 
to nothing; and that it belongs, like cholera, to those contagions which are not only 
powerless when moderately diluted, but powerless upon a frame free from disease, 
in full vigour, and with all or most of the causes of good health about it. We know 
from Thucydides, that before the plague of Athens, — from Livy, that before the 
plague of Rome, — and from Hodges, that before our plague in 1665, great crowds 
were collected in each respective city; that, in the latter case, the sky was serene, 
and the air stagnant; and that the rich escaped so much, that the disease is said, by- 
Clarendon, to have acquired the name of "the j?oor man's plague." 

Putrid Animal Matter. — As mere confinement will not (in general) produce 
fever, without some predisposing cause, so dead putrid animal matter is also said 
to be innocuous, while unaided. An instance of the latter is adduced with respect to 
Paris. In the course of six centuries, there were six hundred thousand bodies buried 
in Saintlnnocent's churchyard, in that city; and they were spread under ground over 
two acres. The soil, by this vast deposition, was raised above the streets; and 
there was an offensive smell; but no fever arose from it. They were partially re- 
moved, in the heat of summer, till the ground was levelled; and the workmen were 
frequently asphyxiated, — frequently fell down senseless; but none of them were 
attacked by fever, although no precaution was employed. It is said that, in Se- 
ville, there is a fetid odour from the ground where ten thousand bodies were de- 
posited, during the time of an epidemic; — that the soil cracked, and great stench 
was produced, but no fever, Howard (the philanthropist) says that, at Smyrna, 
there was a most horrid smell from the burial-ground, after the plague; and many 
corpses lay uncovered; but no bad consequences ensued to the family of the go- 
vernor, whose house was exposed to the exhalations from the spot. Dissecting- 
rooms will not produce fever; unless an individual be either exposed to contagion, 
or very much out of health; — through anxiety of mind, hard study, or some acci- 

» ''Prom artificial, diabolical, and evidently papistical blasts; stirred up from the pit [or 
hell] of Louvain; and privately and most wickedly directed against us," 



CONTINUED FEVER. 315 

dental circumstance. Persons attending a dissecting-room, will become out of 
heallfj, and be ill, and perhaps die, from the very severe effects of slight wounds; 
but I am not aware that fever which will spread to others, has ever been produced 
in tfiat way. Various diseases, confounded with fever, have been produced; but I 
am not aware that fever itself has so occurred, when there was no depressing pas- 
sion, — no anxiety from over study, want of proper rest, or any kind of excess. 
Still if mere stench, unaided by other things, and through delicacy of constitution, 
— not counteracted by the presence of the ordinary causes of health, — should im- 
pair the latter, I can conceive that fever may be produced at last. Nightmen, as 
far as I know, are as healthy as other persons; and yet their grounds are certainly 
offensive enough. A spermaceti-manufactory, the stench of which was intolerable, 
existed near Bristol for two years; but no fever was produced. It is said that, at 
a manufactory (situated at Oldland, in Gloucestershire) where bones were em- 
ployed for the purpose of procuring muriate of ammonia, an intolerable stench was 
produced; and yet no fever resulted from it. It is said that the superintendent re- 
moved to a more convenient house, situated upon a hill; and* that there he and his 
family lost their health; so that he had some idea of returning back to the offensive 
place, that he might recover his health. At sugar-refineries, where blood is kept 
till it is putrid, persons do not suffer. Leather-dressers are exposed to offensive 
smells; and yet they escape. Many persons are employed in the most offensive 
occupations with putrid animal matter; and yet fever never breaks out amongst 
them, if they possess the general means of health, and are well fed and cheerful. 
But if these persons, in the midst of stench, were in a state of famine, and conse- 
quently in great depression of mind, then (in all probability) fever would occur. 
Those who are interested particularly with this point, will immediately remember 
the examples adduced by Mr, Thackrah, in his work on the diseases of the differ- 
ent occupations of life.* Butchers are exposed to more or less stench; glue-manu 
facturers, buckram-makers, and tallow-chandlers, are all exposed to odours more 
or less offensive; and yet they enjoy excellent health; — are ten times more healthy 
than bakers. Orfila mentions the healthiness of knackeries; where there is im- 
mense putrefaction in summer, and the soil has been saturated for years. 

To show that these exhalations do not hasten the decomposition of even dead 
animal matter, the following fact is mentioned. In the neighbourhood of a dissect- 
ing-room behind the Hotel Dieii, — where the odour was so offensive that, after 
numerous petitions, the dissecting-room was removed, — ragouts, bouilli, and good 
things of all sorts kept as sweet in the midst of this horrid smell, as in any other 
situation. A veteran of the imperial guard (to mention another instance) turned 
gut maker; and said that, although his premises were truly offensive, — filled with 
enormous masses of corruption, yet nothing spoiled in his house. It cannot be 
denied, however, that although these things do not generate fever, yet they operate 
strongly when other causes come into play. Though they may all be thrown off, 
as water is from an oiled surface, when a person has no other cause of ill health, 
and is well supplied with good food, and has good spirits, yet they do produce 
mischief when other causes are combined with them. It is also to be insisted upon, 
that if actual contagion be introduced into a place which is offensive, then these 
things appear to tell; and the mischief is greater, on account of the closeness of 
the situation, and the exhalations from the putrefying animal matter. 

It is therefore certain, I think, that mere confinement, — mere exposure to the 
emanations from persons crowded together amidst the greatest filth, will not in itself 
produce fever. I think it is quite certain that animal matter, in the greatest state of 
putrefaction, does not of itself afford any thing which will produce a disease called 
" contagious." It may be that the persons so exposed are fed well; and are in good 
spirits; and have all other means of contributing to health at their command. Still, 
however, if any matter which is in a state of putrefaction,— as is, or was formerly, 
the case in dissecting-rooms; as occurs in ammonia-manufactories, and manufac- 

• See Note to Page 48, 



316 CONTINUED FEVER, 

tories and other places where putrid blood is used, and from which there are horridly 
offensive emanations; — if this alone could produce contagious diseases, we should 
have fever every day, where we have nothing but perfect health. There can be no 
doubt that, if these things throw a person out of health, then any contagion, or any 
other cause of fever, will act intensely in producing this disease. This is allowed 
with regard to cholera. Nobody believes that any putrid emanations, or any thing 
that proceeds from persons crowded together, or the putrefaction of animal matter, 
will produce that disease; but all know that these things have a tendency to throw 
people out of health; and by the body being thus brought into an unnatural state, it 
is rendered an easy prey to any other causes that are applied. 

Can the Contagion of Typhus be Generated Afresh? — There is another ques- 
tion; — whether the contagion of typhus (allowing that it is a contagion) may be 
generated afresh? There is no proof that certain contagions can be generated 
afresh; but others unquestionably may. Want of good food, want of rest, closeness 
of situation, depression of spirits, and exposure to bad air, may (by all conspiring 
together) occasion fever; but whether they occasion contagious fever, I do not 
know. I have never seen an instance of it. I have seen many young men ill 
from close studying, together with being much in a dissecting-room; — especially 
when they came fresh from the country, and were not accustomed to a dissecting- 
room, or to hard study; and were very anxious about their studies. Young men, 
when about to pass examination, — their anxiety being then so much the more in- 
creased, — have certainly had fever; but I never saw their disease spread conta- 
giously. Others say that they have seen it spread, in such circumstances. They 
tell us that typhus is a disease, the contagion of which may be generated de novo: 
but, though this is highly probable, yet one should always be cautious in listening 
to assertions in medicine; because so many assertions are made, without any ground 
whatever. 

Rarely Communicated by the Dead. — The bodies of persons dead of typhus, 
rarely (if indeed ever) give the disease; and typhus, like other epidemics, whether 
contagious or not, grows milder and milder, the longer it lasts; although it be 
spreading more and more. 

Other Noxious Exhalations. — Besides malaria being a cause of remittent and 
intermittent fever, and besides contagion being a cause of continued fever, it is 
very possible there are certain other exhalations, which do harm, — which produce 
actual disease. Sydenham had an idea, that epidemics arose from some peculiar 
changes in the bowels of the earth. It was only a fancy of his; but it is very pos- 
sible that some of these peculiar causes of disease, are exhalations let loose from 
particular spots. Berzelius mentions a curious circumstance. He was making 
experiments with seleniuretted hydrogen; and, after a certain period, catarrh came 
on, and continued a very great length of time. A quantity which he inhaled, while 
making the experiment, did not produce any inconvenience at first; — but after a 
certain period had elapsed, then (as in the case of all specific poisons) it began to 
operate. Now some persons, from such facts as these, conceive that a volcano 
may let loose a substance, capable of producing a peculiar operation on the human 
body. It is not altogether improbable that exhalations, of various sorts, may arise 
^ut of the earth; — independently of the exhalations of diseased animal bodies; and 
independently of the exhalations, from the surface of the earth, of putrefying vege- 
table matter. The subject is not at all understood; but it is certainly an inquiry 
worthy of being attended to, whenever an opportunity occurs. 

c. Proximate Cause, 

Having considered the remote causes, we next come to consider the proximate 
cause of fever; respecting which, there have been, I might say, thousands of hy- 
potheses. In these hypotheses, the writer has generally assumed some one fact 
which had no existence; or has taken up one particular circumstance, from among 
all the circumstances of the disease, and placed that as the cause of the whole. 



CONTINUED FEVER. 317 

Solidism and Humoralism. — Some assume it as a fact, that the disease is all in 
the solids; others assume it as a fact, that it is all in the fluids. Those who ascribe 
every thing in a disease to the fluids, are said to be ^^ humoral pathologists." 
Their fancy is this; — that a certain something is in the fluids, which is deleterious 
to the body: that a process, analogous to fermentation, is going on, which they call 
" concoction;" that the " peccant matter" is then separated, and the process is 
called " despumation;" and, provided it is thrown oflf entirely, there is an end of 
the disease. Now there is not the least proof of any such process occurring. 
There is proof of the depravation of the fluids; but there is no proof of concoction 
and despumation, — of a salutary fermenting and despumatory reform of the fluids 
(if I may so speak). There is nothing peculiar thrown off, when an excessive 
secretion takes place; as at the crises when great diarrhcea or sweating occurs; or 
at least, if there be, we know it not; and it is a mere fancy to say that it does 
occur. So when there is haemorrhage, there is no proof that that portion of blood 
which exudes, is more vitiated than the rest; and it is to be remembered, that it is 
only depart of the blood which escapes. All these changes of the fluids are, most 
probably, owing to the solids in the first instance. A morbid cause makes a 
peculiar impression upon the body, as a living system; it impresses the solids; and, 
by the operation of the solids, the fluids are secreted in a vicious manner, and of a 
depraved quality. It is probable that the vitiated state of the fluids, arises from the 
solids not having manufactured them properly; unless, indeed, a quantity of 
improper materials be supplied to the body; which the body, without any fault of 
its own, can make nothing of. In that case, the solids certainly are not in fault. 
They do their best; but they are obliged to manufacture (if I may so speak) a bad 
article, because they have bad materials. With this exception, I imagine that the 
fluids must become depraved through the solids; though of course they, in their 
turn, must exert an evil influence. Again: it is a fact that fever will continually 
cease, without any discharge; — without sweating, or diarrhcga, or loss of blood at 
all. It is most probable that, when these things take place, they are the result of 
the healthy change altogether. In fever, we may get a patient to sweat profusely; 
but perhaps he will not be any better for it. If, however, we lessen his disease, 
then probably he sweats. His improvement is not the result of the sweating; but 
we have brought him into an improved condition; and sweating then takes place 
spontaneously, as it were. Frequently, in fever, diarrhcea occurs without any 
relief; we stop it, and the patient is all the better for the suppression. The critical 
discharge, too, when it does occur, and when a patient is improved at the same 
time, is for the most part too small to explain the improvement. It would seem 
that the discharge is rather the consequence of the improvement than otherwise. 
The improvement occurs; and the discharge takes place, almost as a matter of 
course. 

Again: it is to be remembered that the fluids do, in fact, undergo a peculiar 
change. As the disease advances and the debility goes on, the saline matters of the 
blood are more or less deficient; and the blood becomes more and more watery. 
It is said by a friend of mine. Dr. Stevens, that we can remedy this state, not by 
the remedies for inflammation, but by supplying the deficient substances in the 
blood. Of that, however, I shall speak presenfly. 

Spasm; Debility. — Some authors have asserted, that fever is owing to a spasm 
of all the small vessels. I presume that there is spasm in fever; — that so long as 
the solids do not secrete, we must suppose that the vessels are closed, so that the 
fluids cannot escape; but though there be spasm at a certain period, when the 
secretions are all deficient, — though we allovv that this is one striking circumstance, 
yet there is no reason to imagine that it causes all the symptoms. Other persons 
have assumed, that debility is the cause of fever; but people are weak enough, 
every day, without having fever; and if debility be one of the circumstances of the 
disease, yet there is no proof that debility is the caxise of the symptoms. 

Inflammalion. — Many think that inflammation will explain' every thing: — not 
only changes of structure (upon the absurdity of which supposition I have already 



318 CONTINUED FEVER. 

dwelt;*) but every thing else that occurs morbidly to the body. It certainly is the 
first circumstance that takes place in many changes; and it accompanies many 
changes, but there is no proof that this is always the case. Syphilis, for instance, 
is an inflammatory disease. The first thing that occurs, is a pustule, or a mere 
inflammatory speck, followed by ulceration; and the next occurrence is an inflamed 
gland; and then, when other symptoms arise, they are more or less inflammatory. 
If blood be drawn during the secondary symptoms, it is often found buffed; and 
we have inflammation in diff*erent parts of the body. Syphilis, however, is some- 
thing more than inflammation. So it is with cancer; so it is with encephaloid 
disease, and melanosis: and so, I think, it is with fever. Inflammation forms a 
part of a large number of cases; but it is not sufficient to explain them; other\^ise 
a mere case of phrenitis would be, in every instance, a case of fever; and every 
case of inflammation of the stomach, or of inflammation of the bowels, would, if 
there were a certain degree of excitement, be a mere case of fever; which undoubt- 
edly is not the case. Another argument against fever being mere inflammation is, 
that it is frequently cut short, in a very early stage, by an emetic; or by cold affu- 
sion; — not ablution, but affusion. Now this could not be done, if the disease were 
nothing more than local inflammation; or if it were inflammation at all. Again: 
inflammation will not explain the difference between typhus-fever and plague; 
which, though different diseases, are nevertheless in many respects analogous. 
Inflammation will not explain scarlet-fever; nor will it explain measles; yet ihey 
are both inflammatory diseases. The symptoms are decidedly those of inflamma- 
tion, in a great number of cases; but there is something more than that. The 
system is in a peculiar state; and inflammation is merely one of the circumstances. 
Some have imagined that inflammation produces even intermittent fever; but we 
have no explanation of it; and this is a mere assumption. Any thing may be said 
in physic; but any thing may not be right. 

That the body, in fever, is frequently in an inflammatory stale throughout, there 
can be no doubt at all; neither can there be a doubt that in fever there is continu- 
ally local inflammation; but there certainly is something more than all this in fever. 
There is a peculiar feeling of debility; a peculiar aspect of the countenance; gene- 
rally pains, at first, in the loins; a tremulous tongue, and universal disturbance; — 
such as cannot arise from any simple local inflammation in any one part. Many 
of these symptoms are certainly not referrible to an inflammatory state; and if the 
disease be contagious, then this shows that there is something more than mere 
inflammation. The local inflammation which occurs, is by no means proportionate 
to the violence of the fever. There is frequently violent fever; and, although local 
inflammation be present, yet the latter is not at all in proportion to the former, fn 
some instances, death takes place at the very first, without any inflammatory state 
being produced; — ^just as in small-pox (which unquestionably is a contagious dis- 
ease) the patient sometimes dies, before any inflammation becomes visible; — death 
taking place merely from the depressed state of the system. Frequently we find 
the disease running on, and proving fatal, without any decided marks of inflamma- 
tion at all;— ^without any thing that bears a proportion to the general sinking of the 
system. Besides, there are peculiar symptoms in fever, which mere inflammation 
would not at all explain; such as the particular look of the face, the tremulous 
tongue, and the extreme feeling of debility of the body. Mere inflammation, 
whether general or local, although it is a circumstance that frequently occurs in 
fever, is nevertheless quite insufficient to explain the whole of the symptoms. It is 
one fact in the disease; but not the whole of the facts; nor is it a fact from which 
any one can prove, that the other set of symptoms arises. 

The Nervous System. — With respect to those who consider that it is neither 
situated in the fluids nor the solids generally, but in some one part of the body, I 
may mention that Hoflfmann thought it was a disease of the nervous system. The 
nervous system certainly is afl^ected, and so likewise are the secretory organs; and 

» See Pages 176 and 177. 



CONTINUED FEVER. 319 

therefore others have just as much right to say that it is a disease of the secreting 
system, as HofTmann had to ascribe it to the nervous system. 

The Capillaries. — Dr. Wilson PhiHp supposes it to be an affection of the capil- 
laries throughout the body; but then there is a peculiar affection of the nervous 
system in general; and there is particularly a disturbance of the abdominal organs. 

The Brain and Abdomen. — ■Some have fixed upon inflammation of the brain. 
Former writers have done that; and a modern pliysician, in liondon, has done the 
same; — he considers it a mere inflammation of the brain. ^ Others, again, in Paris, 
fix upon the abdomen. Broussais, for instance, considers it to be inflammation of 
the stomach and bowels; — what he calls " gastro-enteritis."" Some patronize one 
organ, some another. 

It is true we may find morbid appearances there; but it is also true that we may 
open cases of fever, and find the intestines sound; or, at least, with no such ap- 
pearances as will explain the symptoms of fever. I have, over and over again, 
inspected cases, in which there was no inflammation of the intestines; and which, 
if the fact had not been told, would not have been known to be cases of fever. 
There might sometimes have been a litde more redness than usual, in this or that 
intestine; or if even there was any thing morbid, still it was insufficient to account 
for the general symptoms of fever. The symptoms observed during life, frequently 
depend upon local affection; but frequently there is no disease existing in any par- 
ticular part. Andral° says, that of thirty-eight cases of fever which he examined, 
only eleven presented marks of gastritis sufficient to have influenced the symptoms 
during life, 'i'hirty out of the thirty-eight showed some sort of intestinal affection; 
but only fourteen of these (that is, fourteen out of thirty-eight) exhibited such a 
morbid affection of the intestines, as could explain any of the symptoms during life. 
He also says, that the changes which are seen in the nervous system, are compa- 
ratively rare and slight. I do not think that fever is to be explained by Morbid 
Anatomy. Many of its symptoms, and many of the occurrences which take place, 
may be thus explained. When there is phrenitis, we usually have the marks of 
phrenitis; when there is bronchitis, we usually have marks of bronchitis; when 
there is diarrhoea, we expect to find ulceration of the intestines; — but frequently 
these symptoms are but slighdy or not at all apparent; and after death there are no 
such marks as will explain fever; although there may be enough to explain the 
local symptoms that have occurred. Continually is it observed, in fever, that the 
head is but slighUy affected after the first few days; and that the abdomen is scarcely 
affected at all. 

Now I believe, as I just now mentioned, that the head is frequently in a state 
of inflammation, and so is the abdomen; but occasionally the head is far more 
affected than the abdomen; and in other cases the abdomen is more affected than 
the head. I stated that the local inflammation frequenUy bore no proportion to the 
general symptoms of fever; and sometimes we have violent local inflammation, 
without any corresponding symptoms of fever. The same is the case with regard 
to the relative affection of the head and abdomen. Sometimes the head is more 
affected than the abdomen, and vice versa; — they do not bear any proportion to 
each other. If we assume local inflammation to be the cause, and if we observe 
the phenomena of many cases, we have no more right to settle the affection in the 
head, than we have in the abdomen. 

All these I consider to be mere circumstances constituting a general collection of 

» See "An Inquiry into the Seat and Nature of Fever; by Henry Clulterbuck, M. D."' 
*> "Hisioire des Phlegmasies, ou Inflammations Chroniques. Par F. J. Bronssais." A 

Translation of this work has been published at Philadelphia. 

c Andral, I think, is one of the soundest writers on Medicine. He appears to have no 
theories, but to look out for facts, and to make the most correct and philosophical use of 
them. I have found all that he has said, in his Clinical Reports ("Cliniqne Mcdicale") to be 
confirmed; and though it was not till lately that I read his book, yet 1 was delighted to find 
the coincidence in our facts and inferences. 



320 CONTINUED FEVER. 



truths; but I do not see any reason to suppose that there is disease of one part, 
more than of another/ 

Although I deem it necessary to make these remarks, yet I shall not attempt to 
state what I believe fever to be. I really do not know what it is; and I think it 
is always a great blessing to know one's ignorance. It is well not to fancy our- 
selves acquainted with things with which we are not; because if we fancy we are, 
we sit down contented, and never think of examining the subject further. An ex- 
cellent observation of this kind is to be found in Voltaire's *' Philosophical Dic- 
tionary," under the word "2c/ea." A person is there represented as lamenting, 
that he has got so many ideas; — that his cerebral matter is full of ideas; but that 
he is perfectly miserable, because he cannot tell what an idea is. He fancies it is 
this, that, and the other; he indulges first in one hypothesis, and then in another; 
and says it is a shocking thing not to know what it really is. His friend tells him, 
that — " II est bien triste d'avoir tant d'idees, et de ne savoir pas au juste la nature 
des idees.'"' " Je I'avoue," replies the other; " mais il est bien plus triste, et 
beaucoup plus sot, de croire savoir ce qu'on ne sait pas."'' — ^I imagine that we do 
not know the peculiar state of the system in typhus-fever; any more than in mea- 
sles, or in hooping-coyigh. A peculiar cause has operated upon the body; and a 
peculiar state has been thereby induced; but we can observe only its effects. 



SECTION VI.^TREATMENT. 

Ventilation and Cleanliness. — Notwithstanding this uncertainty, however, the 
treatment of fever is in the highest degree rational, and in the highest degree suc- 
cessful. We must aim, in the first place, at having free ventilation, and the most 
perfect cleanliness: — plenty of washing, plenty of clean linen, and plenty of fresh 
air. With fresh air and fresh water, we may go on very well; but if there be any 
smell, which ventilation and washing will not remove, the chlorides are excellent 
things. They should be sprinkled upon the bed, or upon the floor; and disposed 
in saucers, or in rags dipped in the solutions, and hung on the backs of chairs about 
the room. A solution of chloride of lime ought to be put into the utensils which 
the patient employs; that no unpleasant smell, — no contamination may arise in the 
room. When a patient is first seen, if he be dirty, it is right (before prescribing 
any thing else) to prescribe soap and water. Before any thing else is done, I would 
always have a patient got perfectly clean. When he is well cleansed, with soap 
and water, all over his body; and especially his lower half, and his lower extremi- 
ties, — a portion which is sometimes exceedingly filthy, — you should have him well 
washed with plain water, several times a day. Soap is no longer required; but 
sponging, several times a day, is always of importance. I believe it is always safe, 
in fever, to wash a patient with warm water; but if he say that he is hot, or if (on 
placing the hand upon him) we feel that he is hot, we may employ cold water. 

* The following table, selected from the Journals of the London Fever Hospital, shows 
the comparative frequency of the several local lesions, which arise during the progress of 
fever, as observed in that institution; and offer strong confirmation of the correctness of Dr. 
EUiotson's opinion: — 

I. Cases in which the fever was not apparently complicated with local inflammation in 

any organ -------------- 163 

II. Cases complicated with cerebral affection - - - - - - - -114 

III. Cases complicated with thoracic affection -------- 103 

IV. Cases complicated with abdominal affection --------71 

V. Cases complicated with cerebral and thoracic affection - - - - - - 26 

VI. Cases complicated with cerebral and abdominal affection ----- 30 

VII. Cases complicated with cerebral, thoracic, and abdominal affection - - - 14 

Total 521 

b " It is very sad to have so many ideas, and not to know accurately the nature of ideas." 
c " I confess it; but it is much more sad, and much more foolish, to think we know that 
which we know not." 



CONTINUED FEVER. 321 

Cold or Tepid Effusion. — If the temperature of the patient be steadily above 98° 
(as ascertained by a thermometer placed under the tongue, or in the axilla); if there 
be no pulmonic affection, no general profuse sweating, and the patient himself does 
not say that he is chilly, — we may take him out of bed, and throw a pail of cold 
water upon him. This is "cold affusion;" and may be repeated. The patient 
must be dried, and put to bed; and, as soon as he grows hot again, the same mea- 
sures may be adopted. This plan makes him exceedingly comfortable. Frequently 
it induces perspiration; and frequently it sends him to sleep; but even if it fail of 
this, it nevertheless makes him very comfortable, and sometimes cuts short the 
fever. Upon this subject, Dr. Currie's " Medical Reports"* should be perused. 
But in general I do not find the heat steadily above 98°; — I do not find patients free 
from a certain degree of chilliness; and I therefore content myself with tepid or cold 
ablution. I have never had occasion for affusion; but it is always safe, under the 
restrictions I have laid down. The cold bath is too chilling a thing; — it would 
strike too suddenly. But when it would not be safe to take a patient out of bed, 
and throw cold water upon him, we may always have recourse to ablution, either 
cold or tepid. I always make it a rule to consult the patient's feelings on this point; 
and if I think he cannot bear much cold, I have him stripped, and sponged all over 
with tepid water; and between the intervals of this treatment, basins of cold water 
should be brought to the bed-side, and he should be allowed to put his hands 
into them as often as he thinks proper; and his face, too, should be continually 
washed. If there be any pulmonary affection, or if the patient say that he is chilly 
from the ablution, then we should use it tepid; for I need not say that tepid ablution 
is a great source of relief, and that it cools the patient considerably. It does not 
produce the impression that is made by cold water; but a great degree of evapora- 
tion takes place; and it extracts a certain portion of the patient's temperature. Whea 
it is applied, its temperature need not be 98°. From 80° to 90° is sufficient; and it 
cools the patient by its subsequent evaporation. 

To co-operate with this treatment, the patient should have but few clothes upon 
him; and the windows and doors should be opened; — so that he may have, not only 
a free ventilation, but at the same time a cool temperature. The doors and win- 
dows should be wide open; unless the patient feel chilly, or the draught seem too 
strong for him. As the disease lasts longer, we must apply cold less. There is 
not the same power of generating heat; — the patient is not so hot as before; and 
therefore the application of cold is less advisable; and we find it necessary to use 
tepid ablution, where previously we used cold. Indeed, as the disease advances, 
and the patient is getting better, there is little occasion for much abstraction of tem- 
perature. Ablution, whether warm or cold, is less and less frequently wanted; and 
a low temperature is less and less required. But while, in general, ablution is em- 
ployed for the purpose of coolings, it should still be partially employed for the 
purpose oi cleansing. The hands, the feet, and the head, ought to be looked after. 

Temperature of the Jlpartment. — With regard to the temperature of the room, 
the same rule is to be observed as at the beginning; that is to say, the patient's 
feelings ought to be consulted. If he be delirious, of course we must not attend to 
him, but judge for ourselves; but if he be not delirious, and say that the tempera- 
ture of the room is unpleasantly cold, then we ought not so freely to diminish it. 

Emetics. — While thus attending to the surface of the body, we likewise have to 
attend to the inner surface, — to the alimentary canal. It is a good practice, in the 
beginning, to give an emetic; but if, on making pressure, we find tenderness of the 
epigastrium, or any part of the abdomen, I would not have recourse to any such 
measure. If, indeed, there should be a violent determination of blood to the head, 
I do not know that I should have recourse to it then. Frequently, however, in the 
beginning of fever, it is an excellent practice to give an emetic; — for instance, a 
grain of tartar-emetic, with a scruple of ipecacuanha; but I should never think of 

« "Medical Reports on the Effects of Water, Cold and Warm, as a Remedy in Fever, 
and Febrile Diseases. By James Currie, M. D." 
VOL. I. 21 



322 CONTINUED FEVER. 

giving it, without first ascertaining wliether the abdomen, on pressure, is tenderer 
not. Sydenham gives very good advice on this point. He advises us to premise 
bleeding, before we exhibit the emetic. This practice is noi always necessary; 
but if the pulse were full, and there were great signs of a determination of blood to 
the head, I would bleed first. 

Purgatives. — But whether we give emetics or not, there is no doubt of the pro- 
priety, in every case of fever, of seeing that the bowels are regularly opened; — that 
no filth collects in thejn, any more than on the surface. They should be freely 
opened, for the most part, every day; — at least at the beginning of fever. If they 
be confined, one of the best medicines is a large dose of calomel. The quantity 
must vary from two to five, ten, fifteen, or twenty grains, according to circum- 
stances; but, in most cases, five grains of calomel, followed by castor-oil every two 
hours, will answer every purpose. Now and then we have obstinate constipation. 
A patient may not have had a good stool for many days; and then we may give ten 
grains or a scruple of calomel, and follow it up by castor-oil; but it would be wrong 
to give a dose of that description, if there were every probability that a few grains 
would answer the purpose. Nothing is better than to follow it up with castor-oil; 
but, at the same time, we are likely to accelerate its operation, by g^iving a com- 
mon injection, 'i'his, however, is not to be done if the bowels be sufficiently open 
of themselves; — if they be open once a day. Sometimes it will happen that they 
are too open; — that there is the opposite state, — that of excitement; and then, of 
course, purgatives would be highly improper. The purgative plan, when necessary, 
is to be put in practice at the onset; but, with regard to ablution, I would (as I have 
stated*) continue it during the progress of the disease. Calomel certainly does 
clear out the intestines better than any thing else; although it usually requires 
another purgative to set it oft\ But although we clear out the bowels well in the 
first instance, by means of calomel, we nevertheless often find it a good practice to 
go on with smaller doses of that medicine, or other preparations of mercury, during 
the course of the disease. This will generally prove quite suflTicient to keep the 
bowels open, without any thing in addition; but if from two to five grains, exhibited 
every eight, six, or four hours, do not effect thatobject, we must accelerate the action 
of the mercury, from time to time, either by an injection, or by a moderate dose of 
castor-oil. Senna and salts are given by some practiiioners; but, upon the whole, 
I think castor-oil is best. Indeed, if the stomach or the intestines be irritable, we 
ought not to do more than give an injection. Accumulation and torpidity, however, 
do not always exist; for sometimes we have diarrhoea, and the whole of the abdo- 
men is tender; and of course purgatives, in such a slate, are likely to do more harm 
than good. It is right, before debility arises, to have one, two, or three stools a 
day; but, if they take place without medicine, and be of a watery character, it is 
necessary to restrain them, lest the patient should sink. As a general rule, where 
there is no irritation of the bowels, or much real debility, we ought to make a point 
of procuring two or three stools a day. There is no rule for the dose of calomel; 
but, if given in small and repeated doses, it generally keeps the bowels in an open 
state; — sometimes, indeed, more open than we wish. 

The use of purgatives in fever is very great; but, undoubtedly, it has been ex- 
aggerated by certain writers. •* Some books would lead us to conclude, that we 
have only to turn the patient inside out, in order to cure him; but I am quite cer- 
tain that such is not the case. There is sometimes found a great disposition to 
diarrhoea, which it is absolutely necessary to restrain; but no one can dispute the 
propriety of removing all filth, once or twice a day, from the alimentary canal. 
Costiveness ought never to be allowed; for it causes the tongue to be brown and 
dry; and, except in the last stage of fever, where there is frightful debility, there 
ought to be one stool in the twenty-four hours. 

Blood-Letting. — Tiie treatment already mentioned, will enable us, in the greater 

* See Page 321. 

'' See Dr. Hamilton's celebrated work, entitled "Observations on the Utility and Admin- 
istration of Purgative Medicines in Several Diseases." 



i 



CONTINUED FEVER. 323 

number of instances, to get rid of fever; — snch instances, at least, as I see. In 
other cases, however, it is necessary to be more active. It is necessary to take 
away blood; and it may be done either at the arm, or by what we call ''local 
means." Venesection is certainly not required for mere generally increased action. 
If no organ in particular be suffering; — if we cannot discover great excitement of 
any one organ; — if there be mere general excitement of the system, I do not be- 
lieve that venesection is required. However, if the epidemic be of such a charac- 
ter, that inflammation is sure to come on, it is as well to bleed in the arm; in 
order to prevent such inflammation, when it does come on, from being so violent 
as it otherwise would. But, as a general rule, in the fevers that I see in London, 
venesection is not demanded in one case out of thirty or forty. It would be wrong 
for me to speak of what people see in other places; because fevers differ in differ- 
ent situations. In the country, where people are strong and plethoric, and in hot 
countries where the excitement is sometimes exceedingly great, — the congestion 
■within the head, chest, or abdomen, vary considerable, — the lancet is the " sheet 
anchor;" whereas, in the majority of continued fevers which I see, venesection is 
certainly not necessary; and I am sure that those who employ it extensively in 
this disease, if they do not destroy their patients, yet protract their cases. How- 
ever, it is of great importance to employ local bleeding; and, except in hot coun- 
tries, I think every good may be obtained from it, in the majority of cases, without 
that shock which general bleeding produces; and which is very desirable in mere 
inflammation. In fever, this shock is not demanded. In comparatively mild 
fevers, it would make the disease severe; and in those of an asthenic character, it 
would knock the patient down. 

Blisters. — After a proper detraction of blood, or in a case where the loss of 
blood is not advisable, blisters (applied to the nape of the neck, or to the forehead, 
or behind the ears) are very useful. A blister applied- to the summit of the head, 
is generally a painful thing; and I would not have recourse to it, except as a last 
measure. Before the inflammatory state has much subsided, and before there is 
really more of irritation than of inflammation, the application of blisters would of 
course be doubtful almost anywhere; but particularly at the top of the head. The 
hazard, however, would certainly be far less, if they were applied to the nape of 
the neck, to the occiput, or to the forehead. Leeches must be repeated at inter- 
vals; — as long as the local symptoms seem to demand them, on the one hand; and 
the strength of the patient will bear them, on the other. When, however, not- 
withstanding local inflammation or irritation, we do not wish to apply even leeches 
or blisters, mustard-poultices are particularly useful. When applied over the epi- 
gastrium, they will stop vomiting. They are very serviceable over the abdomen; 
and by many persons they are employed at last, or even in an early stage, to the 
feet; with the view of exciting distant irritation. 

Small Doses of Mercury. — In many of these fevers, it is of the greatest use to 
give mercury; especially if there be a degree of inflammation, and great foulness of 
the tongue. If given in small, but repeated doses, it will answer the purposes I 
have already mentioned.^ It not only purges the patient, but (by degrees) causes 
the tongue and the interior of the mouth to become moist; and when that is 
effected, the patient is almost sure to be better. It is necessary to remember, that 
it should not take the place of local bleeding. It will increase the good effect of 
detraction of blood; and where that is not required, it will do alone; but where 
that is necessary, mercury must not take its place. It must be used as an auxiliary 
to bleeding; and not as a substitute for it. Over and over again, in treating pa- 
tients, I have omitted the mercury; and have seen the tongue grow darker and 
fouler; and then, upon having recourse to it again, I have seen the mouth resume 
its moisture, and tlie tongue become less foul. I have made the observation too 
often to doubt its accuracy. It is true there are many cases of fever, that will do 
without mercury. I only say that, in the mass of cases where mercury is given, 

• See Page 322. 



324 CONTINUED FEVER. 

the success is greater than when it is omitted. We cannot draw any argument 
from a single case; it is only from a series of cases, treated in a particular way, 
that we can arrive at any legitimate deductions; and as far as I have seen, the mo- 
ment the mouth becomes moist, — provided proper detraction of blood be instituted, 
and all other suitable means, — the local symptoms of inflammation generally de- 
cline; and patients recover more quickly than they otherwise would; and many 
recover who (in all probability) would not, unless that practice were resorted to. 
Still (I must repeat) a great number of cases of fever will do well without it; but, 
where the symptoms are severe, we find it a most useful medicine. We should 
not aim at any violent affection of the mouth; and, if that should occur, the medi- 
cine must be omitted till the symptoms remit; but we should feel the patient's 
gums every day, to ascertain whether the mercurial effect is kept up. There can 
be no doubt that mercury will sometimes take effect, not in consequence of having 
cured the disease, but by the disease becoming better (through nature and the 
general means employed), and the mercury being no longer resisted. The proof 
of mercury doing good, consists in this fact; — that if it be given quickly, so as to 
get the mouth sore, the sooner that object is effected, the sooner in general is the 
patient improved. 

Calomel, however, is frequently too active for the intestines; blue-pill, or Hy- 
drargyrum cum Creta, answers better. After a time, even these will purge; so 
that it is necessary, along with them, to exhibit chalk-mixture, or an infusion of 
catechu. It is well to give the infusion of catechu or kino, for it will enable the 
patient to bear the mercury; and we frequently find that Hydrargyrum cum Creta 
is the only mercurial preparation that can be borne. Mercury, if pushed too far, 
increases the mischief; — it induces great irritation of the alimentary canal. A 
remedy, how excellent soever, requires (of course) to be properly used. Small 
doses of opium, I need not say, will tend to check the diarrhoea; and frequently 
there will be no objection to five drops of the tincture, three or four times a day. 

Antimony. — As to antimony, I do not think it an appropriate medicine; for it 
irritates the stomach; — a circumstance which is not wanted in fever. There is so 
frequently also a disposition to sickness, that it is very likely to excite vomiting. 
If we give mercury at the same time, the antimony has a great tendency to 
counteract its effect. It may cause the mercury to be rejected; and, I confess, I 
have never seen any material good done by it. In cases of decided inflammation, 
it would be a good remedy, pushed to a large quantity; but when the case is at- 
tended with great irritation of the alimentary canal, (as many attacks of fever are,) 
and the patient has but little strength, I am sure that it is better not to give anti- 
mony; — lest we make the patient's stomach so irritable, that it will not bear food, 
or any thing else. It is only where there are very decided marks of inflammation, 
that it might be given; and even then I should much prefer mercury. As to its 
sudorific effects, I have given antimonial wine in very large doses, without pro- 
ducing sweating. The best mode to ensure sweating in fever, is to clear out the 
bowels, to reduce the temperature of the surface, and to take away blood locally 
or generally, accordingly as it may be required. I have seen patients lying in a 
carpeted room; with the windows shut, plenty of bed-clothes on, and perhaps a 
fire in the room into the bargain; — and all this, I have been told, was to excite "a 
gentle diaphoresis!" The diaphoresis, however, never made its appearance; but 
on opening the windows, putting out the fire, removing the bed-clothes, taking up 
the carpet, purging the patient well, and removing any local inflammation that was 
present, it has come on immediately. The idea of a few grains of antimonial 
powder, or a fraction of a grain of tartar-emetic, once or twice a day, being im- 
portant in fever, appears to me quite absurd. With the treatment I have mentioned, 
nothmg else will be required, till great prostration of strength sets in. 

Treatment of Local Complications. — It is necessary, in every case of fever, to 
be constantly on the look-out for local inflammation; — every day to ascertain 
what is the state of the head, the chest, and the abdomen. We shouhl always ask 
if the patient complains of headache. Look at his eyes; and see whether they 



h 



CONTINUED FEVER. 325 

are red or not. Ascertain if liis pulse is full; and inquire whether there is any 
throbbing of the head. So, with respect to the chest, we should observe whether 
there is difficulty of breathing; and if there be, it is well to apply the stethoscope, 
and ascertain what rattling there is. The abdomen ought to be carefully fell every 
day; in order to ascertain whether the stomach, intestines, liver, peritonaeum, or 
other parts, be inflamed. When we find a sufficient degree of inflammatory dis- 
turbance of these parts, then it is right to take away blood locally. If the head be 
affected, then we should cup at the back of that organ; or apply leeches to the 
forehead, temples, or behind the ears; but if it be the abdomen which is affected, 
it is always better to employ leeches. If the pain be situated at the front of the 
head, it is better to employ leeches there. I mentioned,* when speaking of in- 
flammation, that the effect of leeches or cupping is often very local. I have seen 
parts where they were applied, relieved; while others, in the neighbourhood, re- 
mained as painful as before. At whatever part of the head the pain is felt, there 
we should direct our means of treatment. If there be delirium, and this delirium 
be accompanied by pain and heat of the head, or throbbing; or if the eyes be red; 
or if there be great vivacity, like incipient delirium of an active kind; we ought 
always to shave the head, then apply a cold wash, or employ a bladder of ice 
(which is one of the best things), and put plenty of leeches on, or employ cupping 
at the occiput. If there be vomiting, or tenderness at the epigastrium without it, 
we should apply leeciies, which are the best for it; for, when there is tenderness 
or vomiting, it generally arises from inflammation of the mucous membrane; and 
leeches will remove it, by removing the causes of inflammation. So, with regard 
to the abdomen at large, when that is tender, there is generally more or less diar- 
rhoea; the intestines are acting too violently; and leeches, freely applied, are the 
best mode of restraining it. After they have been used, apply a blister; but always 
remember, that a blister will not take the place of local bleeding, if the inflamma- 
tion be considerable. If there be local inflammation, we frequently And that the 
application of leeches will remove it; and after it has greatly subsided, slight in- 
flammation, or mere irritation, ma}^ be left; and a blister may be of the greatest use. 
We shall see, when I come to speak of diarrhoea, that leeches and blisters are fre- 
quently the best remedy for it. 

Cooling Drinks. — All cool drinks are proper; and a saline draught is as good as 
any thing which can be given for a drink. People will frequently take half a pint 
to a pint a day. It is always to be remembered, however, that all acid matters, and 
even a saline draught, have a tendency to increase any irritation that may be present 
in the bowels; and diarrhoea is frequently kept up, by a saline draught being con- 
tinued. But if there be no purging, — if tlie alimentary canal be tranquil, acidulated 
drinks are very useful. Upon the whole, however, a downright cool drink, — 
plenty of cold water, is one of the best things that can be given. 

Treatment of convalescence. — As the symptoms all decline, all the remedies 
must be diminished, both as to force and to frequency; and there may be less ab- 
stemiousness practised. Nourisimient may he gradually given; and one of the 
best articles, after slops are done with, is milk. It is very wrong to continue 
starving a patient after fever is gone; for when the fever is over, the appetite 
becomes remarkably keen; — keen in a degree that is never witnessed after any other 
acute disease. Patients, when the fever is over, are sure to say they are very, 
very hungry. Other patients will ask for full diet; but patients after fever ask 
with great earnestness. They seem to have a craving which impels them to ask 
it; — whether they think it will offend or not. Patients are more emaciated after 
fever, than after any other acute disease. Even when no evacuations have been 
practised by the medical attendant, and when the disease itself has not been at- 
tended JDy any great evacuations, there will still be a degree of emaciation, which 
I think is not witnessed after any other disease; and when the fever is over, and 
there is so great a craving for food, it would be contrary to common sense to with- 

» See Pase 133. 



326 CONTINUED FEVER. 

hold it. It seems to be a real call of nature; — it seems that foocMs absolutely de- 
manded. I always make a point of giving them light animal food; — not pork or 
veal, or artificial trash; but plain mutton, and good fresh beef; and carefully watch- 
ing the effect. 

Treatment in Extreme Debility. — Suppose, however, that the disease does not 
run on in this mild form; or that the inflammation does not become subdued, as in 
any inflammatory disease; but that signs of great debility come on; we must then 
have recourse, even in the midst of fever, to good support. Milk should be given, 
m as great abundance as the patient can take it; and, I think, strong beef-tea. 
Some imagine that, tlie digestive process being suspended in fever, animal broths 
cannot be digested; but, however, that may be, I know that persons who take 
strong beef-tea, frequently do admirably well. By ^'strong beef-tea," I mean a 
pound of meat, chopped extremely small, and boiled in a quart of water, until the 
latter is reduced to a pint. Some persons will take two or three pints of it in a 
day; while some require only one pint; — and we find them considerably nourished 
by it. Many persons cannot take milk; but, where it can be borne, it is excellent 
nourishment. Arrow-root, sago, and rice, may be taken with the milk. I believe 
that, occasionally, we must give more nourishment than can be introduced by the 
mouth; and when there is extreme prostration, it is useful to give strong clysters 
of beef-tea, in which an egg may be diffused. I have seen them given to a patient 
every four hours; apparently with the result of getting him tlirough the disease. 
If the clysters be discharged again, and not retained sufficiently long to be bene- 
ficial, it is useful to put into each of the injections a drachm, or two drachms, of 
powdered catechu. 

Wine. — More than all this, however, is sometimes required; and we must give 
a patient wine. If we give wine, as a general remedy for fever, I am certain that 
we shall kill one half of our patients; but if we give it in the latter stages of the 
affection; or if, from the first, the disease be attended with great debility, we shall 
frequently do much good by its exhibition. It is often indispensably necessary, 
but not (so far as I have seen) at the beginning of fever. A great number of cases 
do well without it altogether; but I have seen cases, over and over again, where 
a glass or two of wine has stopped vomiting or diarrhoea. It is where there is 
extreme debility, — where there is irritation rather than inflammation; and where 
we find that the pulse is feeble, — almost fluttering; and the aspect of the patient 
indicates that he is sinking; — it is here that I have found it beneficial. I have 
always been accustomed to quote Sir John Pringle on the exhibition of wine; 
because I think that his directions, both as to the quantity required, and the time at 
which it is to be given, are the best which have been written. He says, " In our 
malignant fever," (he was physician to the army,) "when the pulse sunk, it always 
became very frequent" (that is generally observed); "and in proportion as it rose 
with the wine, it turned slower. I have also had experience of the jrood effects 
of wine, when the tongue has been both foul and dry." Here is an illustration of 
the propriety of not attending to one symptom, but to the whole. A dry and foul 
tongue frequently indicates inflammation; but if no inflammation be present, but 
(on the contrary) great prostration of strength, with a fluttering pulse, an anxious 
countenance, and inability of the patient to move himself,— then we need not fear 
foulness and dryness of the tongue; but may exhibit wine. "When wine is given," 
Sir John Pringle says, "in proportion as the patient grows stronger, the pulse be- 
comes slower. Wine, in health, will accelerate the pulse; but when a person is 
weak, and the pulse is quick in proportion to the weakness, and when this state 
does not arise from inflammation, but downright exhaustion, wine, instead of qinck- 
ening the pulse, makes it slower. The surest indication for wine," continues Sir 
John, "is taken from the long continuance of the disease; the languor, and dejec- 
tion of strength; and the slowness and faintness of the voice; but we can never be 
absolutely certain of its effects till we try it." This is also a point carefully to be 
attended to. We constantly meet with cases, where there is a doubt as to the 
proper mode of treatment to He adopted. This occurs to me every day; and will 



CONTINUED FEVER. 327 

occm* as long ns I live. "We are not certain whether the time has arrived, at which 
to treat the case as inflammatory or not; and we are often made unliappy by this 
circumstance. Whenever a suspicion of this sort arises, it is best to combine both 
modes of treatment; — to lessen any excitement; and to begin stimulating and tonic 
remedies, with great caution. Whicliever is found to do good, must be increased; 
and, in fact, substituted for the other plan. "I have seen," Sir John Pringle says, 
*Mn cases of this kind, strange instances of the power of instinct; for when wine 
was to do good, tiie sick swallowed it greedily, and asked fr)r more; but when it 
was to heat them, or raise the delirium, they showed an indifference, or even an 
aversion to it." It is of the greatest importance, in fever, to attend to the wishes 
of the patient, — provided he be not delirious; for tlien he will talk at random. But 
if he be not delirious, or only partially so; — if he be sufficiently collected to know 
his own feelings, and to give a clear account of those feelings, they should, in 
general, be attended to. "Sometimes," he then continues, " the physician can 
have no belter measure for the quantity requisite, than the appetite of his patient." 
Quantify of Wine Necessary. — Half a pint of wine is sometimes required in 
twenty-four hours; — one glass being given at a time. Generally a pint is the utmost 
that is requisite; though I have given a bottle with advantage. It is best not to 
give Rhenish wines, or thin claret, or any acidulated wine; for, if diarrhcea be 
present, it will increase the irritation of the alimentary canal. Tt is also best not 
to give sweet wines; for they are apt to ferment and become acid in the stomach. 
Sherry, Madeira, and Port, are the best that can be employed. If there be no 
irritation of the alimentary canal, but a torpid state of it, acidulous wines may 
sometimes, perhaps, be admissible. If the patient desire porter, or has been accus- 
tomed to it, that is very good; but we should not give a pint of porter at once. A 
wine-glass or two may be given every few hours; or perhaps only once in the 
twenty-four hours. Because a person desires porter, we are not necessarily to give 
a pint in the twenty-four hours. When there is mild delirium (not "delirium 
ferox,^^ but a ^'muttering delirium"), or when the pulse is rapid and weak, and 
when extreme debility has come on, then it is right to resort to this treatment; for 
it will frequently stop the delirium, or (at any rate) check it. But if we go on 
with it after it has stopped the delirium, it will frequently bring it back; — so that 
the patient is worse than he was before. 

Other Stimulants. — In this state of debility, many give ammonia and ether; 
but I cannot help thinking that wine, or good malt-liquor, is the best article that 
can be exhibited; unless the malt-liquor bring on diarrhoea. It is much better to 
give those stimulants which most people like, than to give ammonia or ether. The 
former are natural stimulants; and are much more grateful to the patient. Care 
must be taken, with all these things, not to overload the stomach. The moment 
you find the head affected by them, or the stomach overloaded, it may be neces- 
sary to give an emetic. For the same reasons that I have already stated, I should 
also prefer giving wine, to giving what are called "-vegetable stimuli;" — such as 
serpentaria. It is true I know nothing about them. I dare say they are good; but 
I have always been able to do without them. 

Tonics. — As to tonics, by far the best is quinina. If we jiidge it right to attempt 
supporting the patient by means of quinina, it should be given, in doses of three or 
four grains, every three or four hours. I certainly fancy that I have saved patients 
in the last stage, when there has been no longer room for giving mercury, by sup- 
porting them well with good nourishment and wine, and by giving sulphate of 
quinina in considerable doses. But it must be remembered that, in giving sulphate 
of quinina as a tonic, it may do harm by purging; and therefore we should be on 
our guard against this, by administering astringents at the same time. I frequently 
accompany it by catechu; and then the irritaticm is generally put a stop to. 

Saline Treatment. — Dr. Stevens says that, in this state of debility, he has seen 
great benefit arise, — far greater benefit'than from any thing else, — from very small 
and repeated doses of the carbonate of soda, nitre, muriate of soda, or chlorate of 
potass; which supply the deficiency of saline particles in the blood. lie has a 



32S CONTINUED FEVER. 

vast collection of testimonies in favour of the saline treatment in yellow-fever; 
where, after a certain period, ordinary treatment o^enerally does more harm than 
good. In all snch fevers, he contends that, in the first instance, it is the best prac- 
tice to bleed the patient and give mercury; but, after a certain period has arrived, 
the blood falls into the condition I formerly stated;* and that condition is made 
worse by mercury; and, of course, by bleeding; but he says it is admirably reme- 
died by small doses of neutral salts, particularly those I have mentioned. Twenty 
or thirty grains are given every three or four hours; except of the chlorate of potass; 
of which about a third of that quantity is a dose. It appears that those who have 
adopted this plan, in the West Indies, have had the greatest success. He informed 
me that, in yellow-fever, many had agreed that they did their patients altogether 
more harm than good by treatment; and that those succeeded best who gave nothing 
but saline draughts, in large quantity. Neutral salts are now given, in the large 
doses I have slated, and with the very best effect. By adding neutral salts to blood, 
however black it may be, we make it of the brightest scarlet; but if we add acids 
or alkalies to red blood, we make it black. 

Opium. — In the last stage of fever, some give opium in small doses, for the pur- 
pose of keeping up excitement. Dr. Wall, of Oxford, and Sir John Pringle did 
so; but others give a dose once in the twenty-four hours, for the purpose of tran- 
quilizing the system. I have no great experience of it as a stimulant; but I know 
that, when a patient has long laboured under fever, it is quite safe to give him a 
dose of this kind, in order to procure him a good night's rest. I suspect that wine 
is a better stimulant than opium; although opium is certainly exceedingly usefid in 
the latter stages of the complaint. Some highly praise musk. I need not say that 
morphia is sometimes greatly adulterated. It is said that opium is not always of a 
certain strength, and that morphia is; but, from being adulterated, morphia is of 
the same uncertain strength as opium. Opium is particularly useful in procuring 
sleep; and in putting a stop to vomiting and purging. The muriate of morphia is 
an admirable form of opium, if not the best. 

Concluding Remarks. — The treatment of fever, therefore, consists in subduing 
inflammation, on the one hand; or in supporting the strength, on the other; and we 
must always carefully look out for local symptoms, and check them. The vomit- 
ing is frequently urgent, and very distressing to the patient; and although efTer- 
vescing draughts will sometimes stop it, as will also hydrocyanic acid, yet if there 
be inflammation present, it is not in the nature of these remedies to arrest it; and 
we must then employ leeches, blisters, or sinapisms. So with regard to purging, 
opium will frequently put an end to it, and so will all astringents; but, as I have 
before said,^ it is best not to give astringents if there be inflammation present. 
Leeches and blisters will then effectually subdue it, when nothing else will. If 
the faeces be exceedingly fetid, it is a very useful plan to give yeast, either by the 
mouth, or in the way of injection. An injection of yeast will frequently very much 
correct the off"ensive odour. Some give it in porter. The injection of the chlo- 
rides would, I fancy, be useful; but I have no experience of it. In fever it is ne- 
cessary, every day, to attend to the state of the bladder. It frequently happens, in 
this disease, that a great accumulation takes place in the bladder; and patients might 
go three or four days without making water. Great inconvenience may, at last, 
arise from this source; and therefore it is a point that should be carefully looked 
after every day. There is only one other circumstance that it is necessary to attend 
to; and that is the longings of the patient, during the progress of the disease and 
afterwards. These should be indulged, unless there be some very good reason 
against it. 

The treatment of fever, therefore, bears an analogy to the symptoms. We have 
seen" that the symptoms of fever vary from those of the most violent inflammation, 
— the most violent excitement of the system, on the one hand, down to extreme 
prostration of strength on the other; and the treatment must vary in like manner. 

» See Page 29L " See Page 145. 



CONTINUED FEVER. 329 

It may be requisite that the treatment should be of the most active anti-inflamma- 
tory kind, on the one hand; or the most j^entle anli-inflammatory treatment, with a 
moderate support of the system, on the other; or it may even require to be of the 
most supporting and stimulating kind. Fever is not to be treated because it \s fever; 
but according to the circumstances of each particular case. If we have twenty cases 
of fever, we are likely to find them more or less different from each other; and re- 
quiring more or less difference of treatment, according to the urgency of the symp- 
toms. Remember, therefore, that in fever we have to vary the treatment; from that 
of an active inflammation, to that which is employed in mortification, when the 
mortification is attended by inflammation. 

[Under the title of Continued Fever, our author, in common with most English 
writers, includes the description of what are by some considered as two distinct 
affections, and commonly designated at the present time under the names of ty- 
phoid and typhus fevers. The former is the principal fever met with in Paris, 
and has been studied wath great care by M. Louis, whose descriptions accord with 
the phenomena which belong to common continued fever in the United Slates. In 
Gi'eat Britain, on the other hand, many cases are met with, where in certain re- 
spects this accordance is not found. Some contend that the differences here 
alluded to are of secondary importance, whilst others maintain that they are to be 
accounted for only by admitting the existence of two radically distinct fevers, as 
above mentioned. The question is both interesting and important, and we shall 
endeavour to lay before the reader a very brief summary of the fads connected 
with it. Let us first recall the most characteristic phenomena of typhoid fever. 
The disease is ushered in by chills, followed by heat, headache, and the usual 
phenomena of fever, accompanied most commonly by a tendency to diarrhosa. As 
the case progresses, these symptoms become aggravated and new ones arise; the 
prostration is great in proportion to the other symptoms; the intelligence dull; 
there is drowsiness or stupor, often accompanied by delirium; ringing or buzzing 
in the ears, sometimes combined with deafness; occasional epistaxis; almost always 
an eruption of rose-coloured spots, chiefly upon the chest and abdomen, in the 
course of the second week, and more or less flatulent distension of the abdomen; 
diarrhoea, the discharges thin, watery, yellowish or brownish, in some cases ac- 
companied with blood; the tongue mostly pasty or dry, sometimes red, at others 
brown and incrusted, cracked, and protruded with difficulty. In the latter stage 
of severe cases, the prostration becomes very great, the discharges involuntary. 
Most commonly, there is throughout, a slight cough, accompanied by sonorous 
rale in the chest. Such are the principal phenomena of typhoid fever, which in 
fatal cases run their course in from eight to forty days, or even longer; and in 
favourable cases, gradually subside so that convalescence supervenes at various 
periods after the fifteenth or twentieth day. In t!ie fatal cases, one lesion was 
found to be uniformly present, viz. that of the glands of Peyer. These patches 
were thickened, elevated and most frequently ulcerated, the corresponding glands 
of tiie mesentery being enlarged, softened and red, in every case. The disease of 
Peyer's patches was most marked near the ileo-ccscal valve, and their elevation 
was due not merely to thickening of the mucous, but also of the sub-mucous tissue. 
Corresponding with this description are the phenomena observed in the common 
continued fever of the United States, in which also the disease of Peyer's glands is 
found to be uniformly present. In a large number of cases, however, of continued 
fever as it occurs in England, this lesion is not met with, and hence the English 
physicians have generally regarded it as an accidental complication, and not at all 
entitled to the rank of an essential lesion. But as already remarked, it is main- 
tained by some that there are in England two distinct fevers, one of which is true 
typhoid fever, characterized by the lesion in question, the other a distinct disease 
which may be called typhus. 

An epidemic of the latter character occurred at Philadelphia in the year 1836, 
precisely similar to that met with in a set of cases introduced from certain emigrant 
vessels arrived from Great Britain, especially Liverpool, where the disease prevailed 



S30 CONTINUED FEVER. 

at ihe time of sailing-. This epidemic has been described by Dr. Gerhard, who . 
found it totally different in some of its symptoms from typhoid fever, whilst at the 
same lime the lesion of the glands of Peyer, characteristic of the latter disease, was 
absent. That it was similar to the typhus fever which prevails so extensively in 
Great Britain is generally acknowledged, and indeed has been satisfactorily es- 
tablished by accounts which have since been published of the fevers of that 
country. We shall now notice the prominent features pointed out by Dr. Gerhard 
and others who have succeeded him in the investigation of this question, as cha- 
racteristic of typhus. In both, the nervous system is disturbed, but at times at least, 
if not uniformly, this disturbance is greater in typhus than in typhoid fever. Thus 
the stupor may begin earlier and constitute generally a more prominent symptom, 
the deafness be more severe, whilst subsultus and spasmodic tremors are more 
frequently present. The eruption in typhoid fever consists of a few oval rose 
coloured spots, easily disappearing under pressure, slightly elevated and generally 
limited to the chest and abdomen, whilst in typhus it is more abundant as well as 
more general, occupying the extremities as well as the trunk, of a more dusky 
colour, and but partially, if at all disappearing under pressure. It shows itself at 
an earlier period also, according to Dr. Gerhard, generally as early as the fourth 
day. The dusky suff*usion of the face and deep injection of the conjunctiva are 
much more marked in typhus, thus giving to the countenance an expression which 
of itself is more or less characteristic. Instead of the abdominal symptoms of 
typhoid fever, diarrhoea and tympanitic distension, we have in typhus, on the other 
hand, cosliveness and an absence of tympanitis. The odour of the body is peculiar 
and offensive in typhus, and the heat of skin more pungent than in typhoid fever. 
The thoracic symptoms in typhus consist in the signs of congestion, such as feeble 
respiration and sub-crepilant rhonchus, whilst in typhoid fever the bronchial mem- 
brane is chiefly affected, and in consequence we have sonorous and sibilant rhonchi. 
The average duration of typhus is less, and death often takes place earlier than in 
typhoid fever. As regards the post-mortem appearances, it has been already men- 
tioned, that the lesion of Peyer's glands is absent in typhus, in which indeed, no 
lesions have hitherto been noticed, but such as are common to other acute afl'ec- 
tions. The most striking of the post-mortem appearances in typhus, is the great 
frequency of congestion, particularly of the lungs, and also of the brain. The blood 
is fluid and dark coloured. Such are the principal phenomena of typhus, which 
are certainly sufficiently peculiar to justify us in regarding it as probably distinct 
from typhoid fever. This view is still further confirmed by other considerations. 
Thus typhus attacks persons somewhat advanced in life, more frequently than 
typhoid' fever; it occurs more frequenffy as an epidemic, also, and is much more 
evidently contagious. The treatment too as a general rule must be more tonic and 
stimulating, and it should further be observed that the influence of remedies is more 
decided and prompt in this than in typhoid fever. As regards geographical distri- 
bution, both diseases, as before remarked, are constantly prevalent in Great Britain, 
whilst on the continent of Europe and in the United States, where typhoid fever 
is of constant occurrence, typhus is met with only as an occasional epidemic. 
Indeed the disease can hardly be said to belong to this country, for it is doubtful 
whether the spotted fever which prevailed in New England as well as further 
south in the early part of the present century was really typhus, and since that 
period it certainly has not prevailed to any extent. In Philadelphia, the disease 
presents itself to our notice chiefly in the persons of emigrants, mosUy from Ireland, 
or of those likely to have had intercourse with them. Even the epidemic of 1836 
was very limited in extent, being in great measure confined to a very circumscribed 
district, the St. Giles of Philadelphia, inhabited by the most degraded portion of 
the population. 

To the American practitioner, therefore, this form of fever is practically of little 
interest; but in view of his correct appreciation of the descriptions of continued 
fever by those English authors whose works are current among us, it is highly 
important that he should be aware, that under the one title, they describe two dis- 



\ 



CONTINUED FEVER. 331 

tinct fevers; one of which, only, is commonly met with in this country. Wiihont 
this knowledge, he would necessarily be at a loss to account for the discrepancies 
which exist between their descriptions, and the phenomena of continued fever, as 
presented to his notice. The question which we liave been considering, is, more- 
- over, one of great interest^ in its bearing upon a number of q\iestions connected 
with ihe history of both typhus and typhoid fevers. If these affections be really 
distinct, it is evidently of the utmost consequence that the point should be well un- 
derstood; and their distinctive characters thoroughly appreciated. The idea of such 
a distinction is nothing new. Thus, we find, that petechial fever, or petechial 
typhus, has been considered by the most profound practical men, as being a disease 
sui-generis. It is thus that Pringle speaks of the jail-fever which he describes. 
Huxham speaks of the great difference between what he calls the putrid malignant 
and slow nervous fever; the want of which distinction, he insists on, as the source 
of no small errors in practice. Dr. Armstrong speaks of typhus as specifically dis- 
tinct from common continued fever; and says, that the duskiness of the skin iii the 
former is so very characteristic, that he thinks he could, by it, at any time distin- 
guish the disease from common continued fever. However, it is only within a (e\v 
years, since diagnosis and pathological anatomy have been so assiduously cultivated, 
that the precise line of distinction which we have briefly sketched, has been accu- 
rately made out. But whilst the points of difference, to which we have alluded, are 
in the main, admitted, it is still contended by some, that they indicate nothing more 
than varieties of one and the same affection. So long, however, as we find in the 
one, a certain train of symptoms during life, uniformly accompanied by a peculiar 
morbid alteration after death; and in the other, not merely a different set of symp- 
toms, but a corresponding absence of the anatomical characteristics of the first; it 
seems to us unreasonable not to admit a radical distinction. Such is the conclusion 
to which we are brought by the paper of Dr. Gerhard, before referred to, as well 
as by Dr. Shattucks' account of the cases of typhoid and typhus fever, observed by 
him in London, in the year 1839. The same is maintained by Dr. Stewart, who 
had observed both diseases at the Glasgow fever hospital; by Dr. Staberoh of 
Berlin, and others who have had an opportunity of observing these diseases, both 
in England and on the Continent. The personal experience of the writer, inclines 
him to the same opinion. The cases of typhus fever admitted into the Pennsylva- 
nia Hospital, occurring chiefly in the persons of emigrants just arrived from Great 
Britain, have, indeed, always appeared to him so distinctly marked, as scarcely to 
admit of being confounded, except by a superficial observer, with typhoid fever. I 
would not, however, be understood as maintaining that llie question is setded. 
Men of acknowledged merit entertain an opposite opinion, and consider the two 
affections to be but different forms of one and the same disease. Professor Roki- 
tanski* adopts the latter opinion; and maintains, as tlie result of his anatomical inves- 
tigations, that this disease is characterized anatomically, by the deposit of a peculiar 
substance, analogous to medullary sarcoma, and that its different forms are depend- 
ent upon variation in the seat of the deposit, the common source of which is to be 
found in a peculiar diseased state of the blood. When this deposit takes place in 
the ileum, the disease is called ileo-typhus (typhoid fever), in the bronchial glands, 
broncho-typhus, the same probably as what we have spoken of under the tide of 
typhus. These results need confirmation. 

Before concluding these remarks, let us observe that we agree with Dr. Elliotson, 
in regarding the local lesions in fever, as secondary, and altogether inadequate to 
account for the origin and progress of the symptoms. Still, we think that the 
lesion of the glands of Peyer holds a rank distinct from the common secondary 
lesions, in Uiis, that it is peculiar and essential, thus constituting the anatomical 
character of the disease, and having probably much the same relation to the latter, 
as the pustules of small-pox have to that afiection. Those of our readers who wish 
to be made more fully acquainted with the distinctive character of die typhoid and 

■ American Journal of Medical Sciences, No. xij July, 1843. 



332 REMITTENT FEVER. 

typhus fevers, and with the nature of the evidence by which the essential distinc- 
tion is maintained, will be amply rewarded by the perusal of the work of Professor 
Bartlett,* lately published. T. S.] 



CHAPTER VI. 

REMITTENT FEVER. 

Its Nature. — I now enter upon the subject of remittent fever; which resembles 
both intermittent and continued fever; and partakes of the character of each. Es- 
sentially it is the same as intermittent fever. It arises, I believe, from the same 
cause, — malaria; but — either through a modification of the malaria, or the influ- 
ence of such causes as predispose to, or excite, continued fever — we have only re- 
missions; — not in/ermissions, but remissions. The disease is really continued, 
although remitting; — having a relaxation of severity at different hours. This 
disease occurs in hot climates particularly; and in cold climates during hot seasons. 
It therefore occurs when and where there is the greatest abundance of vegetable 
matter; and where there are all the circumstances most favourable for decomposi- 
tion, and the production of aguish fevers; and, also, where there is the greatest 
prevalence of those causes, which are likely to excite continued fever; — excite- 
ment and relaxation of the body, and disturbance chiefly of the abdominal organs. 
Many epidemics described, in ancient books, as plagues and pestilences, were 
really remittent fevers. 

Symptoms. — There is continual fever every day throughout the twenty-four 
hours; but the patient is much less hot at one time, than at another; so that, 
although he has constant feverishness, he feels himself far less ill at different inter- 
vals. Sometimes, in addition to the continual fever, there is a regular paroxysm 
of ague. I have seen a person constantly hot day and night; except, perhaps, 
every other day; when he had a cold fit; and then the heat would become more 
intense, and sweating would occur. But when the latter was over, there was no 
intermission; for the patient was hot again. The usual form is continued feverish- 
ness; with a great aggravation of it at particular periods. Or (to put it in another 
way) we have the symptoms of continued fever; but there is a relaxation of these 
symptoms at particular periods. But besides this, (although I do not recollect its 
being described), I have seen continual fever, with a paroxysm of ague coming on, 
at regular intervals, in the midst of it. 

Sometimes, instead of remissions alternating with an aggravation of the feverish 
symptoms, the remittent nature of this continual fever is shown only by occasional 
chilliness. I have frequently discovered that continued fever (as it appeared to be) 
was really remittent fever, by noticing that, although there was continual feverish- 
ness, heat, and thirst, yet the patient, in the midst of it, was frequently chilly; and 
on other occasions by observing that, in the very midst of the heat, there was from 
time to time profuse perspiration. The nature of the disease was pointed out to 
me, either by the occurrence of chilliness (even amounting to rigors) from time to 
time, or by the occurrence of sweating at intervals. The correctness of this opi- 
nion has been proved, by giving the patient quinina; which has restored him to 
health. So far as my own observation goes, I think, that remittent fever shows 
itself sometimes in these two forms. Intermittent fever will become remittent, if 
the cause of continued fever be superadded, after intermittent fever has begun. 
Supposing a patient has ague, and goes through great fatigue or want of rest, or is 

a The History, Diagnosis and Treatment of Typhoid and Typhus Fever, &c. by Elisha 
Bartlett, M. D., 'Professor of the Theory and Practice of Medicine in Transylvania Univer- 
sity, Philadelphia, 1843. 



REMITTENT FEVER. 333 

exposed to wet or cold, he may be thrown into continued fever. These circum- 
stances alone would not cause ague; but as ague already exists, the disease be- 
comes remittent fever. The causes of continued fever, are applied to a consiiiution 
labouring under intermittent fever; and then we have remittent fever. Frequently, 
however, the disease is produced from the very first. 

When remittent fever is acute, it seldom (I believe) lasts more than six weeks. 

Varieties and Duration. — Dr. Macculloch, however, imagines that remittent 
fever is often a chronic affection; that it is often mistaken for hypochondriasis; and 
that the paroxysms are not observed, because they occur in the night. I am per- 
suaded he is correct. I am persuaded ^at many persons have long-continued re- 
mittent fever; — frequently for many months; and, its true nature not being de- 
tected, it is thought to be some indescribable complaint. I had under my care a 
patient, who appeared to be in this state; — a man who was frequently very hot; 
complained of heaviness in the head; was affected in his mind; and had great de- 
pression of spirits. This man took five grains of sulphate of quinina, three times 
a-day, without any effect; but, on increasing the dose to ten grains, I found him 
belter. I have seen many such cases; and they long puzzled me. They are 
principally characterized by oppression of the head, heat occasionally in the night, 
and great depression of spirits. 

Aggravated Form of the Disease. — The disease in its acute form frequently 
assumes a very aggravated type; as dreadful for rapidity as violence. It is in hot 
climates, particularly, that this occurs. This form of the disease is so violent, and 
so acute, that there is at first delirium and violent vomiting; with an absolutely 
roasting heat in the stomach; and great pain, tenderness, and agonizing distress, at 
the epigastrium. Besides these local symptoms of the head and the stomach, 
there are all the signs of a violent inflammatory fever; and these symptoms, both 
local and general, are soon followed by the most awful debility, and by all the 
signs of typhus. 

East Indian Fever. — The fever of the East Indies is a violent and acute remit- 
tent fever; — accompanied by great derangement of the liver and stomach; and oc- 
curs in various other parts of the East besides Bengal. At Bengal it arises from 
the overflowing of the Ganges, and the subsequent fall of the waters, acted on by 
a high temperature. After the Ganges has overflowed, the waters fall in Novem- 
ber and December; and, in consequence of the heat, such emanations are produced 
as to cause this fever. The violent delirium, pain, and vomiting are succeeded, 
after a certain time, by a remission and a sweat. This occurs about twelve or 
fourteen hours after the attack; and the pulse, from being 130, may fall down to 
90; and then the delirium ceases, and the mind is restored. The remission, how- 
ever, is but short; for the symptoms soon reappear; and are then succeeded by the 
awful debility to which I have referred. If the disease prove fatal, there is very 
soon no remission at all. The gastric symptoms become more violent than before; 
the tongue becomes black; the pulse small; and the patient sinks. If it be fatal, it 
generally proves so (we are told) between the third and the seventh day; but oc- 
casionally it has been known to last fifteen, or even twenty days. Of course, I am 
only speaking from information which I have derived from authors. 

Yetlow-Fever. — This disease has appeared, with some other symptoms, in the 
Mediterranean, in North America, and in the West Indies. In the Mediterranean 
it has appeared at Rochfort, Bourdeaux, Lisbon, Gibraltar, and Minorca. In ad- 
dition to the symptoms I have already enumerated, the fever is characterized, in 
these countries, by yellowness of the skin, and a vomiting of black matter. Thus 
varied, it has been called " yellow-fever," — from the yellowness of the skin. In 
America it is said that thirty-six, or even seventy-two hours, generally elapse be- 
fore the remission takes place. 

The Black- Vomit. — The black-vomit, which is as much characteristic of yellow- 
fever as the yellowness of the skin, is thought to be bile a little changed from blood; 
— imperfecUy formed bile; or even blood only a little changed. Indeed, some sup- 
pose that, of the two, it would be more proper to call it ''blood'' than ''bile.'' It 



334 REMITTENT FEVER. 

is said to have been found on the surface of the stomaoh, when there was none in 
the duodenum; — as though it had not come from ihe liver. This black-vomit is 
said ti) be by no means acrid. Dr. Physic, of America, says it is tasteless; and 
that he dropped some into his eye, and the organ did not become irritated. He also 
says that he found an abundance of it in the stomach, when a different fluid was 
observed by him, botli in the gall-bladder and the gall-ducts. It is decidedly of the 
appearance of charred blood; — of blood that has undergone certain changes, and is 
poured forth from a mucous membrane. Another gentleman has carried his expe- 
riments, with the black-vomit, farther. Dr. Firth tells us that he procured two 
ounces from a patient (whether dead or alive I do not know); that he drank it un- 
diluted; and found it harmless. Before this he had drunk a large draught of it, 
mixed with water, with impunity; but he took two ounces in its genuine state, and 
said he was none the worse for it. He wished to try it in a solid form; and there- 
fore made an extract into pills; and he says that he found as little inconvenience 
from tliem, as he had previously done from his " black draughts." The fluid and 
concretion of melanosis, also, are generally inert. 

Yellowness of the Skin. — The yellowness of the skin is ascribed by some to 
bile pervading the system; but there are very great doubts as to whether that is its 
origin. The bile is very abundant in this disease; and may be regurgitated, by 
violent vomiting, into the veins, through the compression of the parts; but there is 
no obstruction. At any rate, it is certain that, if it be bile, it is not obstruction that 
produces regurgitation of it; for the faeces are well tinged with bile.- One reason 
for saying that it is not bile, is that it will occur in patches. It is not more visible 
in the eyes and nails, than in other parts of the body; and it is not diffused equally 
throughout the body, as we observe in jaundice; but occurs in patches, as ecchy- 
moses would do. It would appear rather to owe its origin to the blood being 
changed; — to the serum, with a few red particles, escaping more or less into the 
cellular membrane; — the blood having undergone a change. It is altogether analo- 
gous to ecchymosis, when nearly gone; and we know that an ecchymosis does not 
arise from bile; but from an effusion of blood, that is subsequently in a great mea- 
sure absorbed; — the portion which remains giving a yellow colour. Sir Gilbert 
Blane says, that when yellow fever prevailed in the West Indies, he has observed 
it spread from bed to bed; and that it bore no proportion to the malignity of the 
disease. It appeared in two vessels (the Alcides and the Royal Oak), when there 
was only a slight indisposition. He also says that, unlike jaundice, it begins usually 
about the parotids. There is usually fulness and flushing of the face and neck; but 
particularly about the parotids. Here there is the most blood; and here it is that 
the yellowness appears in the most distinct manner. 

Climates and Seasons most liable to Fellow-Fever. — This yellow-fever (or 
*'causus icterodes," as some call it) is apparently another form of bilious remittent 
fever; and occurs only in countries and in seasons, where the heat is such as would 
destroy or arrest the plague. It occurs, too, in hot seasons;— such as would usually 
put an end to contagious typhus-fever, when that is prevailing. Yellow-fever, and 
bilious remittent fever, are always extinguished by cold weather. As soon as the 
cold sets in, they cease.* It is said that the blacks, in America, are usually less 
violently affected than the whites; but that if they go into a cold country, and re- 
side there for a time, and then return to America, they suffer equally with the 
whites. Persons who are unaccustomed to a high temperature, it appears, suffer 
most from this disease. Blacks coming from hot countries, or having descended 
from parents born in hot climates, suffer less; but if they reside in cold climates, 
their constitution partakes in some degree of that of the white; and then they suffer 
far more than others of their black brethren. 

» There is noliiing, connected with yellow-fever, which seems so invariable as the decline 
of the epidemic on the setling-in of cool weather. At a temperature of about 50° (F'ahren- 
heii), fresh cases soon cease to appear; and, in Spain and North America, the disappearance 
of the disease at a pariicular period, is usually calculated on with precision. — Dr. Gil /crest, 
on the Yellow Fever; in the ^'■Cyclopadia of Practical Medicine;" Volume^; Page 219. 



REMITTENT FEVER. 335 

Cokl countries, and the cold seasons of hot climates, are free from this disease. 
It generally occurs only in the tropics, and elsewhere when the heat is as high as 
in the torrid zone; but very intense heat, in cold climates, has been known to oc- 
casion it. If the temperature have accidentally been as high as in a hot country, 
then even a cold climate has been subject to it. Sir John Pringle, for example, 
says that he has sometimes seen yellowness of the skin in Flanders. Dr, Brock- 
lesby mentions seeing it, in 1758, in the Isle of Wight. Dr. Home saw it at Worms, 
in Germany, in 1743. It prevails in the West India Islands, in Charleston, Nor- 
folk, Providence, Philadelphia, New York, Baltimore, and Boston. Those places 
that have the largest quantity of vegetable matter for decomposition, when the hot 
weather comes, and have the most moisture, are most subject to this yellow-fever. 
It occurred at Lisbon till the earthquake happened. It occurs also at Cadiz, Bour- 
deaux, Rochefort, Seville, and Gibraltar. The latter place is situated high enough; 
but. although high in reference to the sea, the town is low in reference to the moun- 
tains. The rain that runs off four thousand acres, it is said, streams towards the 
town; bringing with it a quantity of vegetable matter from the hills, as well as 
fragments of vegetable refuse from the markets. Even straw has been said to afford 
the source of this disease at Gibraltar. Sir John Pringle says, that the straw was 
very injurious to the army there. The rocky soil increases the mischief, as it 
causes the water to remain. 

Causes of Yelloiv-Fever. — However, notwithstanding it would appear that yellow- 
fever is the product of malaria, there has been a difference of opinion on this sub- 
ject entertained at different times. A Mr. Vines, a planter and *'physicker" in the 
West Indies in 1647, writing from Barbadoes, ascribes the yellow-fever to " the 
Lord's heavy wrath;" and not to any thing in the climate. The island was not 
cleared for a consicierable time after he wrote. The disease prevailed then, lo a 
greater extent than it does now. A Spanish officer named Armesta, who ascribed 
the disease to local situation and atmospheric causes, was actually at one time ar- 
rested; and was obUged to retract his views, as being '* false, dangerous, and sedi- 
tious opinions." So violent, at one time, was the opinion that it had nothino- to do 
with local situation, that fifteen hundred copies of this officer's book were burned. 
In the year IhOO, the government had a different opinion; and ascribed ii to some- 
thing in the atmosphere. And this is really the case; for it is owing to miasmata. 
Is Yellow-Fever Contagious? — A great question has arisen in the western 
hemisphere, and in the Mediterranean, as to whether yellow-fever is contagious or 
not. Dr. Firth, of Philadelphia, who tasted the black-vomit in the way I have 
stated,' says that he has frequently inoculated himself with it; and also with the 
serum, saliva, &c., of patients labouring under the yellow-fever; but that no pre- 
judicial effect was produced. It is said that it is never propagated a mile from 
Philadelphia; and that therefore it must owe its origin to local causes. Dr. Rush 
— who was a celebrated American physician, and a violent contagionist — contended 
that this was a contagious disease. He afterwards retracted his opinions; and 
begged the forgiveness of the friends of science and humanity, if the publication 
of his former opinions had had the effect of increasing the miseries attendant upon 
the disease. He says, indeed, that such is the pain he feels in recollecting that he 
ever entertained or propagated the opinion of its being contagious, that it will 
always lie heavy at his heart; and deprive him of the pleasure that he might 
otherwise have derived, from a review of his attempts to fulfil the duties of his 
public station. He says he was misled by Dr. Lining, and other writers. "I am 
aware," he says, "of the influence which changes in opinion have upon a medi- 
cal man's reputation; but still I would cheerfully make a sacrifice of that kind, 
could it avert the evils which are connected with the belief of its being a contagious 
disease." The mode in which a false belief in contagion does harm, is by pre- 
venting the healtliy from attending upon the sick; by stopping commercial inter- 
course; and by allowing the patients to remain in the unhealthy spot, wliich really 
causes the disease. 

/ 'See Pasre 334. 



336 REMITTENT FEVER* 

It is impossible for us who live here,* to know any thing about these matters; 
for there is as much evidence on the one side as on the otlier. In the East Indies 
it is never thought to be contagious; but in the West Indies it is so considered, by 
a large number of persons. The fever in Gibraltar gives rise to a diversity of 
opinion; and there are as many protestations as to its being contagious, as there 
are as to its arising from malaria. Dr. Stevens thinks that he has discovered the 
reason of all these discrepancies of opinion. He says there are three distinct 
yellow-fevers in the western hemisphere. In the first place, there is one in which 
there is no contagion at all; but which is a climate-fever; and arises simply from 
excessive heat. It occurs to new comers, who are operated upon violently by the 
intensity of the temperature. Severe bilious symptoms arise; but he says there is 
nothing contagious in it. He contends, next, that there is the remittent fever; 
the yelloio-kver; arising from the local cause of malaria and heat together; — a 
fever which is seen by every body, and acknowledged to exist by most. Besides 
these, he says there is a yellow typhus-^ever; which he has been able to trace to 
the negroes in America, who have come from Africa. It is a contagious disease, 
attended with yellowness of the skin, and brought there by the Africans. He 
says that all these three fevers are attended with yellowness of the skin. What 
his observations are, or how numerous they may be, from which he has drawn 
these conclusions, I cannot tell. He says that the symptoms of these fevers are 
all different at first; but after a time they are all the same; and that although the 
general treatment of the whole is the same, yet (as they differ in their minutiae) 
they require a modification of treatment. I cannot say more upon this subject. I 
give no opinion upon it; but I should think it likely to be the case; — that there are 
two or three different kinds of fever; and that the intensity of the heat occasions 
them all to be characterized by great yellowness of tlie skin, some by a depraved 
state of the blood poured forth under the skin, and others by jaundice. I have no 
doubt that Dr. Stevens has founded his opinions on numerous facts; and that 
many of them will be found well established. I believe that the greatest autho- 
rities in America are satisfied that the yellow-fever (as it prevails there) is, for the 
most part, not contagious; but that it is sometimes contagious, appears very certain. 

Dr. Stevens'' s Opinions on Contagion. — In a conversation which I had with Dr. 
Stevens, he mentioned an instance of yellow-fever occurring in a family, situated 
at a great distance (across the sea) from any place where the disease had prevailed. 
The captain of a vessel was in a port, where yellow-fever prevailed; and, being 
continually among the people, his clothes and his linen were impregnated with it. 
I am not sure whether he had the disease himself; but he had been in the midst of 
those who laboured under it. When he left the port, he cheated the quarantine; 
and went, with his linen unwashed, to another place, where no fever had prevailed. 
According to the quarantine regulations, his linen should have been washed; but I 
understand that, under those regulations, washing is very dear; and that every 
thing is charged double. He, therefore, to save his double expense, contrived to 
take some of his dirty linen with him; — satisfied that the disease was not contagious. 
The linen was taken out by his family, in this place where yellow-fever had not 
prevailed; and, in a very short time, one and another of the sisters and maids who 
washed it for the captain, died; and an old woman who lived in another part of 
the country, and came to help them, was also seized with the disease. It spread 
from house to house, all through the town; and produced very great devastation. 
Dr. Stevens says, that he knows it was the contagious form; that, in fact, it was 
what he calls "African typhus." He took a voyage for the purpose of inquiring 
into the circumstances. The sisters said that it arose from the dirty linen; and it 
appears that he was able to trace it with the greatest accuracy. He also mentioned 
his opinion that cholera is contagious; but he is satisfied that the contagion is not 
efficient at first. He says we may be exposed to a person labouring under 
'* African typhus" (as he calls it), or to a person labouring under cholera, without 

* In England. 



REMITTENT FEVER. 337 

any fear of catching it, while in h'\s Jirst emanations; but that if exposed to these 
emanations after they have continued to pass from him many days, then we stand 
a chance of getting the disease. He considers tliat what proceeds from the bodv 
is not, at first, efficient; — that it is not a perfect poison when it is first produced; 
but that it undergoes a change, which enables it to produce the disease. He rea- 
sons in this way. Many persons who have visited cholera-patients, have escaped; 
but they have suffered as soon as they have been exposed to fomites, in which the 
secretion was contained. How that may be, I do not know. He also says that 
he has ascertained another circumstance; — that, before the disease breaks out, the 
blood will show the disease. He says that this may also be remarked in scarlet- 
fever. A medical man, finding that he was ill, was bled. The blood was shown 
to Dr. Stevens; who found that it would not turn red with the usual neutral salts. 
He Slated that he was satisfied the gentleman was about to have a contagious 
disease; and, in three or four days after this, scarlet-fever occurred. He says that 
he has seen yellow fever in the blood, before the disease appeared; and that, in all 
instances where the disease subsequently appeared, he found the blood was of such 
a character, that it would not redden on the application of a mixture of neutral salts. 
Of course, all these things are exceedingly crude at present; but it is the opinion 
of many eminent chemists, that we are upon the eve of some important discoveries, 
with regard to the nature of all these matters; — that, by the treatment which Dr. 
Stevens has recommended, great light will be thrown on the pathological changes, 
which take place in the various fluids of the system; and on the nature of many 
diseases. I feel satisfied with the truth of much that has been said; and I feel 
satisfied that a strong and new light will be thrown upon a number of these matters, 
respecting which we are all at present in the dark. The latent period of this 
yellow-fever, is thought to be from two to ten days. 

Treatment. — With regard to the treatment, the best writers agree that, in the 
first instance, there should be copious venesection. Whether it be the fever of the 
western hemisphere, or the mere bilious remittent of the east, cold affusion, or cold 
ablution, is always serviceable. Great attention should be paid to any local in- 
flammation that may occur; and local bleeding may be demanded. As to emetics, 
they cannot be employed if there be any tenderness of the epigastrium on pressure. 
Mercury is found useful in the first instance; but not afterwards. When there are 
symptoms of violent inflammation, it is very useful; but still a person may die with 
his mouth sore, if it be given too late, or bleeding to a proper extent be not prac- 
tised. Of course moderate purging is necessary; but as soon as the remission 
occurs, sulphate of quinina should be given in great abundance; and Dr. Stevens 
says, that when the symptoms of typhus-fever come on, — after venesection, and 
mercury, and cold affusion have been freely had recourse to, — no time should be 
lost in pouring in neutral salts. He says he has strong evidence to show that, 
where these fevers had proved fatal to a frightful extent, the mortality has been 
reduced almost to nothing, by practitioners having listened to his advice. By giv- 
ing neutral salts (as the carbonate of soda, the chlorate of potass, and common salt) 
every hour during the disease, the beneficial effects has been infinitely beyond what 
any one could have anticipated. I know that this gentleman states nothing as a 
fact, but what is strictly true. If he merely give an opinion, of course (like other 
men) he may be wrong; but upon whatever he states as a fact, the greatest reliance 
may be placed; and if he say that a certain number of cases out of the whole 
number have been cured, the statement may be depended upon as correct. 

Sol- Lunar Influence. — Before I conclude the subject of these fevers in hot 
countries, 1 must mention that, in the East Indies, the sun and moon appear to have 
a great influence upon them. Dr. Balfour has written a work upon what he has 
called "the sol-lunar influence;"" and he proves that bilious remittent fever is most 
easily taken at new and full moon; that at new and full moon the disease is greatest, 
and relapse most common; and that those suffering from " pernicious fever,"* 

» " Treatise on the effects of Sol-Lunar Influence in Fevers, &c. By WilHam Balfour, 
M. D." 

VOL. I.— 22 



338 RBMITTENT FEVER. 

which has destroyed the constitution, are particularly affected at that period. This 
may appear incredible or whimsical; but I have no doubt of the fact. I have seen 
medical men who have practised in the East Indies; and they say it is well enough 
for 7is not to believe it; but they have suffered enough to know that it is perfectly 
true. I do not suppose that it is to be ascribed to the direct influence of the sua 
and moon upon the body; but that it arises from the operation of these upon the 
tides. The new and full moon, with respect to the elevation of the water, may 
have very great effect; and the tides, again, may have an effect, by causing more 
or less malaria to be disengaged; so that the atmosphere is more impregnated with 
it at those periods, than at others. I believe there can be no doubt whatever on 
the subject; — that at new and full moon, in the East Indies, fevers are most easily- 
taken, relapse is most common, and fevers are most intense; and that those who 
have suffered most from these fevers, then feel a strange sensation about them; — 
just such as we continually find here, when the east wind blows upon a person who 
has previously laboured under ague. 

Remittent fever. [Dr. Stewardson), 

[Remittent fever is one of the principal diseases of the middle and southern sec-, 
tions of the United States. I agree with Dr. Elliotson, in believing that essentially 
it is the same disease as intermittent fever, at least so far as this, that both depend 
upon a common cause, and possess certain common and characteristic features, 
which at the same time distinguish them from other fevers. 

No disease, probably, presents itself under such varied aspects in different cli- 
mates, localities and seasons, and hence besides those designations which directly 
indicate some predominant feature, as the inflammatory or bilious, we often 
find it referred to under the title, for instance, of Walcheren, Mediterranean, or 
Carolina fever, according to the country in which it has prevailed. I shall not un- 
dertake to give even a summary view of the precise forms which the disease 
assumes, in these different localities. Such a course, indeed, could be of little 
service in enabling the reader to appreciate the general features of the disorder; 
and besides, there is always great risk, that in endeavouring to condense and 
combine the more enlarged descriptions of particular epidemics or endemics, which 
we have not ourselves witnessed, we may compose a disjointed description, 
which will be far from being true to nature. I therefore prefer to examine sepa- 
rately the principal phenomena of remittent fever, and especially such as .are more 
particularly characteristic of it; in doing which, I can appeal in part to my own 
observation.^ Yellow fever is not included in this description, because I regard it 
as a totally distinct affection, and shall give a separate account of it. 

Symptoms. — Remittent fever is commonly ushered in by a chill, which some- 
times does not amount to more than a sensation of coldness. Sometimes there is 
no recurrence of chills, whilst at others they are repeated at intervals of 24 or 48 
hours, for the first few days, and then disappear altogether; or again they may re- 
appear during convalescence, and sometimes at intervals during the course of the 
disease. According to my own observation, where this recurrence takes place, it is 
most commonly at the tertian period. During the febrile exacerbation, the heat of 
skin, though often great, is rarely pungent, whilst during the remission it is often 
natural, or even less than natural, and accompanied by perspiration, which some- 
times, especially towards the conclusion of the attack, is very profuse. The 
febrile exacerbations, though occurring daily, are commonly most marked on the 
alternate days, at which time we usually find a manifest augmentation of all the 
symptoms. The remissions vary very much in degree, and although generally 
very marked, are sometimes not readily perceived, or may for a time entirely dis- 
appear. 

» See Page 269. 

b The results of the writer's observations on Remittent Fever were published in the Ame- 
rican Journal of the Medical Sciences for April 1841, and April 184-2. 



REMITTENT FEVER. 339 

The pulse of course varies exceeding-ly, being more or less frequent during the 
exacerbation, scarcely exceeding the natural standard, or even falling below it, dur- 
ing the remission. On the whole it is less rapid than *in proper continued fever. 
As regards otlier characters, such as softness, fulness, 6lc., they vary exceedingly 
under different circumstances. 

As the disease progresses the skin is disposed to assume a sallow, and especially 
in the more malignant bilious form, a yellow colour. In the pernicious or conges- 
tive form, it is more apt to assume a pale or leaden hue. I have never in a single 
instance noticed rose-coloured spots, so frequent in t3''phoid fever, and although 
sudamina are occasionally met with about the neck, they are much less frequent 
than in the latter disease. The dusky eruption of typhus too, is, so far as I am 
aware, entirely absent in remittent. It is true that in the most aggravated form of 
the latter, petechiee are sometimes mentioned as occurring towards the conclusion; 
but these were no doubt true petechiae, such as are at times present in various affec- 
tions, and very distinct from the proper eruption of typhus. 

Pains in the back and limbs are the usual concomitants of the disease at the com- 
mencement. So also is headache, which usually persists during the early period, 
or even longer, like most of the other symptoms, however, being most marked dur- 
ing the exacerbations, subsiding or disappearing entirely durinsf the remissions. 
The mind is not often much affected. There is wandering of course at times, 
during the violence of the exacerbation, and occasionally active delirium; but in the 
main the intelligence is not disturbed. Stupor also is sometimes pre^ht, and may 
even be very profound, but is not often of long duration; and like delirium does not 
exist as a prevailing feature. In these respects there is a remarkable difference 
between remittent and typhoid fever. Instead of the steadily increasing wander- 
ing, stupid expression, and slow answers met with in the latter, we have for the 
most part in remittent, an intelligent or even active expression, with prompt an- 
swers, the sense of hearing being commonly unaltered. Such at least is the case 
in our ordinary remittent, so far as ray observation extends, and essentially the 
same appears to be true of the disease generally in its common form, judging from 
the descriptions of authors. As regards delirium, however, it should be observed 
that it is spoken of as a very prominent feature in some epidemics. Thus we are 
told by Pringle, in his account of the intermitting and remitting fevers of the camp, 
that in some instances the head was so suddenly and violently affected, that with- 
out any previous complaint the men ran about in a wild manner, and were helieved 
to be mad, till the solution of the fit by a sweat, and its periodic return, discovered 
the true nature of their delirium. Again, in the pernicious form of the disease, the 
patient is often thrown into a state of stupor or lethargy; but here as in the pre- 
vious instance, the affection is more or less prompt in its onset, and subject to as 
rapid abatement, which circumstances, together with the different expression of 
countenance, the general absence of deafness, &;c., sufficiently distinguish the cere- 
bral disturbance of remittent, even when present to a considerable degree, from 
that of proper continued fever, whether typhus or typhoid. Sometimes, it is true, 
the delirium of remittent is spoken of as progressive and permanent, but onlv in 
the latter stage of severe cases. The thoracic organs mostly suffer but little. Not 
so, however, the abdominal viscera. Nausea or vomiting, indeed, are among- the 
earliest and most frequent symptoms. The matter vomited is commonly bilious; 
but in those cases which have been styled hepatic remittents, there is an ab- 
sence of bile in the matters evacuated, whether by vomiting or stool, until towards 
the close of the attack, when in favourable cases there are large evacuations of dark 
pitch-like matter, which have been regarded as critical. Costiveness generally 
prevails, but sometimes at the commencement there is free spontaneous purging. 

Besides the nausea or vomiting, a painful sense of weight and tension in the 
epigastric and hypochondriac regions, particularly the right, with oppressed and 
anxious respiration, are usually described as among the most prominent symptoms. 
In severe cases the epigastric anxiety and oppression are often extreme, and some- 
times they are noticed in conjunction with deadly sickness, as perfectly intolerable. 
E'-sn in the milder forms of the disease, I have generally found more or less ten- 



340 REMITTENT FEVER. 

derness of the epigastrium, and frequently of the left hypochondrium, the latter 
probably being chiefly dependent upon enlargement of the spleen, which enlarge- 
ment, I suspect, can generally be detected, if carefully sought for through the aid 
of percussion as well as the touch. 

Meteorism is said to be frequent in the latter stage of those cases which assume 
an aggravated form. Such, however, does not appear to be the case in the milder 
forms of the disease. For myself, I have almost always found the conformation 
of the abdomen natural, unless when there was some fulness about the epigastric 
and hypochondriac regions, and indeed in the only case, accompanied with con- 
siderable meteorism, which I recollect to have met with, this stale was, I think, 
especially marked above the umbilicus. 

The state of the tongue is very various; so far as I have observed, there is much 
less tendency to its becoming dry, chapped, brown, or preternaturally red, than 
in typhoid fever, but in the most severe forms, it is described as becoming dry and 
black and accompanied with sordes about the teeth. 

The last circumstance to which I shall allude, is the tendency to yellowness, 
which is especially marked in the conjunctiva. Sometimes this tinge is not at all 
observable in the skin, which at other limes is sallow, or positively yellow. In 
some severe cases the whole surface of the body is of the colour of brass. The 
same bilious impregnation is met with in the urine, to say nothing of the contents of 
the stomach and bowels already mentioned. 

Varietiesil^li has been already remarked, that under different circumstances the 
disease assumes very different aspects. In its simplest form, such as it occasionally 
presents itself in temperate climates, the symptoms are generally mild, the epigastric 
distress moderate or even entirely absent, the biliary functions but little disturbed, 
and the complexion little or not at all altered. The type of the fever is mostly 
double tertian, the remissions being most marked on the alternate days. The re- 
missions are sometimes very complete, more so in some years than others, whilst 
again they may be so indistinct as to give to the disease a pseudo-continued aspect. 
Still, however, the practised observer will generally be able to detent its periodical 
character during a part of its course, especially by watching the character of the 
remissions on alternate days. These cases may run on for several weeks, and 
where the remissions are indistinct, may readily be mistaken for mild cases of ty- 
phoid fever. From the latter they may be distinguished by the clearness of the 
intellect, the comparatively natural expression of countenance, and the absAice of 
deafness, of rose-coloured spots, of meteorism, and of diarrhcea, all which con- 
stitute such prominent features of typhoid fever. 

In another and more prevailing form, which maybe styled simple bilious remit- 
tent, the bilio-gastric symptoms already described are more marked, the breathing 
oppressed and anxious, the eyes assume a yellowish tinge, and the symptoms 
generally become more aggravated. Between this and the bilious remittent of the 
highest grade, there are many transition shades. In this latter, the symptoms are 
most violent, and often rapid in their course. The pains in the head, loins and 
limbs, are excruciating, the sickness deadly, with great epigastric distress, restless- 
ness and oppression, the heat of skin during the exacerbation pungent, its yellow 
colour becoming of a deep shade as the disease advances, whilst towards the con- 
clusion petechiae and vibices are said to make their appearance, the tongue l)ecomes 
covered with a black crust, the teeth with sordes, the breathing laborious, the 
anxiety extreme, and finally the extremities become cold, and death closes the scene, 
most commonly from the fourth to the eighth day. 

Besides the various shades and varieties of bilious remittent, there is another 
very distinct form of the disease, described by the continental European writeis 
under the title of pernicious, and generally known among us as congestive fever. 
It is sometimes described under the head of malignant, but this term is also em- 
ployed to designate any very violent form of disease, without reference to its par- 
ticular character. The pernicious or congestive remittent is especially characterized 
by symptoms of great prostration and congestion. The patient is lethargic, drowsy, 
or even comatose; the countenance is swollen, the respiration is oppressed, there is 



REMITTENT FEVER. 341 

nausea or vomiting, with anxiety, faintness, diarrhoea, &c. During tlie chill, which 
is often accompanied with icy coldness, the pulse is scarcely to be felt, and when 
the fever supervenes, it developes itself but slowly, being weaker, smaller and softer 
than in ordinary cases. During the remission, it may even be slower than natural. 
As the disease advances, the remissions become more and more indistinct, till they 
are scarcely perceptible, and the fever becomes pseudo-continued. Prolonged and 
cold perspiration, cold livid extremities, &-c. often maik the concluding stages. 
Where these symptoms are extreme, it is sometimes called the cold plague, and 
may prove rapidly fatal. 

Such are the most important symptoms of remittent fever in general, and of its 
principal varieties. It has been already remarked, that no disease assumes such 
varied aspects, from differences of climate, situation, and other circumstances. 
Sometimes perhaps we may meet with an epidemic in which the symptoms are 
intermediate between the more inflammatory bilious and the pernicious remittent, 
and such a combination would probably pass under the title of congestive in most 
portions of our country. To enter more into detail, however, and describe the 
exact combinations of symptoms which have been met with by different observers 
in different countries, would unnecessarily encumber if it did not confuse the sub- 
ject. Enough has been said to convey a pretty distinct impression of the pheno- 
mena of remittent in general, as well as of its principal varieties. 

Duration and Terminations. — The duration is very various. In the most 
malignant forms, death takes place in a few days, or even in the very first paroxysm, 
but more commonly it occurs towards the end of the first or in the course of the 
second week. Sometimes the disease is protracted for six weeks or more, with 
moderate fever, emaciation, sallowness or yellowness of skin, prostration, &c. 
Such cases, so far as I have observed, are generally accompanied by evidences of 
subacute inflammation of some of the abdominal viscera. The state of the stomach 
and spleen, as well as of the biliary apparatus, ought here to be carefully inquired 
into. Diarrhoea or dysentery may also supervene. In the favourable as well as in 
the fatal cases, however, the course of the disease is usually rapid, convalescence 
commonly taking place between the fifth and eleventh days, or at any rate within the 
first two weeks. The mean duration, according to my observations at the Penn 
sylvania Hospital, may be estimated at about fifteen days. But in this, as in so 
many other respects, there is scarcely any disease which presents so many differ- 
ences under different circumstances. One thing, however, is clear, viz. that its 
mean duration is considerably less than that of typhoid fever, under similar circum- 
stances. The same is true of the mortality, which in the violent forms of the 
affection in hot climates is very great, whilst in the simple forms in the more tem- 
perate climates it is very small. The proportion for three successive years in the 
Pennsylvania Hospital was one in ten and a half. 

Besides the protracted form already mentioned, the disease may be converted 
into intermittent, and give rise to the same consecutive phenomena as the latter 
affection, viz. enlarged spleen, cirrhosed liver, dropsy, &c. 

Critical Days. — Before leaving this part of the subject we will say a few words 
in reference to critical days. These have given rise to much disputation at 
different times. It seems, indeed, to be now pretty generally admitted that the 
commencement of convalescence in acute diseases is often marked by the occurrence 
of certain phenomena, particularly an increased discharge from the skin or some 
other emunctory, and such phenomena have been called critical. Besides, it can 
hardly be doubted that these acts are absolutely serviceable in bringing about the solu- 
tion of the disease. But the doctrine of Hippocrates on this point, — to say nothing 
of his views upon the mode of production and object of these critical evacuations, 
views of course which are intimately associated with the hypothetical opinions of 
the day, and which we would not be understood as maintaining — went much 
farther in reference to a mere question of fac'l, for he maintained that these crises, 
especially when most favourable, were most apt to occur on certain days, as the 
7ih, 9th, llih, &c. whilst the intermediate days were unfavourable. So far as the 



342 REMITTENT FEVER. 

proper continued fevers are concerned, such as typhus and typhoid, it seems well 
established that there is no particular tendency to abate or terminate on particular 
days; and these, it is to be recollected, are almost the only fevers met with in 
London or Paris, as well as the other great centres of modern medical doctrine. 
But it does not hence follow that t!ie same is true of all fevers, or that the opinion 
of Hippocrates which supposes certain days to be more favourable than others, 
has no foundation in fact. Now as regards remittent fever, we frequently find it 
mentioned by authors that a favourable termination is particularly likely to take 
place on certain days. By Jackson, in his account of the remittent fevers of 
the West Indies, it is expressly stated that of sixty cases which terminated 
favourably, ten terminated on the third, ten on the fifth, twenty on the seventh, ten 
on the ninth, five on the eleventh, three on the thirteenth, and two on the seven- 
teenth. On the other hand, of nine which terminated fatally, one terminated on 
the sixth, one on the seventh, six on ihe eighth, and one on the tenth. This 
perfect regularity may of course be variously interfered with; the regular tertian or 
double-tertian revolution, usually of forty-eight hours, may be accomplished in 
rather less; but if, in addition to other evidence, we recollect that most writers agree 
in this, that the tertian or double tertian type is the most common type of remit- 
tents, we can scarcely fail to admit that the disease has an especial tendency to 
terminate at particular periods, separated generally by intervals of about forty-eight 
hours. Now it should be recollected that the fevers with which Hippocrates was 
principally conversant, as we shall have occasion to point oiit more particularly 
when speaking of the diagnosis, were of periodical basis, being either distinctly 
remittent or only pseudo-continued, but essentially distinct from the true continued 
fevers, whether typhus or typhoid, of England and France. It is perfectly clear 
that opinions based upon the observations of these latter, however correct in refer- 
ence to them, may be altogether inapplicable to other fevers, and such we believe 
to be the fact. At least, it seems to us highly probable that the doctrine of Hip- 
pocrates in reference to the point in question, is based upon sound observation, and 
applicable to that species of fever which predominates in Greece and its neigh- 
bouring islands. Much of the discussion, then, about critical days might probably 
have been saved if these points had been properly considered. Especially we may 
hence learn the importance of making proper distinctions in fevers, and of not 
hastily applying to fever in general, what is true only of some particular kind. 

Causes. — The circumstances under which remittent fever arises, are much the 
same as those which give origin to intermittents. Both are regarded as depending 
upon certain emanations, styled marsh miasmata or malaria, of highly analogous, if 
not identical nature. The subject of malaria, however, has been so fully discussed 
under the head of intermittent, that I shall not further allude to it. Remittent fever 
is rarely met with in the centre of large cities, except in the case of individuals 
who have been exposed to its causes elsewhere. This, we are convinced is true of 
Philadelphia, in the neighbourhood and on the outskirts of which the disease pre- 
vails uniformly to a greater or less extent in the fall of the year, whilst at the same 
time it is rarely if ever met with in the heart of the town, unless in the case.s men- 
tioned. It is said that the disease has sometimes arisen under the influence of heat 
alone, and under circumstances where malarious emanations could not have operated, 
as in the case of vessels at sea. In general, however, where the disease prevails 
on shipboard, it is said to make its appearance when the vessels are approaching 
the land or entered into port, and it may be doubted whether heat alone, uncon- 
nected with malaria, is ca[)ahle of producing it. Remittent fever, it is scarcely ne- 
cessary to say, is especially a disease of warm climates. It is endemic in all the 
southern sections of Europe and Asia, — being especially violent within the tropics. 
It is far, however, from being equally prevalent in all sections of these countries. 
In Europe it is especially rife and severe in the south of Italy and some other 
portions of the Mediterranean coast, but it also prevails at times with severity in 
sections nnich farther north, where the character of the soil and other circumstances 
are favourable to the production of malaria, as in Hungary and the Netherlands. 



REMITTENT FEVER. 343 

Of tropical countries, certain portions of the East Indies, as the Deha of the 
Ganges, and the western and central section of Africa, are subject to the most de- 
structive forms of the disease. In our own country it prevails most severely in its 
southern section and in the neighbourinir islands of the West Indies. In general 
it diminishes in severity as you proceed northward, but in the northern section of 
the western States, on the borders of the great lakes, it is more prevalent than on 
the atlantic coast, in corresponding latitudes. The New England States, indeed, 
are in great measure exempt from it, whilst farther west, in the neighbourhood 
of the lakes just mentioned, it often prevails with great severity, and assumes, I 
believe, frequently, more or less of the congestive form. 

The causes of remittent are chiefly operative during the summer and autumnal 
months. In this neighbourhood it is almost exclusively met with during the months 
of August, September and October. Besides climate and season, the various cir- 
cumstances of moisture and dryness, the character of the soil, its elevation, &;c. 
are powerfully influential, as already mentioned when speaking of malaria, under 
the head of inlermittents. Besides these various conditions, however, there is at 
times a wide spread epidemic influence, such as prevailed a few years since in the 
United States, the causes of which are not understood. 

x4.s regards individual constitution, it is well known that persons long resident in 
a malarious district are less liable to be attacked than strangers, — men also are more 
frequently the subjects of it than women, but there is no proof that this is owing 
to any greater susceptibility, but only to greater exposure to the causes of the dis- 
ease. 

Great fatigue, exposure to the heat of the sun, or to cold and wet. &;c. may 
operate as exciting causes, but only, I believe, where there has been previous or 
simultaneous exposure to the terrestrial emanations which we call malaria. 

Post-mortem appearances. — The morbid anatomy of remittent has been much 
less extensively and carefully investigated than that of typhoid fever. This no 
doubt is chiefly owing to the fact already mentioned, that remittent fever is so little 
known in those places which have been the principal seats of modern investiga- 
tion on this subject. For our knowledge indeed of the morbid anatomy of remit- 
tent, we are chiefly indebted to French or English practitioners, who have been 
temporarily located in districts where the disease has prevailed. It is not to be 
wondered at, therefore, if their descriptions are often far from being minute. More- 
over, it is to be recollected that, with few exceptions, these investigations, although 
comparatively recent, were made at a time, w-hen our acquaintance with morbid 
anatomy generally, and particularly the lesions met with in fevers, was much less 
satisfactory than at the present time. It is, therefore, suificiently evident why 
many points in reference to the morbid appearances, cannot be stated with the 
completeness and precision which would be desirable. 

As regards external appearances, yellowness of the surface and livid blotches 
are often met with. If death takes place early, the yellow tinge is slight, but if 
at a later period, it is deeper and more general. 

The brain is sometimes spoken of as being inflamed, its vessels turbid, wnth 
efiusion beneath the arachnoid or into the ventricles; but it may be fairly questioned 
whether the appearances here referred to were for the most part of much import- 
ance, or such as would at all warrant the inference of inflammation. At all events, 
it is now well understood, that appearances of a probably similar character, are 
met with in continued fevers and other afl*ections, both where the functions of the 
organ were disordered during life and where they were not, and that such apnear- 
ances are to be regarded as pseudo-morbid, connected often with the mode of death, 
or the mere result of the last agony, and not at all to be looked upon as evidences 
of any serious disease of the organ having existed during life. 

In the cavity of the chest are sometimes found engorgement of the lunffs, se- 
rous eff'nsion in the pleura, flabbiness of the heart, its lining membrane stained of a 
deep violet colour, ic. — Some of these lesions must be considered in part at least 



344 REMITTENT FEVER. 

cadaveric, whilst the whole of them are strictly secondary in their character, and 
for the most part the product of the last stages of the disease. 

It is in the abdomen that the most important lesions have been found. The 
spleen is commonly described as enlarged and softened; the liver as engorged with 
blood, enlarged, softened, and generally of a dark colour; the stomach as the fre- 
quent seat of inflammation. Other lesions are met with, but of their relative fre- 
quency and importance, it is impossible to form an opinion, from the very loose 
and general way in which they are noticed. 

Such is a condensed summary of the principal appearances spoken of by different 
writers. I shall now proceed to lay before the reader, an outline of what I have 
met with in my examinations at the Pennsylvania Hospital, a detailed description 
of which was given in the paper before referred to. 

The brain was found to be the seat merely of such alterations as are common to 
all acute diseases, its lesions being slight and comparatively unimportant. 

The same is true of the lungs, which presented nothing particularly remarkable, 
except in a single instance where they were highly congested, their colour through- 
out being nearly black. The heart was frequently flabby, and its lining membrane 
of a deep red or violet colour, a condition often met with in other acute diseases. 
The stomach presented evident marks of inflammation in every case except one, and 
there was also a remarkable development of the glands of Brunner in the duodenum, 
in every case where the organ was particularly described; but the rest of the in- 
testinal canal presented no important lesion except in two cases, in one of which 
the mucous membrane of the small intestine was softened and thickened; and in 
the other, that of the large intestine was softened and ulcerated, with thickening of 
the sub-mucous and muscular tissues. In the latter, dysentery was a prominent 
complication, whilst in the former the disease was protracted, and towards the 
close accompanied by diarrhcea. The liver was frequently enlarged, and its con- 
sistence generally diminished; but the most remarkable alteration was one of co- 
lour, which was met with in every instance. This colour more or less resembled 
bronze, or a mixture of bronze and olive, or some shades of lead colour. In de- 
scribing the liver in the paper referred to, I have remarked that the most correct 
idea of the colour just mentioned, " would perhaps be conveyed by stating its pre- 
dominant character, the same in every case, to be a mixture of gray and olive, the 
natural reddish brown being nearly extinct, or only faintly to be traced. This 
alteration existed uniformly or nearly so throughout the whole extent of the organ, 
except in a single instance, where a part of the left lobe was of the natural reddish 
brown hue. As the alteration of the colour pervaded both substances, the two 
were frequently blended together, and the aspect of the cut surface remarkably 
uniform. In one case, however, there was a marked distinction of colour, the 
olive being predominant in the parenchyma, the brown in the acini." In several 
cases where the disease had been protracted, the cut surface instead of the remarka- 
ble smoothness which it frequently presented, was more or less rough from hyper- 
trophy of the lighter coloured substance (commencing cirrhosis). The bile in 
the gall-bladder was commonly abundant and perfecdy fluid. The spleen was en- 
larged and softened in every instance, and generally to a great degree. The state 
of the intestinal canal and the development of the glands of Brunner in the duode- 
num, has been already mentioned. In one case, also, these isolated follicles were 
unusually developed throughout the whole of the small intestine, and in another in 
the last two feet of the ileum. The glands of Peyer were healthy in every in- 
stance. The mesenteric glands also were healthy wherever their condition is 
noted. In the paper already referred to, I have remarked that of the above lesions, 
*' two only were constant or observed in every case, viz. that of the spleen and 
the peculiar alteration of the liver. We might perhaps include among the con- 
stant lesions, the development of the glands of Brunner in the duodenum, but it 
may admit of doubt whether these glands were really morbidly enlarged in every 
case, although at the same time, their frequent enlargement and uniform distinct- 
ness, constitute a striking peculiarity of the disease. Of those which were not 



REMITTENT FEVER. 345 

constant, the inflammation of the stomach is unquestionably the most worthy of 
attention, both on account of its great frequency and the importance of the organ 
itself. The lesion of the spleen, though constant, was similar in appearance to that 
found in other diseases. It was remarkable, however, for the uniformly great de- 
gree to which it was carried, and for being frequently accompanied during life with 
pain on pressure in the left hypochondrium, a circumstance not usually accompany- 
ing enlargement and softening of the organ in other acute affections. The liver, on 
the other hand, was the seat of a morbid change, not only present in every case, 
but of a character not met with in other diseases; and as it was the only lesion 
which afforded these two conditions, the conclusion is obvious that it constituted 
the essential anatomical characteristic of the disease, as it presented itself to our 
observation. As the number of cases was small, such a conclusion, when viewed 
as a general proposition, applicable to remittent fever universally, can only be re- 
garded as the indication of a probable truth, the full confirmation of which requires 
the analysis of a more extended series of observations, conducted after the same 
manner." The probability, however, of its proving generally true, was increased 
by considering that the cases, although few, occurred in different seasons, and 
originated in different and widely separated places. Neither were they limited to 
any particular form of the disease, for some were of the pernicious character, 
whilst others were highly bilious, and others again of a more benignant form. 
The correctness of this view has been to a certain extent confirmed by subsequent 
observations which I shall presently refer to. Of the nature of the lesion in ques- 
tion, but little can be said. That it is inflammation will scarcely be contended by 
any one who does not make use of the term as synonymous with morbid action. 
As for congestion, its effect would be to produce a deeper red, not to destroy this 
tint. If infiltration of bile be appealed to, we must at the same time admit a pecu- 
liar alteration of this fluid and of the liver, inasmuch as the peculiar appearance 
here presented, is not met with in other diseases. In speaking of other diseases, 
however, I do not mean to include intermittent fever, which in its mode of origin 
and other features is so analogous to remittent, that, with Dr. EUiotson, I regard 
them as essentially identical. Since the publication of my paper, in which, be- 
sides my own cases, is mentioned one which occurred under the charge of my 
friend. Dr. Gerhard, at the Blockley Hospital, and where the liver, which was sub- 
mitted to my inspection, presented the same characters, I have met with but one 
fatal case. This occurred at the Pennsylvania Hospital, in the fall of 1843, was 
rather obscure as well as mild in character, and proved fatal only by the superven- 
tion of pneumonia of the lower lobe of the left lung, which was found hepatized 
throughout nearly its whole extent. The liver offered the characters above men- 
tioned, the spleen was enlarged and very much softened, the stomach without evi- 
dent marks of inflammation, the rest of the intestinal canal presenting nothing 
worthy of note, the glands of Peyer healthy. 

Recently I have been highly gratified at receiving through Dr. Stille, of this city, 
a communication from Dr. Power, of Baltimore, in which the above observations 
are confirmed. Dr. Power is the attending physician to the Baltimore Alms-house, 
where in the fall of 1841, he met with three fatal cases of the disease. In all these 
cases the liver was large, softened or friable, and without sanguineous engorgement. 
The colour in one case is described as grayish-olive, which was uniform through- 
out, the two substances being confounded together; in another as slaty bronze, the 
two substances not being distinguishable; whilst in the third it was of a uniform 
dark slaty-gray hue. The spleen in every case also was enlarged and softened. 
In one case there was evident inflammation of the stomach as well as of the duo- 
denum, which last was thickly sprinkled with enlarged mucous crypts, the rest of 
the intestinal canal as well as the mesenteric glands being nearly or quite healthy, 
the glands of Peyer scarcely distinguishable. In the other two, although the exa- 
minations were made severally 28 and 20 hours after death, putrefaction was so far 
advanced that the mucous membranes could not be satisfactorily examined. In one 
of these, however, it is mentioned that the glands of Peyer weie neither ulcerated 



346 REMITTENT FEVER. 

nor enlarged, whilst in the upper part of the jejunum the glands of Brunner were 
liypertrophied. The above is a summary of the principal post-mortem appearances 
met with by Dr. Power. I have made it out from the more detailed account which 
he so kindly placed at my disposal, and at the conclusion of which he further 
mentions that at the same lime he had met with two other fatal cases of remittent, 
one in town, the other in the service of his colleague Dr. Annan. "In both," he 
says, "the slaty bronze colour of the liver was marked; the organ was also en- 
larged, and its uniform hue, its friability, its strange appearance, so different from 
what I have met with in other diseases, dispose me to think, that this lesion is 
constant in remittent fever." He also observes that to his mind, these cases "bear 
out Dr. Stewardson's views as to the pathological lesion in this disease." Before 
leaving this part of the subject, I wish to call attention to the fact noted by Dr. 
Power in all his cases, viz., the absence of sanguine engorgement of the liver. 
That the peculiar lesion of the organ is not dependent upon sanguine congestion is 
sufficiently evident, but that this congestion was not even a concomitant, I had only 
alluded to as probable in the paper already mentioned, for indeed, I felt doubtful 
whether I had observed this point with sufficient attention to justify me in speak- 
ing with positiveness, in the face of the statement often made by those who have 
mentioned the condition of the liver in remittent, viz., that it is commonly engorged 
with blood. The observations of Dr. Power, however, confirm me strongly in my 
impression that this is questionable, especially as I can readily conceive that the 
enlargement, softening, and dark colour of the organ, might easily be passed by as 
evidences of sanguine engorgement, where the attention of the observer was not 
particularly directed to the distinction, and especially where the idea of congestion 
was previously present to his mind. This, however, as well as many other points, 
must be left to the determination of future observers, for however valuable the 
writings of former times, and however important their study in reference to those 
features of disease, to which in the then state of knowledge the minds of their 
authors were particularly directed, it cannot be supposed that by their perusal we 
could arrive at any thing more than the merest presumption upon many points 
which are either not noted at all, or in a very loose and general way. Before con- 
cluding the account of the morbid changes, it should be mentioned that from the 
thinness of the blood, and the absence of large firm fibrinous coagula in the heart 
after death, we may presume that its condition is in some respects analogous to 
what is met with in other fevers, but very different from that found in inflamma- 
tions. 

Nature of the disease. — This subject need not detain us long. It is scarcely 
necessary at the present day to remark that the phenomena of the disease cannot 
be traced to gastro-enteritis alone or combined with engorgement of the spleen, 
for the plain reason that these lesions are often met with where no such pheno- 
mena are present. It is equally clear, that in the present state of our knowledo-e 
at least, we cannot regard them as consequent upon the lesion of the liver, and 
hence we are forced to look for the essential element of the malady in some other 
portion of the economy. By some this is supposed to consist in a peculiar disorder 
of innervation, the traces of which in the nervous structure are not cognizable by 
the knife, and by others in congestion of the capillaries. A morbid condition of 
the blood has also been appealed to as the grand source of the malady; but all these 
views are more or less hypothetical, and incapable of any thing approaching to de- 
monstration. It is something, however, to know what the disease is not; to have 
escaped the error of supposing that we have reached the source of the morbid phe- 
nomena, where in fact we are profoundly ignorant of it. Under such circumstances 
we are contented to accept such a partial theory as facts will warrant, leaving its 
complete development to a future period, when the progress of science shall have 
supplied us with more ample data. At present, then, it seems to me that all we 
can assert with safety is, that the sensible effects of the malarious influence, what- 
ever it may be, are chiefly displayed in the disorder of the liver, spleen, stomach 
and duodenum, for these are the only organs which after death are found either 



REMITTENT FEVER. 347 

uniformly or very generally to present distinct evidences of organic derangement, 
and during life many of the most prominent and characteristic symptoms can be 
traced to them, such as the epigastric distress and tenderness, as well as that of the 
hypochondriae, the prsecordial anxiety and oppression, the bilious vomiting, &c., as 
also the more remote consequences of the hepatic lesion, viz., the yellowness of 
the conjunctiva, the sallow or yellow hue of the complexion, &c. 

The predominance of the gastro-hepatic symptoms in the severe forms of re- 
mittent, especially in hot climates, has generally attracted the attention of observers; 
but this general statement requires the enlargement and precision which more recent 
investigations have given to it, before it can assume the importance which I think 
it deserves. It is quite one thing to speak of an organ as being the frequent seat of 
local determination in a given disease, and quite another to regard that organ as of 
necessity the seat of a certain form of morbid action, of greater or less severity, 
wherever the disease is present. Thus in typhoid fever we have a certain lesion 
of theglands of Peyer always present, whether the abdominal symptoms be severe 
or slight, and this lesion bears a totally different relation to the affection, from those 
local determinations which are common to all acute febrile affections, but universally- 
present in none. In smallpox we have a pustular eruption upon the skin extending 
to the fauces and sometimes to the larynx. This lesion may be so severe as to 
give rise to the most horrid symptoms, or so slight as scarcely to occasion annoy- 
ance, but in any case it is present and forms a part of the disease, and nobody 
would think of regarding it, or the inflammation of the skin, fauces or larynx to 
which it might give rise, in the same light with the secondary local determinations 
above mentioned. To my mind, however, this would be just as reasonable as in the 
instance of typhoid fever to place the lesion of the glands of Peyer on the same 
level with mere local congestions and inflammations of variable seat. The first is 
essential, the latter accidental; the first is intimately associated with the peculiar 
morbid action which constitutes the disease; the latter belong to it principally as it 
is a disturbance of the circulation, and hence are common to all acute febrile affec- 
tions. Some authors, however, will admit no such distinction, and place all the 
lesions found in fever upon the same level, so far as the point in question is con- 
cerned. For myself, I cannot so view it, and as regards remittent fever, I am 
disposed, for the reason, mentioned in the previous section, to regard the lesion of 
the liver which I have described, as belonging to the class of essential lesions. 
That of the spleen also is to be viewed in somewhat the same light, but as enlarge- 
ment and softening of the organ exist in other diseases, this lesion cannot be 
regarded as strictly characteristic. The stomach, too, is so generally inflamed, as 
well as tlie glands of Brunner in the duodenum enlarged, that we must look upon 
these also as being more intimately associated with the affection than ordinary local 
determinations. As regards the morbid appearances found in the other organs after 
death, whether viewed in reference to their character or comparative frequency, 
they reveal only such local disorders as are common to all fevers. It is to these 
last, only, in my estimation, that we can consider as strictly applicable the remark 
often made by writers, that under different circumstances of climate, season, &c. we 
find the lesions of different organs predominating. Those lesions which are essential, 
may vary in severity indeed, but must always be present; they cannot, like the 
former, be present at one time or in one place, and not in another. This dis- 
tinction between essential and accidental lesions, is one which is absolutely impe- 
rative in the present stage of scientific investigation, and one which should con- 
stantly be kept in view. So much for the organic alterations observed in remittent 
fever, and their relative value. But it must be recollected that whilst a number of 
the prominent symptoms are to be traced to the chief of these, they will not 
account for the whole train of phenomena. We must admit that there is something 
beyond, not cognizable by the knife, and which has hitherto eluded our research; 
something more general, be it a disorder of the nervous system, of the blood, or of 
any otlier portion of the economy. Upon this unknown element, essentially the 
same in all probability with that which is present in intermittent, we may presume 



348 REMITTENT FEVER. 

that the paroxysmal feature of the disease more directly depends, and that the 
curative influence of quinine, so controlling an agent in both affections, is especially 
directed. Whether the grand difference between intermittents and remittents con- 
sists in some modification of this element, or in the supervention in remittent, of 
local disease not present in intermittent, is not easy to determine. The first sup- 
position, I think most probable; for although at first sight it seems very natural to 
suppose, that remittents are formed out of intermittents by the supervention of an 
inflammation, most probably of the stomach, by which the intermissions are more 
or less obscured, this idea does not seem to be borne out by post-mortem investi- 
gation. It is true that ordinary intermittents rarely^ prove fatal in, the acute period, 
but so far as the point can be determined by a reference to what occurs in malignant 
intermittents, it would seem that gastritis is a frequent accompaniment of both 
diseases, and that the other local lesions, certainly that of the spleen, are much 
the same in the two afli'eclions. Of course I do not speak of the precise alteration 
of the liver which I have myself described, for whether this is present in intermittent 
as well as remittent, or uniformly present in either, can only be determined by- 
future observation, now that attention is directed to the subject. It seems probable 
then that remittent differs from intermittent, not in the supervention of a local 
aflfection not belonging to the latter, but in some modification of the more general 
element above spoken of, which constitutes the great substratum of the disease. 

Diagnosis. — From intermittent fever, remittent can be distinguished only by the 
circumstance of the intermission which occurs in the former. In other respects 
they are similar, and as it is sometimes difficult to say whether an intermission is 
perfect or not, the distinction between the two affections is at times more or less 
arbitrary. Not so, however, with the diagnosis between remittent and continued 
fevers, understanding by the latter those fevers which are uniformly and essentially 
continued, such as typhoid and typhus fever. We say uniformly and essentially, 
because in remittent fever, the remissions may at times become so obscure as to 
give to it more or less of a continued form, but this continuity, so to speak, is ac- 
cidental, and rarely if ever so complete but the sagacious observer will be able to 
detect the evidences of its remittent basis, at least in some part of its course. 
When the remissions, however, become thus obscure, the disease is said to pass 
into the continued form, and this in one sense is true; but it is to be feared that 
many physicians are, from the use of this mode of expression, insensibly led to 
regard the disease as then really identical with proper continued fever. This is a 
great error, and to avoid such confusion it would be better to designate this state as 
pseudo-continued. The term remittent is applied to the disease before us, as ex- 
pressing one of its general characteristic features, but then it is to be recollected 
that this is not the only one which distinguishes it from those fevers technically 
styled continued. Whether, then, the remittent type be so distinct as to approach 
to the intermittent, or so obscure that the fever becomes pseudo-continued, the dis- 
ease is still technically remittent, its essence remains the same, its other charac- 
teristic features still persist. To these features we shall now allude; and first as 
regards the cerebral functions: In the benignant and even some of the more ma- 
lignant varieties of remittent, the intelligence is comparatively sound, the senses 
perfect, and the answers prompt, whilst in others, especially those partaking more 
or less of the pernicious character, there may be violent phrenitis or profound coma; 
but the suddenness, the severity, and, unless where soon followed by death, the 
comparatively rapid abatement or even the entire disappearance of these symptoms 
in a very short time by the occurrence of a complete remission, sufficiently dis- 
tinguish them from the constant and progressively increasing wandering, dulness, 
delirium and stupor of typhoid or typhus fever, accompanied as they are, each by 
a peculiar expression and a dingy redness of complexion which does not belong to 
remittent, in which, on the contrary, there is more commonly sallowness, or lividity, 
or yellowness of surface. Besides the diflTerence of hue, the former are accom- 
panied by an eruption of a few rose-coloured spots upon the trunk in one case, 
and of a more extensive and deeper coloured efflorescence in the other, neither of 



REMITTENT FEVER. 349 

which are met with in remittent. In the latter, the thoracic organs suffer but little, 
whilst in typhoid fever, there is frequent bronchial irritation, and in general a greater 
tendency to inflammation of the lungs themselves. Great oppression of the respi- 
ration seems more common in remittent, but this is probably in great measure 
owing to the state of the abdominal viscera, of the symptoms of which we will 
now speak. To say nothing of costiveness in remittent, as contrasted with diar- 
rhoea in typhoid fever, it is here especially important to observe that the presence 
of early bilious vomiting, of hypochondriac tension and soreness, of episgastric 
distress and anxiety, which in cases of extreme severity become perfectly intole- 
rable, accompanied by the most deadly sickness and constant retching, are positive 
phenomena highly characteristic of remittent when compared with either typhus 
or typhoid fever. On some of these M. Littre has laid particular stress, in his 
admirable essay introductory to the epidemics of Hippocrates, where he has most 
successfully established the opinion previously maintained, but never fully proved 
and carried out by some of the English writers, that the fevers observed by Hip- 
pocrates were to be classed with the remittents of hot climates, and entirely dif- 
ferent from the continued fevers of temperate climates, especially of Paris, where 
typhoid fever prevails almost exclusively. Thus he finds, upon examining the 
cases recorded by Hippocrates, that this great observer has noted the presence of 
swelling, or tension, or pain of the hypochondria, in about one-third of them, a 
result exactly in accordance with that obtained by an analysis of the cases reported 
by Twining in his account of the fevers of Bengal. On examining, however, the 
cases of fever at Paris reported by Petit and others, a very different result is at- 
tained, for here the hypochondria are scarcely ever the seat of any notable symp- 
toms. Hence M. Littre concludes that the condition of the hypochondria in the 
former is remarkably characteristic; for, says, he, it indicates a peculiar lesion. 
Besides the features already mentioned, we should notice the rapid course of re- 
mittent, proving fatal, as it sometimes does, in a very few days, and consequently 
the early presence of certain symptoms, in cases where they are met with at all, 
such for instance as dryness of the tongue, all which is in marked contrast to 
what is met- with in either ty-phoid or typhus fever. In connection with the 
paroxysmal character of remittent, we of course often have free perspiration, cool 
surface, &c., in the remission, or chilliness preceding the exacerbations, but in per- 
nicious remittent the tendency to coldness becomes extreme, being accompanied by 
cold sweats and livid extremities, thus constituting another remarkable feature of 
remittent when compared with typhoid or typhus fever. 

If from a consideration of the symptoms, we turn to the post-mortem appear- 
ances, we find equally striking differences, remarkably in accordance with those 
met with in the former. For instead of the diseased condition of the liver, spleen, 
stomach and duodenum, already so fully described as belonging to remittent, accom- 
panied as they are by a comparatively healthy condition of the rest of the aliment- 
ary canal, we find nearly the reverse true of typhoid fever, in which the liver is 
commonly healthy, or nearly so; the mucous membrane of the stomach equally, if 
not more frequently healthy than in the generality of acute diseases of all descrip- 
tions; the spleen presenting, indeed, evidences of engorgement, which, however, 
from the absence of pain and uneasiness in that region during life, must evidently 
be of a more passive character than that belonging to remittent; whilst in all cases, 
the glands of Peyer, in the lower portion of the small intestines, are found to be the 
seat of a peculiar lesion not met with in remittent fever, or any other disease. As 
regards typhus fever, no characteristic lesion has yet been found; all the alterations 
hitherto met with being such as are common to other acute diseases. 

Now, if we reflect upon the above differences in symptoms and post-mortem ap- 
pearances, and, at the same time, call to mind the differences in the mode of origin, 
prevalence, <fec., as well as the different terminations of these fevers, we cannot 
fail to recognize the fact, that remittent fever, however it may assume a pseudo- 
continued form, is at all times essentially distinct from typhoid or typhus fever. 
This is important to observe, on various accounts. It is important in practice, that 



350 



REMITTENT FEVER. 



we may avoid the error of supposing, that in proportion as the fever beoomes more 
continued by the remissions becoming more obscure, it really assumes the nature of 
what is technically called continued fever. It is of the last importance, too, in 
discussions on the subject of fever, and in comparing the writings of different ob- 
servers. It is for want of making this distinction, as M. Littre has shown, that 
the epidemics of Hippocrates have been so imperfecdy appreciated in modern times. 
How, indeed, could this be otherwise, when we reflect, that the Hippocratic views 
of fever were based upon the observation of a disease scarcely known, except by 
the accounts of travellers, in the great modern European schools, whose views of 
fever, on the other hand, were based upon the observation of quite a different affec- 
tion. So long, therefore, as what we meet with in the latter, was made the test of 
the value of the views of Hippocrates on the subject of fever, his writings could 
but be misinterpreted and his observations be unjusdy appreciated. To be under- 
stood, his ^^ epidemics''^ must be studied under the conviction that they belong to the 
history of remittents, of the course, symptoms and prognosis of which, in the 
opinion of M. Littre, they may still be regarded as containing one of the best ac- 
counts which we possess. We cannot help remarking how admirably enlarged and 
philosophical is the spirit with which this gentleman has conducted liis examina- 
tion of these v/ritings, comparing what is therein contained with the results of 
modern and cotemporary investigation, with a view to mutual illustration and sup- 
port, a spirit so delightfully in contrastwilh that narrow-minded and jealous dispo- 
sition, which seems especially to delight in discovering only such notices in the 
older writers as can be turned, however unjustly, to the disparagement of more re- 
cent observations. 

We have extended our remarks on this subject, mainly with the view of enforc- 
ing the importance of making a proper and just distinction between the fevers men- 
tioned. Practically, however, in the great mass of cases there is litde difficulty in 
the diagnosis. It is chiefly, I believe, in the milder form of remittent in rather tem- 
perate climates, where the remissions may happen to be indistinct, that the difficulty 
of diagnosis between it and typhoid fever chiefly arises. The presence, however, 
of the chief phenomena of remittent already alluded to, even though not strongly 
marked, together with the absence of the characteristics of typhoid fever, cannot, in 
general, long leave the well instructed practitioner in doubt. Severe bilious remit- 
tents appear often to be confounded with yellow fever, but of the distinction be- 
tween these we shall speak when treating of the latter. 

Treatment. — In cases where the inflammatory excitement is moderate, and un- 
accompanied by severe local symptoms, the use of a mild cathartic, with rest, low 
diet, and the common adjuvants of an antiphlogistic course, are all that is necessary 
to bring the disease to a favourable termination. Not so, however, in its more se- 
vere forms; and here we have first to consider the propriety of employing the 
lancet. In those cases where the inflammatory excitement runs high, especially 
when accompanied by strong local determinations, it cannot be questioned that free 
bleeding at the commencement is not only proper, but imperatively demanded, and 
usually followed by the most prompt relief. When, however, a greater softness of 
the pulse and other circumstances indicate a different condition of the system, 
bleeding, although it may still be proper, should be cautiously employed. It is 
said by Twining, in his account of the fever in Bengal, that the loss of blood at 
the commencement of the first or second paroxysm in severe cases of remittent, is 
almost always useful. At a later period, however, unless its use is indicated by a 
high degree of arterial action, or distinct evidences of local inflammation, he says 
that it is of doubtful value; whilst in the more advanced stages, if it becomes neces- 
sary to resort to it, the patient should be carefully watched, in order that its in- 
jurious effects may be promptly met by the use of quinine and other means. 
Besides the stage of the disorder, great stress is laid by the same author upon the 
period with reference to each febrile exacerbation, when blood should be drawn. 
When the paroxysm is on the decline, the pulse becoming soft, and the skin in 
a state of perspiration, the loss of blood is no longer admissible for the time, 



REMITTENT FEVER. 351 

because of the approaching stage of collapse and prostration. He has even 
known some cases in which local depletion, accidentally delayed to this period, 
has been followed by fatal results. Of course it is only in severe cases where 
the tendency to prostration is great, that such extreme consequences would 
be met with, but still in milder cases the effects might be injurious. As a 
general rule, then, it may be stated that venesection is highly advantageous when 
resorted to during the first few days after the attack, especially when the disease is 
highly inflammatory. Not only is it followed by the immediate good effects of a 
more rapid solution of the paroxysm and complete remission, but permanent visceral 
obstructions and alterations are less likely to supervene at a later period. Where 
the signs are rather those of oppression, caution, of course, is to be observed; the 
effects of the operation carefully watched, and its happy influence promoted by 
the use of counter-irritants. In a disease of such varied character, whether from 
climate, season, locality, or other cause, only the most general rules of practice can 
be laid down, and hence as regards the propriety and extent of depletion, the prac- 
titioner must be greatly influenced by what experience has taught him in reference to 
its safety and advantage in a particular epidemic, locality, &c.: as a general rule it is 
safer in a dry than a humid climate, and amongst those who have recenfly arrived 
from a more northern climate, it is better borne than by the natives of hot climates. 

Emetics. — Experience seems now decidedly opposed to their employment. 
They are apt to bring on or aggravate gastric irritability, followed perhaps by 
evidences of more general intestinal irritation, watery discharges, &c., and also to 
render the course of the disease more prolonged and the remissions less distinct. 
The practitioner should not be misled by the momentary relief which may follow 
the administration of an emetic, especially when given in the decline of the pa- 
roxysm, the relief being really attributable perhaps to the natural remission, and 
followed by tenfold aggravation in the succeeding exacerbation. However, even 
supposing that emetics are occasionally beneficial, it is scarcely to be doubted that 
they are more commonly injurious, the sickness of stomach being aggravated, and 
the vomiting sometimes rendered constant and uncontrollable. Still in some cases 
it may be desirable to evacuate the stomach at the outset, and if so we should resort 
to the mildest measures, as a draught of chamomile tea, or the like, to the complete 
exclusion of antiraonial or other irritating emetics. 

Of the propriety of freely evacuating the bowels by a mild cathartic, there can 
be no question. In ordinary cases, epsom salts alone or combined with magnesia 
will answer every purpose; or a few grains of calomel followed by a saline cathartic 
may be employed. Irritating cathartics should be avoided, or at least, if occasionally 
demanded, they should not be persevered in, as they would be liable to aggravate 
the morbid condition, by inducing intestinal irritation, thin acrid discharges, 
tormina.and tenesmus. It is scarcely necessary to observe that when the stomach 
is very irritable, we should endeavour to allay this condition by the effervescing 
draught, iced cold drinks and other usual remedies, before giving a purgative, the 
administration of which, under such circumstances especially, is better deferred 
until the remission, when not only the gastric disturbance, but the general excite- 
ment, has more or less subsided. Where, for the time, cathartics cannot be admi- 
nistered by the mouth, and it is desirable promptly to evacute the bowels, enemata 
of course should be resorted to. 

Such is the plan of treatment usually requisite in the early stage of most remit- 
tents. At the same time the patient should be kept in a slate of repose, his apart- 
ment freely ventilated, his face and arms sponged with cool water when the skin is 
hot, and all the usual adjuvants of an antiphlogistic course resorted to as occasion 
may require. As the case advances, unless where remedial means are called for 
to counteract local determinations, or where symptoms of prostration should rapidly 
supervene. Hide more is requisite than to confine the patient to bland mucilaginous 
or farinaceous articles of diet, and administer such mild remedies as may be calcu- 
lated to promote gentle diaphoresis and keep the bowels freely open, wiiliout occa- 
sioning too frequent discharges. A free use of citrate of potash or some similar 



352 REMITTENT FEVER. 

article, will often answer both these indications, and is eminently serviceable; or it 
may be necessary to make use in addition of some mild laxative from time to time. 
In addition to the means already mentioned, however, it should be observed that 
by some it is recommended to administer calomel freely during the first few days, 
until the system is moderately brought under its influence. As regards the ordinary 
remittents of this section of country, such a practice is, I am satisfied, altogether 
unnecessary, and sometimes, at least, injurious. It would be unwise, however, to 
infer from hence that under other circumstances, and especially in warmer climates, 
the practice of resorting to large and oft-repeated doses of calomel is not called for. 
This point, we conceive, remains to be settled by the careful observations of en- 
lightened practitioners under the circumstances mentioned. It should be recol- 
lected, however, that such practice, if proper at all, is so only in the early stage, 
and that strong mercurialization or ptyalism is at all times to be avoided. 

One of the most important points of treatment in the progress of remjttent, is 
to attend to the local affections. According to our own observation, there is very 
generally in the course of the disease more or less tenderness of the epigastric or 
hypochondriac regions, especially the left. Even where this soreness is not great, 
and is accompanied with but slight sensations of uneasiness or oppression, it is 
often serviceable to detract a fevi' ounces of blood from the part, by cups or leeches. 
It not only relieves the local uneasiness, but is most efficacious at this stage in 
bringing on a complete remission, and thus favouring the solution of the disease. 
Frequently, however, the tenderness, pain, and other associated symptoms are so 
severe, as imperatively to demand local depletion with a view to their relief. This 
measure is most serviceable and especially called for during the exacerbation, 
when the epigastric or hypochondriac pain and tenderness is most marked. Not 
only so, indeed, but it is also necessary to be cautious even in the local abstrac- 
tion of blood, in those forms of the disease where sudden prostration is to be 
dreaded, that we do not resort to it when the remission is about taking place. 
Topical depletion to the epigastric or hypochondriac regions should be repeated 
during the successive exacerbations as long as there is much local uneasiness and 
the state of the pulse will admit of it. In conjunction with this practice, it may 
be desirable to keep up a decided action upon the bowels, and for this purpose, 
small doses of blue pill and rhubarb, to be repealed every few hours, may be ad- 
vantageously resorted to in addition to the sahne draughts, &;c. already mentioned. 
Before leaving the subject of the local abstraction of blood from the episgastric and 
hypochondriac regions, we should observe that this measure is important not 
merely for its immediate effects, but with a view to prevent those chronic altera- 
tions of the spleen and liver, which when firmly rooted are so obstinate in cha- 
racter and sometimes fatal in their ultimate result. The condition of these organs 
should also be kept in view in those cases which become protracted, with slight 
fever or rather febricula, imperfect remissions, emaciation, dryness of tongue, &c. 
Here it will often be found that inflammatory engorgement of the spleen, or sub- 
acute inflammation of the stomach or neighbouring parts, is the grand source of 
difficulty, and that the local abstraction of blood, a bland diet, the omission of 
tonics, if they had been previously resorted to, and the use of a small portion of 
opium or Dover's powder to allay irritation, &c. will bring about a most happy 
change. 

Local depletion to the temples or back of the neck is often needed during the 
exacerbation, to relieve the determination of blood to the head. Where stupor or 
coma supervenes in the course of remittent, the same remedy is called for where 
the pulse will admit of it, in conjunction with a brisk cathartic, and the prompt 
application of a large blister to the back of the neck, if the symptom does not 
quickly give way. 

Besides the local affections already mentioned, various accidental complications 
may arise, which must be met by the usual remedies. The same may be said of 
the general system, which, as in other febrile affections, may call for the use of 
small doses of blue-pill, ipecacuanha and opium, for instance, where the tongue 



REMITTENT FEVER. 353 

becomes dry and brown, or of the various stimulants, such as carb. of ammonia 
camphor or the like, where the powers of life fail. There still remains, however, 
an important feature in the treatment of remittent, which has not yet been noticed* 
we mean the use of bark or its preparations. 

On the propriety of having recourse to cinchona in this disease, there has been 
much difference of opinion amon^ medical men. Some advocate its use as soon 
as the remission has declared itself, whilst others strenuously condemn it. Such 
difference of opinion can hardly be accounted for, without supposing that the effects 
of the remedy are very different in different forms of the disease, and in different 
years and climates. Thus in the fall of 1839, in the neighbourhood of Philadel- 
phia, the disease, after a few days of preliminary treatment, was marked by very 
perfect remissions, and was then promptly controlled by quinine, the effect of which 
in other years has been far from being so happy, at least until a later period of its 
course. There can be no doubt also that in the great majority of cases, the disease, 
after a certain duration, will arrive at a favourable conclusion without the use of 
bark or quinine, which, on the contrary, may be productive of injury if injudiciously 
resorted to. On the other hand, it seems equally clear that there are cases, in 
which this remedy is our grand resource, and where without it, a fatal result would 
almost necessarily follow; whilst at the same time there are many more, where if 
judiciously employed, it is of very important advantage. It must also be recollected 
that objections formerly made to crude bark may no longer apply to quinine, which 
is much less likely to disagree with the stomach and bowels, or occasion any gene- 
ral irritation of the system, whilst at the same time it may be administered in vastly 
more effective doses. As a general rule it may be stated, that in proportion as the 
disease is inflammatory with imperfect remissions, quinine is inapplicable, whilst 
on the other hand, the more it is characterized by softness of pulse, prostration, 
and especially by those symptoms which belong to pernicious remittents, the more 
this remedy is demanded. It should be given in the remission in large doses, from 
5 to 10 grs., and repeated at short intervals previous to the ensuing exacerbation. 
In violent pernicious remittents, still larger doses may be called for, for here the 
life of the patient may depend upon the arrest or modification of the ensuing pa- 
roxysm. It is best given in solution, and may often be advantageously combined 
with sweet spirits of nitre or laudanum, or even with a stimulant, where the system 
requires to be roused. In these lethargic pernicious remittents, quinine is impera- 
tively demanded, as well as in many which hold a middle rank between these and 
the pseudo-continued inflammatory remittents. Sometimes where inflammatory 
symptoms are present, they subside as the disease advances, and the remissions be- 
come distinct. Here again, quinine may be resorted to, and this leads us to the 
further observation, that it is almost always serviceable in the decline of the affec- 
tion under any form, by rendering convalescence more firm and prompt, and by 
lessening the risk of its being converted into chronic intermittent. Of late years 
this remedy has been much employed in the United States as well as elsewhere, and 
it seems abundantly evident that it is capable of exercising over remittents a control 
very analogous to that which it does over intermittents, whilst at the same time it 
is less universally applicable, and is more often contra-indicated in the former than 
in the latter. Some of these contra-indications, we have endeavoured to point out, 
as well as the general conditions in which the remedy is most applicable. As 
regards its special applicability in particular cases, much must be left to the dis- 
crimination of the practitioner, aided perhaps by a cautious trial of its effects. All 
that I would insist on, is the general value of the remedy, as proved by numerous 
and competent observers, and of which my own experience has afforded me ample 
confirmation. 

In conclusion, let us observe, that besides the differences of treatment dependent 
upon the multiplied varieties of form assumed by the disease, the practitioner should 
always keep in view its remitting tendency, since a remedy, like venesection, for 
instance, may be required at one moment, and yet be altogether inadmissible a few 
hours later, when a different medication may be demanded. These variations and 
VOL. I. — 23 



354 YELLOW FEVER. 

the probnble period of their recurrence should be constantly kept in view in order 
to the proper regulation of the treatment. He sliould carefully attend to the evi- 
dences of local disorder, particularly in the epigastric and hypochondriac regions, 
recollecting that the force of the disease, so far as this becomes localized, appears 
to be mainly spent upon the organs there situated, and of course that it is highly 
important to moderate at once, by local depletion and other means, any excess of 
action which may be there displayed. Finally, he should recollect the special 
control exercised by quinine, and its importance and value, under the circumstances 
before mentioned. These are grand features of the treatment of remittent, which 
have no application to typhoid or typhus fever. To say, then, that the indications 
of treatment in remittent are much the same as in proper continued fever, is entirely 
erroneous. On the contrary, the very different indications which belong to the 
former, point out, like every other portion of its history, how radically distinct it is 
from the latter. 

Yellow Fever. (Dr. Stewardson.) 

At the present day it seems pretty well established that this disease must rank as 
a species of continued fever. In some of its symptoms, it is analogous to the 
severe forms of bilious remittent, and hence it has often been confounded with it, 
and regarded by some as a mere variety of the latter. Sound observers have not 
been wanting, however, from time to time, who, like Jackson in his account of the 
fevers of Jamaica, have appreciated with more or less clearness the distinction 
between these two affections. Accumidated evidence seems to me to have esta- 
blished this distinction, almost beyond doubt. By far the most important essay 
which has recently appeared, is that published by M. Louis, containing an account 
of his observations upon the disease, as it appeared at Gibraltar in the year 1828. 
Not only has he described its symptoms with remarkable accuracy, but also its 
morbid anatomy, whence he has been enabled to define its pathological characters 
with more precision than had previously been done. As in other acute affections, 
the symptoms may vary somewhat in different epidemics, but still they commonly 
present such uniformity of character, that the description of one epidemic affords 
a sufficiently accurate portraiture of the disease in. general. M. Louis, in his 
general description of the fever of Gibraltar,^ gives, firsts the symptoms met with 
in the fatal cases; secondly, those of the severe cases which recovered; and lastly ^ 
those presented in the mild cases. 

1st. In fatal cases the disease commenced at different periods of the twenty- 
four hours, usually with an intense headache, accompanied by chills, shivering, 
pain in the limbs, and soon after, pain in the back. A heat, rarely intense, suc- 
ceeded to the chills, and was sometimes followed by perspiration. At the same 
time the countenance became red and animated; and in some cases, as it were, 
swollen. The eyes were red, glistening, suffused, and in many cases the patients 
complained of a sensation of smarting in them. The thirst was intense, the ano- 
rexy complete. The first symptoms, the headache, the pain in the limbs, the 
anorexy, the thirst, the heat, the redness and the pain in the eyes, continued, the 
headache during half the disease, the pains in the limbs a little longer, and the heat, 
which in many cases was but slightly increased, continued so during nearly the 
same time. The pain at the epigastrium, so rare at the commencement, came on 
usually fifteen or twenty hours later. It was generally inconsiderable, and very 
few patients complained of severe or acute pain. With the epigastric pain came 
the nausea and vomiting, excited by drinks and purgatives in several cases, spon- 
taneous in others. The dejections were infrequent, that is, where no laxatives had 
been administered. The abdomen preserved its form, was supple and not painful 
to the touch, except in the epigastric region. The sleep was inconsiderable; some 
patients were restless, in some there was a good deal of jactitation during the night. 

» Researches on the Yellow Fever at Gibraltar, by M. Louis, translated by Dr. Shatluck, 
Boston, 1839. 



YELLOW FEVER. 355 

Others, and the smaller number, experienced as early as the third day, a real 
anxiety, could not remain quiet in any posture, and in some cases there was de- 
lirium. But this symptom did not usually come on till the last day of life, and for 
this reason it is to be considered rather as belonging" to the agony than to the 
disease. Otherwise, with few exceptions, there was neither prostration nor stupor. 
The pulse was moderately accelerated, regular, generally hearing relation to the 
degree of heat, which was almost always slight, as I have before said. The skin 
of the thorax was injected in some cases. This redness, and that of the eyes, 
diminished towards the middle period of the disease, or a little later, and new symp- 
toms appeared. To the injection of the integuments of the chest there succeeded 
a slight yellow tint of that part, and the eyes were of the same colour. When 
this colour appeared thirty-six or forty-eight hours before death, it became rapidly 
brighter, so as to be of some intensity at the time of the fatal termination. In other 
cases, where it came on only just before death, it was slight at the autopsy, and 
commonly limited to the trunk. At about the same period, or a little later, the 
matter vomited, from being of a yellow colour, became brown or black, and the 
dejections blackish or black. At the commencement of this change of colour, the 
vomit was of a liquid matter more or less grayish, mixed with a greater or less 
quantity of mucus; in which were to be seen blackish parcels, like soot. At this 
period of the disease, the uncomfortable feelings and the anxiety continued during 
different lengths of time and in different degrees, the strength diminished, the tem- 
perature fell, so that the limbs were cold before the agony; in some cases there 
was suppression of urine. Sometimes also a sort of remission or apparent ame- 
lioration of the symptoms was observed, and death took place when it would least 
have been expected, had not experience taught the practitioner to distrust this de- 
ceitful remission. In some subjects the violence of the headache, that of the pains 
in the limbs, the marked febrile symptoms, the numerous vomitings, the uncom- 
fortable feelings, the anxiety, the bright redness of the eyes, gave to the disease a 
truly serious aspect, whilst in others the mildness of the fever and of the pains 
wherever seated, the absence of agitation and delirium, the slight diminution of the 
strength, impressed on the disease a character of mildness, calculated to deceive at 
once the patients, their attendants, and the physician. It is under this form of 
the disease, that patients died without taking to their beds, on foot, as it was ex- 
pressed by their friends. 

In the severe cases which recovered^ the symptoms at the commencement were 
much the same as in the fatal cases. In a certain number, vomiting came on from 
the first to the third day. The epigastric pains were wanting in a greater number 
of cases; the pulse was moderately accelerated; the heat slighdy increased. In 
some subjects, the stools became black towards the middle of the disease or a little 
later. The brown and black vomit occurred in the cases of a few individuals only, 
and these were mostly children. The redness of the eyes rarely increased after 
the first day, and on the contrary, gradually became less. Restlessness at this 
period was rare. The extreme restlessness, the jactitation, which took place in 
those who died, was not met with in the cases now under consideration. Yellow- 
ness was wanting in a great number of cases. Towards the fifth day, the symptoms 
became less severe; the skin became cooler; the pulse calm; the epigastric pain 
diminished or completely disappeared; the thirst was less; the appetite returned, 
and convalescence commenced. This was generally long, that is, in proportion to 
the duration of the disease, the mean duration of which was from seven to eight 
days. The strength was not perfectly re-established sooner than from ten to twenty 
days after the cessation of the febrile symptoms. 

The mild cases differed from those just described, not only in the mildness, but 
also in the smaller number of the symptoms, and in the extremely short duration 
of the disease. The epigastric pains were rare, and so too were the vomitings, 
which were almost never spontaneous, and in no case of a brownish colour. The 
heat and thirst were moderate, and so slight was the diminution of the strength, 
that the patients did not keep their bed at all, or were there for half a day only, 



'■lii 



356 



YELLOW FEVEK. 



1 



thus, according to their expression, going through with the disease on foot. Here 
also the convalescence was long, longer even in proportion to the duration of the 
disease, than in the severe cases. A relapse was rare. 

Such is the remarkably accurate description given by M. Louis of the epidemic 
of Gibraltar. In its principal features, it accords with the accounts of other writers. 
The grand characteristics of the affection appear to be nearly the same in all 
epidemics. 

Anatomical Characters. — We shall first give an abstract of these as observed by 
M. Louis and described in the work already quoted. The brain was found to be 
the seat only of such slight alterations, as are met with more or less frequently in 
the most common acute diseases. In the spinal marrow likewise there were no 
appearances peculiar to yellow fever. Except in one respect, the same was true 
of the organs contained in the cavity of the chest. The pleurae indeed were re- 
markable only for the absence of recent lesions of any importance, and the lungs 
were found hepatized in but a single instance, and then only in a space about equal 
to that of a hen's egg. But although inflammation of the pulmonary tissue was 
rare, exhalation of blood into it was frequent. This exhalation was marked by the 
presence of numerous black spots, or masses of the same colour, the latter con- 
taining no air, not granulated, without evident organization, usually easily broken, 
and in some cases yielding by pressure the blood of which they were almost 
entirely composed. The oesophagus was completely deprived of epidermis through 
its whole length in a third part of the cases, and partially so in a greater number. 
The stomach contained a clear or dark red coloured liquid, a blackish or a perfectly 
black fluid, in three-fourths of the cases. Its mucous membrane was very frequently 
inllamed, being natural as regards consistence, thickness, &;c., in only one-fifth of 
the cases. The mucous membrane of the small intestine, presented unequivocal 
evidences of inflammation in but few cases, and the glands of Peyer, save a slight 
tumefaction of some of them in one case, that of a child, were perfectly healthy. It 
contained a greater or less quantity of reddish, brownish, blackish, or perfectly black 
matter in two-thirds of the cases. The same was found in the large intestine in 
nearly the same number. The liyer was natural as regards size in nearly every 
case; it was firmer or more coherent than natural in a {ew cases, whilst in some 
others it was rather less so; its colour was altered in every case; sometimes it 
was of the colour of fresh butter, sometimes of a straw yellow, a clear coffee and 
milk colour, sometimes of a gum yellow, sometimes of an orange colour. This 
change of colour existed throughout the whole extent of the organ except in three 
cases, where the right lobe preserved its natural colour either in part or entirely. 
In the others, also, the discoloration was most marked and uniform in the left 
lobe. At the same lime, there was a diminished quantity of blood, the sections 
being dry, where the discoloration was well marked. But little bile was found 
in the intestinal canal, and that contained in the gall-bladder was scanty, thick, and 
of a dark green colour. The spleen was natural in half the cases; in some it was 
a litde enlarged, in others somewhat softened, but with one exception to a moderate 
degree only. 

Of the lesions just described, two, viz. that of the liver, arid the red or black 
matter found in the intestines, are peculiar to yellow fever; the others, common to 
it and other acute diseases. The alteration of the liver being not only peculiar to 
the disease, but present in every case, must of necessity, concludes M. Louis, be 
regarded as constituting its anatomical character. That the principal features of 
the above description are not peculiar to the Gibraltar epidemic, is sufficiently evi- 
dent from observations since made in the West Indies and elsewhere. In a case 
which I had the opportunity of examining in the Pennsylvania Hospital, the ap- 
pearances met with were remarkably similar to those just described.* It must be 
left, however, to future observation to determine, whether the alteration of the iver 
is constant under all circumstances, and hence properly to be regarded as the essen- 
tial anatomical character of the disease. It cannot be questioned, however, that 



» Amer. Journ. of Medical Sciences. January, 1842. 



YELLOW FEVER. 357 

this condition is a very general and important feature in tlie post-mortem appear- 
ances. M. Catel says that in the epidemic of 1838-39, at St. Pierre, the liver 
was found pale and yellow in all the cases examined, which amounted to one hun- 
dred and fifty. The gall-bladder, also, was most frequently empty. 

Diagnosis and nature. — It is evident that the disease as observed at Gibraltar, 
was a continued fever, and it may fairly be doubted whether it is ever characterized 
by regular and distinct remissions. Towards the third or fourth day, especially in 
the inflammatory form, there appears to be sometimes a rapid abatement of the 
more violent symptoms, the pulse falls, and the skin becomes cool. This abate- 
ment, however, is but the precursor of a favourable, but more commonly of a fatal 
termination, and not to be confounded with a true remission. It is also said, that 
shortly after the attack has commenced, in the course of the first twenty-four hours, 
the patient will express himself as feeling better, although the symptoms indica- 
tive of intense disorder still persist. "A trifling abatement of tfie symptoms," says 
Dr. R. Jackson, "was sometimes taken notice of, in ten or twelve hours after the 
commencement, but in no instance, so far as I have observed, was there ever so 
much alleviation, as with any justice could be called a remission." It is not unlikely 
that these changes, especially where the mind of the observer was already prepos- 
sessed with the idea that yellow and remitting fever were essentially the same 
aflTection, may have led to the supposition that the former presented a truly remit- 
ting character. That it ever does so, appears at least to be very doubtful. 

In severe cases of yellow fever, the presence of black vomit and dejections, the 
yellowness, the extreme distress, combined with the rapid course of the disease, 
render it readily distinguishable from any other afl'ection, if we except those vio- 
lent and rapid forms of bilious remittent, which are accompanied by yellowness 
and extreme gastric distress, to which we shall presently refer. In some cases, 
however, the characteristic symptoms are wanting, and here a real difficulty may 
arise; so much so, indeed, that it may be impossible to arrive at any thing more 
than a probable conclusion, by taking into the account the circumstances of the 
attack, the prevalence or not of an epidemic at the lime, and how far it is possible 
to account for the symptoms on any other supposition. Of course, in the few 
fatal cases, where doubts exist during life, these may be removed by a post-mortem 
examination, the presence of the black matter in the stomach and intestines, or the 
specific alteration of the liver, affording conclusive evidence. 

We now proceed to consider the distinction between yellow fever and the severe 
bilious remittents, with which it may be confounded. In the former, as already 
remarked, the fever is generally, if not always, of the continued type; and hence 
this feature alone would be sufficient to settle the question, where we have an 
opportunity of carefully watching a case from the commencement. But unless 
other differences could be pointed out, it might be fairly questioned whether the 
two diseases were essentially distinct. In remittent, then, let us recollect, that the 
matter vomited is usually bilious throughout, whilst in yellow fever it is first clear, 
then yellowish, and finally blackish, or completely black. It is said also that in 
the latter the stomach is emptied without effort, and the desire to vomit ceases for 
the time, whilst in remittent the act of vomiting is painful and difficult, and the 
nausea persists. In remittent, there is a tendency to fulness of the hypochondriac 
and epigastric regions, whilst in yellow fever, according to Louis, the abdomen 
uniformly preserves its natural form. I cannot help thinking that this diff'erence in 
the conformation of the upper part of the abdomen, will be found to be an important 
distinctive feature; but to determine the question requires further observation, and 
I therefore throw it out as probable merely. The probability is to my mind much 
increased by considering that in remittent the spleen and liver are, generally at 
least, enlarged, and often to a great degree, especially the former, whilst in yellow 
fever they preserve their natural size, or nearly so, and hence we should naturally 
expect a correspondiug difference in the conformation, at least of the hypochon- 
dria. In remittent, also, the hypochondrias, especially the left, are sometimes 
painfiil, a condition, so far as we are aware, not noticed in yellow fever. The 
character of the yellowness is said to be diflferent in the two diseases; and Dr. 



358 



YELLOW FEVER. 



Stevens affirms that in yellow fever the patients do not shake nor tremble like those 
who are under the influence of marsh poison, and that the expression of counte- 
nance is so peculiar, that those who have once seen it, easily recognise it. R. 
Jackson, also, in his account of the fevers of Jamaica, says that the horror and 
shivering which so usually precede fevers, were seldom great in degree in the dis- 
ease before us. Cramps, too, are said to be much more frequent in this than in 
remitting fever. Such appear to be the principal points of difference, so far as 
regards the symptoms; and if we consider them in connection with other differences 
presently to be mentioned in reference to the origin, prevalence, &;c. of the two 
diseases, the very opposite condition of the liver and spleen, as discovered by post- 
mortem examinations, and the presence of a brown or black matter in the stomach 
and intestines in the one case, which is not met with in the other, it seems to me 
that it is scarcely possible to avoid the conclusion that the two diseases are essen- 
tially distinct. The enlargement and softening of the spleen in bilious remittent, 
and other types of fever of malarious origin, is a prominent fact attested by most 
writers; and this fact alone is almost sufficient to convince us that yellow fever, 
in which the spleen rarely presents any considerable traces of disease, must be 
essentially distinct in its nature. The very opposite conditions of the liver are 
also especially worthy of notice; that in yellow fever being anemic, with deficiency 
of bile in the gall-bladder, — that of remittent being usually enlarged, and with the 
gall-bladder fully distended. To this different condition of the liver and spleen in 
the two diseases we may probably refer for an explanation of another distinguish- 
ing feature in their history. T allude to the fact that in yellow fever the convales- 
cence is complete, the supervention of chronic disorder being a rare circumstance, 
whilst in remittent fever it is very liable to arise, especially in the organs referred 
to. The rarity of chronic disorder as a consequence of yellow fever, is attested by 
M. Catel in his account of the disease as it prevailed at La Martinique in 1838-'39. 
Of more than a thousand patients in the hospital of Saint-Pierre who recovered, not 
a single one presented at the time of his discharge any evidence of disease which 
was likely to become chronic. Before dismissing the subject of diagnosis^ we 
should mention that Dr. Stevens states that there is still another disease very similar 
to and often confounded with yellow fever, but really distinct, viz., the seasoning 
fever of the West Indies, the mere consequence of excessive heat in persons un- 
accustomed to the climate. 

As regards the essential nature of yellow fever, we are entirely ignorant. The 
local lesions, however important or characteristic, are clearly insufficient to account 
for all the phaenomena, in their origin and course. We cannot agree with those 
who would designate the disease, as has lately been done by M. Catel, as a gastro- 
entero-cephalitis, for the plain and sufficient reason that gastro-enteritis is a condi- 
tion constantly met with, but characterized by phenomena very different from those 
of yellow fever, and that if we invoke cephalitis in addition, we are no nearer an 
explanation of the peculiarities of the disease, whilst at the same time we are 
assuming what is not true, at least in a large proportion of cases. But although 
in the present state of our knowledge, we cannot arrive at the basis of the morbid 
phenomena, we must not neglect to connect these, as far as we can, with the ob- 
served alterations in particular parts. Thus the remarkable alteration of the liver, 
its pale and anemic condition, so opposite to either inflammation or congestion, 
accounts for the general absence of bile in the evacuations, at the same time that it 
is in harmony with the condition of the gall-bladder, which, as well as the stomach 
and intestines, usually contains but little bile. The gall-bladder, says M. Catel, 
was most usually empty. Whether the yellowness of the skin is a proper jaundice, 
and to be referred to disorder of the liver, has been questioned. Some are disposed 
to regard this yellowness, which is generally of a different shade from that of pro- 
per jaundice, darker, often mixed with a brown or mahogany tint, as dependent 
upon the oozing of the serum of the blood, in which, changes afterwards take place, 
analogous to those which occur in cases of ecchymosis. They see in this, one of 
the evidences of that hiemorrhagic tendency, which undoubtedly belongs to the 
disease. It is not improbable that both these causes may be concerned in the pro- 



YELLOW FEVER. 359 

diiction of the symptom in question. At any rate its analogy to jaundice in the 
parts where it commences, and in its progress, render it probable that it is con- 
nected with an imperfect elimination of bile, whilst on the contrary, certain modi- 
fications of its character may depend upon a peculiar condition of the circulating 
fluid, connected with a general haemorrhagic tendency. 

To the inflammation of the stomach, of course are to be referred those symp- 
toms which are common to yellow fever and gastritis, as tenderness of the epigas- 
trium, nausea, and the vomiting which belongs to the early and middle periods of 
the disease. As regards the mode of production of the black vomit, which charac- 
terizes chiefly the latter stage of fatal cases, some doubt exists. Not that there is 
any question that this matter is a product of the stomach itself, a position long ago 
maintained by Dr. Physick, and now we believe universally admitted. But it has 
been further maintained, that this matter was a product of the inflammation, and 
doubtless its secretion is favoured by this state, in numbers of cases. But that the 
most important element in its production is something besides inflammation, is 
evident, if we recollect that gastritis is a common accompaniment of other acute 
diseases, whilst true black vomit is perhaps never found except in yellow fever. 
Inflammation, then, merely as such, cannot account for it. It must be associated 
with some other special condition. Bui it is said that inflammation is not even 
necessary to its production, as this matter has been met with in the stomach where 
the mucous membrane was nearly or quite healthy. The aspect of this matter, 
whether vomited during life or found in the alimentary canal after death, varies 
considerably. Sometimes it resembles soot and water, at others it is of a brownish 
black, very thin and mixed with black flakes, or finally it is more consistent and 
presenting more or less the characters of pure blood. It would seem, indeed, that 
this fluid, in transuding through the mucous coat of the stomach, was in some cases 
altered by a true secretory process, whilst in others it escaped almost or quite pure. 
But this transudation is, as before mentioned, no mere consequence of inflamma- 
tion, and not even necessarily connected with it, and although often favoured by it, 
is intimately associated with another condition, viz., the general tendency to hae- 
morrhage. Even this, perhaps, will not account for it fully, for it sometimes, as 
where it resembles a mixture of soot and water, oflers more or less the charac- 
ters of a peculiar secretion. Again, as before mentioned, it more or less resembles 
blood, and this seems to be now generally regarded as its principal constituent. 
We must view it, therefore, as in part at least connected with the general tendency 
to haemorrhage which constitutes so prominent a feature of the disease. This 
feature is manifested in various ways. Thus, to say nothing of the discharge by- 
stool of pure blood, or of a black matter analogous to that already described, hae- 
morrhages are occasionally noted as occurring from the mucous membrane of the 
nose, mouth, eyes, &c., and are, as we have already seen, most remarkably fre- 
quent in the substance of the lung, constituting pulmonary apoplexy. 

Causes. — The origin and mode of propagation of yellow fever have been the 
subject of much discussion. No evidences of its existence are to be met with 
amongst the ancient writers. The notices in Hippocrates of violent fevers with 
yellowness, must clearly be referred to remittents, which now, as when he wrote, 
prevail in Greece, Asia Minor and the Islands of the Archipelago, where, however, 
yellow fever is utterly unknown. The great theatre of its ravages, indeed, is the 
AVest India islands and the neighbouring portions of the American Continent. 
From time to time it has been met with in some of the more northern cities on the 
Atlantic coast, in some parts of the southern coast of Europe, particularly that of 
Spain, and at a few points on the western coast of Africa. The sphere of its pre- 
valence is, therefore, very limited, and as regards most of the places mentioned, it 
has been much disputed, whether the disease originated in them from local causes, 
or had been brought thither from" other points. This brings us to the subject of 
contagion and infection, in reference to which we shall merely state the few conclu- 
sions which seem to be most fairly deducible from the numerous statements which 
have been advanced. 



360 YELLOW FEVER. 

, That the disease is properly contagious is an idea now very generally abandoned. 
It is agreed on all hands that an individual affected with it, if removed from the 
*' infected district," will not communicate it to another person. These infected 
districts are of limited extent, and principally met with in points on the sea-coast or 
the shores of large rivers, where the population is numerous; rarely, if ever, in 
interior and elevated districts. It should also be mentioned that in the cities of the 
United States, the disease first shows itself on the river side and along the docks 
where ships are moored, and sometimes does not extend to any great distance 
beyond. Whilst, however, it is admitted that the danger of contracting the disease 
is confined to certain limited districts, that beyond these it cannot be transported 
by individuals affected with it, it is equally clear that vessels of a certain size may 
become theatres of infection, as well as places on shore. Whether this can arise 
from certain conditions of the vessel itself, or depends in all cases upon the reten- 
tion of an infection which has been acquired in an infected port, we will not under- 
take to inquire. Siill less would we undertake to determine, whether in certain 
cities of the Atlantic coast of North America, Philadelphia for instance, the origin 
of the different epidemics of which it has been the seat, is to be traced to vessels 
so infected. I should be far from maintaining such a proposition; but at the same 
time it is undoubted that a vessel, as just mentioned, may be the seat of infection, 
and convey the disease from place to place. Instances of this kind are too nume- 
rous to admit of question. Even Dr. Rush records an instance of this sort in his 
account of the fever of 1798 in this city. The ship Deborah, shortly before 
arrived from the West Indies, was moored at Kensington, a village to the north of 
the city, "where," says Dr. R., "the foul air which was emitted from her hold 
produced several cases of yellow fever, near the shores of that village." Whether 
under such circumstances, the cases of fever are limited to such persons as are 
exposed to the effluvia from the vessel, or whether this may become a centre of 
infection which will gradually spread even after the removal of the vessel, is a 
point about which much difference of opinion has existed, and, indeed, such is the 
contradictory character of the statements made by different persons, that a rigorous 
conclusion can scarcely be attained. One thing, however, is quite clear, namely, 
that if the disease ever does spread extensively from such a source, it must be under 
very favouring circumstances of climate, season, and temperature. So far as the 
northern Atlantic cities are concerned, it has always prevailed in the warm season, 
commencing usually in August and terminating upon the approach of cool weather. 
But supposing that an infected vessel cannot give rise to an extensive prevalence of 
the disease in any port where she may arrive, and that those only are exposed to 
any danger who are brought within the sphere of her contaminated atmosphere, 
there is still sufficient reason why quarantine regulations in this respect should not 
be entirely abandoned. Not that we would advocate the detention of passengers, 
or even of a vessel for any length of time; but we maintain that it would be un- 
justifiable to allow a vessel which, during the warm weather, had just arrived from a 
port where the yellow fever was prevalent, to be moored in the dock of a large 
city and there unload, when the risk could be in great measure if not entirely 
obviated, by opening her hatches at some convenient place in the neighbourhood, 
ventilating and purifying her hold, and removing such articles of her cargo as are 
most likely to retain any infectious principle. That such a principle is capable of 
transportation, even though the disease itself be not properly contagious, is not at 
all unreasonable; for where a vessel, for instance, has taken in her cargo at an in- 
fected port, what is to prevent such an amount of the infectious principle being 
retained in her hold, as, when opened in another place, will be sufficient to com- 
municate the disease to those exposed to it. But upon whatever principle we may 
account for it, the fact is undoubted, and Dr. Rush mentions instances where the 
disease has been transported even by trunks of clothes. On the other hand, it can- 
uot be too strongly insisted on, that the disease is not properly contagious, that 
there is no effluvia generated by one patient which will communicate the disease 
to another, in a healthy district. Such, at least, experience has hitherto proved to 



YELLOW FEVER. 361 

be true, though at the same time, it would be hazardous to assert that under no 
circumstances could the disease be communicated from one person to another by a 
kind of infection bordering on contagion. 

As regards the real sources of the infection in the districts where the disease 
prevails, nothing certain is known. That it is very different from the malaria of 
remittents, is sufficiently evident, if we reflect that the latter prevails extensively 
in all climates where certain conditions of heat, moisture, and soil are present, 
whilst the geographical distribution of yellow fever is very narrow. Not only so, 
but it is generally met with in positions which do not give rise to remittents, as in 
portions of densely populated towns where remittents do not exist. Thus for 
instance in Philadelphia, yellow fever has never prevailed except on the Delaware 
side and along the docks, where no sources of marsh malaria exist and where re- 
mittents are unknown; whilst on the other hand, the latter occur annually on the 
outskirts of the city on the opposite side and in the neighbourhood of the Schuyl- 
kill river, where yellow fever is and ever has been unknown, but where the ordinary 
conditions of marsh malaria are abundantly present. At St. Pierre (Martinique), says 
M. Catel, intermittents are unknown, a proof that malaria is foreign to the pro- 
duction of yellow fever there. The disease, then, cannot be traced to marsh ma- 
laria, and it is equally impossible to attribute it to heat which exists to as great an 
extent in climates where the disease is unknown, as elsewhere. In short, we can 
trace the disease neither to marsh malaria, to contagion, nor to any appreciable 
atmospheric condition, as its efficient cause, however much some of the latter, as 
heat and moisture, may favour its extension and severity. 

Mortality and other Circumstances. — The mortality is very various at difl^erent 
times. At Fort Royal, between the years 1820 and 1827, it varied in diflferent 
years from one in 2^ to one in 5. During the late epidemic, it was one in 6.* 
The disease is generally less severe amongst women and children than among adult 
males. Those of feeble constitution are also said to be less liable to it than those 
of strong plethoric constitution. In some epidemics, women and even children 
have been found to be entirely exempt. Between the tropics it is commonly 
much less likely to attack the natives and permanent residents, than foreigners or 
those lately arrived. Negroes, also, are less liable than whites. 

Although from time to time, instances are met with of persons having the disease 
a second time, it is generally agreed that those who have once passed through the 
disease, are on that account much less liable to a future attack. Proofs of this fact, 
on a large scale, were furnished to the French Commission at Gibraltar. 

Treatment, — Very diff'erent modes of practice have been instituted in this dis- 
ease, not merely at different times, but in the same epidemic; still, however, the 
value of no particular method has been established on such grounds as to command 
the general assent of medical men. Some have placed their great reliance upon 
active and vigorous depletion; others extol calomel carried to the extent of salivation; 
Dr. Rush was a warm advocate of both. As regards general depletion, it can 
scarcely be doubted that where the patient is vigorous, the headache severe, the skin 
hot, and the fever in short of a sthenic or inflammatory character, this remedy 
proportioned to the state of the system, is decidedly proper and advantageous at 
the outset of the disease. On the contrary, where the fever is of a more congestive 
character, the pulse compressible, the heat moderate, &;c., the use of the lancet 
may be of doubtful utility or absolutely improper. In the late epidemic at Gibraltar, 
the medical men of the British army bled largely at the commencement of the 
epidemic, but afterwards discontinued the practice, or used it only as an auxiliary 
to purgatives and large doses of calomel, this last becoming to be regarded as their 
sheet anchor. The practice of the Spanish physicians in the town was much 
milder. It consisted of laxatives, as castor oil, at the commencement; enemata, at 
first emollient, and afterwards, where the gastric symptoms were severe, somewhat 
purgative; acidulated drinks in the early stage, and afterwards, when the patient 

• That of Gibraltar, according to Louis, was one in 6^. 



362 YELLOW FEVER. 

became more feeble, draugbts containing distilled water of orange flowers and lemon 
peel, or where the debility became greater, an infusion of bark, or a little broth 
and wine. Vinegar and water lotions were used when the skin was hot, and 
mercury resorted to in very severe cases only. The inhabitants of Gibraltar regarded 
the latter practice as more successful than that of the British army surgeons, and 
at first sight, this opinion would seem to be justified by the results, for in the army 
the ratio of mortality was one in four and a half, whilst in the city it was only one 
in six. We are reminded, however, by M. Louis, that the patients of the army 
surgeons were mostly robust individuals, men in the vigour of life, whilst in the 
city, the male patients were less robust, and a large proportion were women and 
children. Now if we consider that the disease was less severe amongst the latter, 
and take this circumstance into the account in estimating the comparative mortality 
under the diff*erent plans of practice, we can no longer attribute to either any 
decisive superiority in the result. 

In the late epidemic at St. Pierre, M. Catel placed his chief reliance upon general 
bleeding, pushed to the extent of producing syncope, at the outset of the attack, 
followed by topical depletion to the epigastrium or elsewhere as the symptoms 
required, associated with the use of cool drinks, mild enemata and other adjuvants 
of an antiphlogistic course, with sinapisms or blisters to the epigastrium, to allay 
the vomiting. His success appears to have been very great, the mortality being 
only one-eighth. On the other hand, at Dominica, it is asserted by Dr. Imray', 
who has practised in the colony for a number of years, that the antiphlogistic treat- 
ment had to be abandoned, and that the most active stimulants had to be resorted 
to in order to save life. Upon the whole, it may be staled, that however proper 
either of these extreme methods may be under particular circumstances, a mild anti- 
phlogistic course, with the use of calomel in severe cases where it is really requisite, 
is most commonly demanded. The indiscriminate employment of calomel, carried 
to the extent of salivation, can scarcely be considered as justifiable. Cold affusion 
has been said to be very serviceable, and even to have cut short the disease, when 
employed at the very commencement. Cool sponging when the skin is hot, is no 
doubt salutary and agreeable, as in other fevers. 

Emetics are often hurtful, and on the whole are condemned by most practi- 
tioners. 

Of late years the experiment of giving large doses of quinine in the forming 
stage, has been tried in this country, and it is said, with the most happy effects. 
It has been given in one very large dose, from 20 to 60 grains, and with the effect, 
it is said, of completely breaking up the morbid condition. 

Dr. Stevens's practice of administering neutral salts is described by Dr. Elliotson. 



PART III. 
LOCAL DISEASES 



BOOK I. 

CUTANEOUS DISEASES. 

I HAVE spoken of those diseases which may affect various parts of the body— 
inflammation and different structural diseases — and have termed them '''general dis- 
eases."* 1 have spoken, likewise, of certain diseases which appear to pervade, 
nearly or entirely, the whole of the body; and may be called ""universal diseases."" 
I now come to the affections of particular parts; and I said'' that I should proceed 
from the head to the foot, — a capite ad calcem; — that being as good an arrange- 
ment as any; and much more serviceable than an alphabetical arrangement; for, in 
this way, diseases which are situated in contiguous parts, and must therefore have 
many symptoms in common, are considered together.*^ Before we begin with the 
head, it will be better to consider those which affect the surface; and after we have 
gone over the surface, we can proceed into the interior. 

The diseases of the surface of the body are commonly called ^'■cutaneovs dis- 
eases." They are far more numerous than would be supposed from the works of 
Dr. Willan, and his pupil Dr. Bateman.^ Their works may be considered as the 
same; for the labour and honour was Willan's; and Dr. Bateman added little to 
what he learnt from his master; who was profoundly read in cutaneous diseases, 
and had laboriously observed them. The best work on cutaneous diseases I con- 
ceive to be that of a French writer, — Rayer.^ He treats of all the diseases of the 
skin and its appendages; — thus taking a more enlarged view than Willan; and he 
treats of a much more considerable number of affections of the skin itself. "When 
I say that Rayer's is altogether a much better book than Willan's, I do not at all 
wish to depreciate the latter; for a great part of the merit of Rayer's is ascribable to 
Willan. As far as Willan went, Rayer is under great obligations to him. Willan 
preceded Rayer; and the arrangements of the latter, in reference to the subjects 
treated of by the former, are grounded altogether on his publication. Rayer's is 
the best book; — on account of its arrangement, the greater number of diseases of 

a See Page 71. b See Page 216. c See Page 70. 

d The advantages which Dr. Elliotson here contemplates, are best secured by Dr. 
Fletcher's " Physiological Arrangement of Diseases;" which has been published, as a 
Chan, by Butler, Medical Bookseller, St. Thomas's Street, Southwark. 

e " Description and Treatment of Cutaneous Diseases; by Robert Willan, M. D." 
" Praciical Svnopsis of Cutaneoys Diseases; according to the Arrangement of Dr. Willan; 
by Thomas Bateman, M.D." With the generality of readers, Dr. Bateman's reputation is 
as great as Willan's; -just as smalterers in phrenology speak of Gall and Spurzheim as 
equal; though the originality and glory is all Gall's; and his pupil, Dr. Spurzheim, learnt 
the science from him; worked under Gall, as his assistant; and has merely added to and 
improved upon Gall (if he has added and improved; which I will not deny); and stands at 
a humble distance from his master. 

f " Trai e Th^orique et Pratique des Maladies de la Peau, par P. Rayer; accompagn^s 
d'un Bel Atlas de 26 Planches, Gravees el Colori<«es avec le plus grand soin; represeniani, 
en 400 figures, les Diff^rentes Maladies de la Peau et leurs Varieies." This work, published 
at Paris, has been translated into English by Dr. Willis. 



364 CUTANEOUS DISEASES. 

which it speaks, and the fuller and more scientific account of the nature, causes, 
and treatment of the diseases. 

Rayer^s Classification. — Rayer divides the diseases of the surface of the body 
into four groups: — I. Diseases of the skin itself. II. Diseases of the appendages 
of the skin; — such as the nails, and the cutis which furnishes the nails. In this 
division are to be found whitlow, and morbid affections of the nails, the hair, and 
sebaceous follicles; — such as plica polonica, baldness, grayness, &c. III. Foreign 
bodies which sometimes beset the skin; as others do the intestines. These are 
divided into "inanimate" and "animate;" — inanimate, such as the sebaceous mat- 
ter on the scalp of new-born infants; — ayiimate, which (I need not say) include 
fleas, bugs, and lice; together with certain other animals of which we shall speak.. 
IV. Those affections which commence in other parts of the body; and afterwards 
implicate and disfigure the skin; such as the disease called "elephantiasis;" in which 
the skin becomes implicated only secondarily. The whole describes, in a very 
comprehensive way, the diseases of the surface of the body. 

Then, again, truly cutaneous diseases are arranged by Rayer into six classes:— 
1. All those diseases of the skin which are inflammatory. 2. Those which are 
mere congestions; and cutaneous and subcutaneous hsemorrhages. 3. Those which 
are nervous affections of the skin; — such as morbid or deficient sensibility of it. 
4. Changes of colour in the skin; — not at all dependent upon congestion. 5. 
Morbid secretions of the skin. 6. Diseases of the structure of the skin. This is 
a very useful view of diseases of the skin itself. 

Willaii's Jlrrangemeut. — They are arranged by Willan without any reference 
to their real nature. He arranges cutaneous diseases, as follows: — 1. Mere pim- 
ples, without any contents; — "papulae." 2. Scaly; — "squamae." 3. Diffused 
patches of redness; — "exanthemata." 4. Collections of water; — "bullae." 5. 
Secretion of pus; — "pustulae." 6. Little vesicles; — "vesiculae." 7. Tubercular 
appearances on the skin; — "tubercula." 8. those in which there are stains; — 
"macules."^ Several sets of diseases thus arranged by Willan, come together in 
the arrangement of Rayer, under the one head of "inflammatory diseases." 

Willan's work (and Baieman's) is rather one of Natural History than Pathology. 
His delight and excellence are in the description of appearances. Rayer's work 
is excellent for deeper matters. This is the natural progress of knowledge. First, 
perfection is attained in distinguishing the outward appearances of objects and 
phenomena; and, this accomplished, their nature and causes come next to be in- 
vestigated. Willan accomplished much, though greatly indebted to foreign prede- 
cessors; but his labours were only a stepping-stone to what then became important. 

Frequently Dependent on a Diseased State of the System. — It is very important 
to remember, that although these are called "diseases of the surface of the body," 
many of them are affections of a much deeper nature; — that the affection is fre- 
quently connected with, or dependent upon, a general diseased state of the system. 
Frequently the mucous membranes are affected as much as the skin; — for example, 
the conjunctiva of the eye, the Schneiderian membrane of the nose, and the mucous 
membranes of the mouth, throat, and of the whole of the air-passages and aliment- 
ary canal. All these parts are liable to be affected, in some diseases of the skin. 
In measles, which is called " a disease of the skin,^^ we frequently have inflam- 
mation of the various mucous membranes which I have just named. So in the 
disease which is called "purpura," and which is considered a disease of the skin 
(because there are purple spots on that organ), we have often the same appearances 
within, as upon the surface. I formerly mentioned,* that this was as much an in- 
flammatory disease as one of congestion; and it may be entirely inflammatory. 
The intestines, the lungs, the liver, and even parts within the head, are sometimes 
beset with black patches: for, in this disease, blood has sometimes been effused in 
such quantity, that apoplexy has occurred. Although these diseases particularly 

* A Chart of the various diseases of the skin, arranged according to this system, has 
been published by Builer, Medical BooksjjUer, Si. Thomas's Street, Southwark. 
b See Page 136. 



CUTANEOUS DISEASES. 365 

affect the skin, yet in many of them, before the affection of the skin appears, there 
is some internal derangement; which occasionally ceases when the external affec- 
tion appears, but which sometimes continues throughout. In many there is an 
internal derangement, at a certain time, during the affection of the skin. In many 
of these cutaneous affections, the whole system appears more or less in an inflam- 
matory state; and in others the whole system is in a slate of extreme debility, — 
complete exhaustion. Although, therefore, these are called "diseases of the sAim," 
— from their producing very prominent symptoms there; yet it is to be remem- 
bered, that many of them are of a more deep and extensive nature. Many, of 
course, are really local; such as a change in the colour of the skin, — called " pty- 
riasis versicolor;^^ where a person has a yellow appearance of the skin (very com- 
mon on the necks of young women); and diseases of the appendages of the skin; 
such as diseases of the nails, and various affections of the hair and sebaceous 
glands. These are pure diseases of the integuments of the body; but many affec- 
tions, called ''^cutaneous diseases," are only cutaneous in one point of view. 

Lr. Elliotson^s Arrangement. — We see, therefore, that the diseases of the in- 
teguments of the body may be considered, in the first instance, according as they 
are diseases of the skin itself, or of the appendages of the skin; as there are 
foreign bodies upon the skin; — which cases are still allowed to be called " diseases 
of the skin;" or as the disease begins in other parts, and implicates the skin. We 
have, then, to consider whether cutaneous diseases, like others, are inflammatory 
or not; and we therefore group together all those that are inflammatory. Then all 
those are naturally grouped together that depend upon congestion; such as ecchy- 
moses, cutaneous tumours, and subcutaneous bloody tumours, — sometimes called 
*'naevi materni." Thirdly, those which are seated in the nerves of the part; 
fourthly, changes of mere colour; fifthly, morbid secretions; and, sixthly, mal- 
formations, and structural changes of the skin. In this way we shall bring before 
us all the diseases of the skin itself. 

The inflammatory diseases of the skin are arranged by Rayer, first, as they 
occur in patches of inflammation, — "exanthemata;" then, as they produce col- 
lections of water, — "bullae;" then, as there are minute collections of water,— 
"vesiculae;" then, as there is suppuration, — " pustulae;" or as there is more exten- 
sive suppuration, — "furunculi;" then, as there are mere specks of inflammation, — 
"papulae;" then, as there are tubercular appearances, — " tubercula;" then, as 
there are scales produced, — "squamae;" then, as there is inflammation in lines, — 
''linear inflammation;" then, as there exists a disposition to gangrene, — " gangrae- 
nosi" (as plague, malignant pustule, and glanders); and then he makes a class 
called " multiform;" in which diseases have no fixed appearance (such as syphi- 
lis). It appears to me, that the most simple way of considering these inflammatory 
diseases, is to consider them, first, when the inflammation is in the most minute 
extent^ — simple inflammation not larger than the point of a pin; — " papulae." 
Then we shall come to a more extensive inflammation, — "exanthemata;" then, to 
one which produces a little collection of water, — " vesiculae;" then to a large col- 
lection of water, — "bullae;" then, where pus is secreted, — "pustulae;" then, where 
pus is secreted in larger quantity, — boils, or '^ furunculi f then to where the in- 
flammation proceeds to gangrene; then where there is organic disease; — first of 
the slightest kind (only of the cutis) as in the " scaly diseases;" — then of a kind 
seated more deeply, as in the "tubercula;" and thus we shall go on in a more 
natural way, than that which Rayer has adopted. 



S66 



CHAPTER!. 

PAPULA. 

Definition. — We now enter upon the consideration of inflammatory diseases of 
the skin itself; and, in the first place, we shall speak of those which produce no 
secretion whatever; — no pus, no water; but which consist simply in inflammation, 
and that of the most limited extent; — producing a little speck of inflammation. Of 
course there may be a number of these little spots. When inflammation of the 
skin appears in minute spots, these are called " papulae," the English of which is, 
strictly speaking, " pimples."* The word "/jim/)/e" is commonly used to signify 
any little elevation or inflammation of the skin; — whether there are no contents, or 
whether there is water or pus; but, in strictly correct language, by a " pimple" is 
meant a minute inflammation of the skin, causing a very small acuminated elevation 
of the cuticle, without any contents whatever. Dr. Willan's definition of a papula, 
or true pimple, is — "a very small and acuminated elevation of the cuticle" (I 
should suppose of the cutis and the cuticle together), " with an inflamed base; not 
containing fluid; not tending to suppuration. The duration of papulae is uncertain; 
but they terminate, for the most part, in scurf."'' If such a slight inflammation be 
attended by watery contents, it is called a '^vesicle;^^ but if the contents be pus^ 
we call it a ^'' pustule;^'' — so that with respect to the most minute inflammation of 
the skin, we have a papula, a vesicle, or a pustule; — in other words, mere inflam- 
mation, inflammation with water, or inflammation vf'whpus. 

Progress and Termination of Papulse. — Where these papulae (which are, more 
or less, of a red colour) occur, there is experienced an uneasiness, which may be 
called pain; but it is pain of an itching character; — a " painful itching," we might 
say. Inflammation of this description may end in resolution, without any formation 
of scurf; or it may terminate in a more extensive separation of the cuticle, which 
is called " desquamation;" — a separation of the skin in scales. For the most part, 
however, the cuticle is separated in such minute portions, that only a fine dust 
[scurf) comes off"; which will take place, not only with evident inflammation, 
but sometimes with so exceedingly slight a degree of inflammation, that we 
can hardly call it more than " a little irritation." A new cuticle is found under- 
neath the exfoliation. There is no rawness produced: but, under the minute 
portion of cuticle which comes oflf, we see a fresh cuticle. There is no moisture 
at all; — the parts being still perfectly dry. If this inflammation be increased by 
the person rubbing or scratching the part, or by heat improperly applied, it may 
proceed to the formation of water; — so that we convert the papula into a vesicle. 
Again: if we add still more irritation, we may cause it to produce pus; and so 
convert it into a pustule. If the individual scratch himself still more, and great 
irritation be excited, instead of mere pustules we may have boils; — pretty large 
collections of pus; but all this is not the tendency of the disease itself. These 
papulae, which consist of mere spots of inflammation, are not contagious. 

Seat of PapuldR. — These papulae are considered, by Dr. Willan, as inflam- 
mations of the papillae of the skin; which he considers to be enlarged, elevated, and 
indurated; but I should think, if it be the papillae which are inflamed, we should 
be justified in saying, as I have said, that there is something more than elevation 
of the cuticle. If the papillai be inflamed, of course we must consider the disease 
as situated in the cutis; — the cuticle being elevated above the skin itself. The 

a The word ^'papula" is derived from "pappa," a nipple; and the diminutive "ula" 
(from t;X»)); and signifies, therefore, "a little pimple." 
b " Description and Treatment of Cutaneous Diseases;" Definition 5. 



PAPULA. 367 

inflamed base cannot be in the cuticle; — that is out of the question; and therefore 
it must be situated in the cutis. 

Varieties of Papulsp,. — Dr. Willan makes three kinds of papulae. These are the 
"strophulus'' (or "red-gum") of children; the "lichen" of adults; and the disease 
called " prurigo." His first plate contains a good representation of them. But I 
think that there are only tivo; for I believe that strophulus and lichen are purely 
the same disease; and I think it would be better if the name '•'lichen''^ were given 
to both; or if both names were dropped, and one term substituted for them. The 
disease called "prurigo," is characterized by great itching; and is often mistaken for 
itch. Neither lichen nor prurigo has any particular name in English. 



SECTION I.— STROPHULUS. 

This disease is peculiar to infants; and is called, by the common people, "red- 
gum" or "red-gown." It is supposed that "^wm" is a corruption of ""gownf 
and, in some old dictionaries, it is still written " redde-gowney It is also occa- 
sionally called, by the common people, the " tooth-eruption." It is a very un- 
important disease. The least irritation will cause it; — whether in the gums, 
abdomen, or other parts of the system; and, with a very little attention, it goes 
away. In fact, it need never create any alarm. It is divided, by the common 
people, into "red" and " white." Several parts of the body are affected in suc- 
cession; — it does not come out at once. It chiefly aff*ects the face and extremities; 
and is sometimes intermittent;— not penorfica/; but coming and going. 

Varieties. — It is divided, by authors, into a number of tiresome varieties; which 
only serve to burden the memory, and are soon forgotten in practice. The great 
point which I would insist upon, at present, is to recollect the characters of diseases 
in general; and as to the particular varieties, we can learn them afterwards, as 
diff'erent cases present themselves to our notice; and then we need not trouble 
ourselves so much about the names of these varieties, as about remembering the 
fact that there are some varieties in the appearances of the afl'ections, and some 
varieties in the condition of the system, and of iXiepart affected in these diseases; — 
a fact that is not sufficiently dwelt upon by subdividers. It is impossible to recollect 
all the minute divisions of these different diseases, without seeing patients; and 
then it is impossible to learn them all at once. It is a work of time; and there cj(a 
be no doubt it would be quite as well, if many of them were not so subdivided fcy 
authors. This particular aflfection is divided into: — 1. Strophulus intertinclus, 
2. Strophulus albidus. 3. Strophulus confertus. 4. Strophulus volaticus. 5. 
Strophulus candidus.^ 

If the papulae be of a vivid red colour, but are intermixed with red dots or specks, 
called " stigmata,"** it is then called " strophulus inter tinctus.'''' If the papulae con- 
sist of whitish specks, it is called " strophulus albidus;^^ — that is to say, " white- 
gum;^^ and this is often intermixed with the other. If the papulae be all united 
together, it is called " strophulus confertus;'''' and, by the common people, " rank 
red-gum," or "tooth-rash." It is hardly worth while to give particular names to 
these little variations of the disease. We sometimes observe different varieties in 
different parts of the same child. If the papulae of strophulus be of large size, and 
have no inflammation at their base, they are called " absolutely white," — " stro- 
phulus candidus.^^ This, however, is a contradiction; for a papula, according to 
Dr. Willan's definition,*' is " an acuminated elevation of the cuticle, ivith an 
in/lamed base.^^^ This variety usually succeeds acute diseases of children a year 

* These affections are represented, extremely well, in Dr. Willan's "Description and 
Treatment of Cutaneous Diseases;" Plates 2, 3, and 4. 

Willan, in his "Description and Treatment of Cutaneous Diseases," (Definition 4,) 
defines a " stigma" (from <rri?loo, to inflict blows) to be " a small, red speck, occasioning no 
elevation of the cuticle." 

c See page 366. 

<» See his " Description and Treatment of Cutaneous Diseases:" Definition 5. 



368 



PAPULJE. 



Old, If, after continuing' some time, they produce a scurf, and then disappear, and 
another crop comes on, it is then called " strophulus volaticus;^^ — coming and 
going; — continuing but for a short time. The patches are regular, and turn brown 
in a few days; and the whole series ends in a few weeks. I am sure it must be 
difficult to remember the differences, which occasion the disease sometimes to be 
called "candidus," and sometimes " albidus;" the important point will be, how- 
ever, not to recollect the names of these little particulars, but to remember the 
general character of the disease. It is sometimes pretty severe; and a great many 
papulae are crowded together; and then the variety is called "strophulus confertus;^^ 
the papulae are extensive, crowded, smaller, and less vivid. This form will occur 
in children from seven to eight months old. The patches may be hard; and they 
usually exfoliate in a fortnight. In this severe form, it sometimes begins in the 
legs, and spreads upwards to the loins and navel, with a general redness; — the 
cuticle cracking into large pieces; and this will occur, every now and then, for two 
or three months. Some children will labour under it, till they have cut all their 
first teeth. 

Causes. — With regard to the causes of it, I believe that any little irritation of 
the alimentary canal will produce it. The irritation of teething, and very fre- 
quently exposure to cold, — especially if aided by wet, — will induce this, and 
various other inflammatory diseases of the skin. 

Treatment, — Whether the disease appear in this aggravated form or not, one of 
the best things is to give mild purgatives, with some alkaline matter; as, for ex- 
ample, a little Liquor Potassas, or carbonate of soda, or magnesia, two or three 
times a day. There is, generally speaking, acidity; which may be corrected by 
something of this description. Moderate aperients can be given at the same time; 
and the warm-bath is found particularly useful. If the disease should prove obsti- 
nate, I would certainly give Hydrargyrum cum Creta; — mercury in a very innocent 
form; but, for the most part, it is not required. There is no essential difference, 
however, in the treatment of the different varieties of this affection. Great attention 
should be paid to the diet; for, very frequently, the disease arises from some little 
error in that respect; — something improper having been accidentally (or design- 
edly) given. If the disease suddenly disappear, we may find the child evidently 
in want of stimuli; and, when that is the case, a few drops of Liquor Ammonias, 
two or three times a day, will be of use; particularly if it be conjoined with the 
warm-bath, and good nutritious food. The warm-bath is one of the most important 
measures that can be had recourse to, in diseases of the skin, when we want to bring 
out an eruption, or to encourage it. I am told that the warm-air-bath does as well; 
but I have no experience of it. To avoid cutaneous irritations, nurses should 
always ivash infants' napkins, and not merely dry them. 

In this disease, if we should find a pretty active inflammation of the skin, we would 
of course give stronger purgatives; and there might be no harm in applying leeches. 
If, on the other hand, we found debility, it would be well to give tonics, — iron or 
quinina; and to order nutritious diet. Cutaneous diseases occur in all states of the 
body. Sometimes there is such debility, that we cannot cure the affection without 
the temporary use of meat, wine, porter, iron, &;c.; while, in other cases, there is 
an inflammatory state of the body; — making it evident that bleeding must be had 
recourse to, and low diet. So in this disease of children, sometimes there is 
debility of the whole body; — the disease continuing because the whole system is 
out of order; and then better nourishment and tonics will be required. In other 
cases, local bleeding and stronger purgatives will be necessary; but, in general, all 
that is wanted is a warm-bath, and alkaline and aperient substances. 

Avoid Exposure to Cold. — In this disease, be particularly careful that the child 
is not exposed to cold. It is dangerous to put a sudden stop to the eruption, by 
allowing the child to catch cold. It is possible that the eruption may cease, and 
that the child may fall into a state of depression; in which case the warm-bath will 
be required. But internal inflammation may be the result; and in that case, also, 



PAPULES. 369 

the warm-bath may be useful; but antiphlogistic measures may be required in addi- 
tion; for when eruptions suddenly cease, there is often an internal inflammation 
suddenly set up. It is right to know that these accidents may happen; but, for 
the most part, the disease is a mild insignificant affection; — more a matter of curi- 
osity, indeed, than any thing else. 



SECTION II.— LICHEN. 

This afTection occurs in adults, and is similar to strophulus. Indeed there is 
scarcely any difference in the appearance of these diseases; and I have always been 
accustomed to consider them as the same; — affecting children, and called "strophu- 
lus;" — affecting adults, and called " lichen."^ When I read Rayer's work for the 
first time, I was glad to find that he entertained the same opinion as myself. I 
always spoke of them as the same; but I thought I might be wrong; for I do not 
pretend to be so skilled in these matters, as those who have devoted themselves 
entirely to them. But Rayer says he would unite them, were it not for the fear 
of making more confusion, by introducing a new division in the history of papular 
diseases, which Dr. Willan has described with minute accuracy.* I think it had 
better be done; as it would simplify the matter at once, and burthen the memory 
with one disease and set of names the less. 

Seat and Varieties of Lichen. — This disease, in adults, usually occurs in the 
extremities; and particularly on the outer and posterior parts of the extremities. 
The size of the papulae is that of the head of a very small pin; and they generally 
terminate in scurf. The disease is sometimes acute; sometimes recurrent; some- 
times chronic; sometimes general; sometimes partial; and sometimes connected 
with internal disease. It is divided, by authors, into — I. "Lichen simp/ea:." 2. 
" Lichen joi/am;" that which occurs particularly about the roots of hairs. 3. 
"Lichen circumscriptusf^ a form in which the papulae are clustered together. 4. 
" Lichen agrius;^^ a very severe form indeed. 5. " Lichen lividus.^^ 6. " Lichen 
twpicusy 7. " Lichen urticatus.''^ In the simple form, we must expect the 
papulae to be larger than when they occur in children. If they be very severe, they 
cluster together; the skin becomes inflamed; and they form deeply red patches.*^ 

Duration and Progress of Lichen. — The simple form of this complaint lasts, 
generally, from ten to twenty days. Sometimes, it is preceded by nausea, vomit- 
ing, and pain of the head; and sometimes these symptoms will disappear as soon 
as it comes; while, at others, they will continue with it. It sometimes takes place 
at the end of certain cutaneous diseases; particularly after fever and catarrh, and 
(it is said) even after peritonaeal inflammation. Some persons have it annually; — 
some at the beginning of summer, others in autumn; while some are so unfortunate 
as to have it in both. I know a young lady who had it every spring and every 
autumn. It was observed by the Romans, who called it "sudamina;" and the 
Greeks, who noticed it, called it tSpcoa. In this country, in hot weather, we often 
have a great tingling of the skin. It is sometimes rather a sharp disease; but there 
is nothing dangerous in it, though the general excitement is great. It is said, that 
when it occurs about the hairs ("lichen pilaris^''"') it is often chronic. When it 
occurs in the severe form, called "lichen agrius,''^ there is a great degree of itch- 
ing, and a great degree of heat; and the inflammation is sometimes so violent, that 
we have vesicles and excoriations. This severe form of the disease, is sometimes 
preceded and accompanied by nausea, pain at the stomach, and pain of the head; 
and may last several weeks. It is much more frequent in women. It corresponds 
with " strophulus confertus.''^ This variety is sometimes connected, but only 

a " Spring-eruption," « scorbutic pimples," &c. (Willan.) 
b See his " Description and Treatment of Cutaneous Diseases;" Order 1. 
c These are well represented by Willan, Plates 5 and 6} and also in Rayer's Work, 
Plate 6 (First Division). 
VOL. I.— 24 



mi , 



370 PAPULA. 

locally antl temporarily, with a pustular disease, called "innpetigo;" with another, 
in which serum is secreted, — "eczema;" and another, in which scales are formed, 
— " psoriasis;" and sometimes it will degenerate into ihem. Sometimes, though 
rarely, the papulae are livid; and the variety is called " lichen lividus,^^ More fre- 
quendy it is united with petechiae; or dark spots of congestion. 

PricJdy Heat. — There is one kind of this affection, called " lichen tropicus^'''' 
which is attended by a great degree of tingling. This is mentioned by all writers 
on the diseases of hot climates; and it is described by them as a most distressing 
affection. When a person is subject to this variety of the affection, the moment 
he goes to bed or takes exercise, he has a most violent pricking of the skin, called 
*' prickly heat." It is called " lichen tropicus;'^ — from the disease occurring in 
tropical climates. It is not easily repelled; and its sudden cessation is generally 
the effect, not the cause, of an internal affection. The " prickly heat" is thought 
to be a sign of good health. Sometimes the papula3, in this disease, are attended 
with little bumps, like the bites of gnats or bugs; and then it is called " lichen 
urlicatusy It affects the neck and face, — particularly in spring and summer; and 
is attended by a stinging pain. But though there are bumps or wheals, still there 
are papulae. It chiefly affects the neck, face, and hands. It corresponds with 
*' strophulus candidus.^^ 

Treatment. — In all these forms of the disease, the treatment is to be the same 
as in the strophulus of children. If there be great excitement of the system, and 
headache, we should bleed. If a patient have a strong pulse, even without excite- 
ment, by far the shortest way is to take a litde blood from him, put him on low 
diet, purge him well, and order him the warm bath. Do not allow the hot-haih; 
for, if we apply much heat to the skin, we shall in a great number of cases make 
matters worse. Just as in the case of strophulus of children, purgatives (espe- 
cially combined with alkaline matters) given two or three times a-day, and low diet, 
will usually remove lichen; but if the disease be severe, the shortest way is to bleed 
in the arm in addition. Even if the severity of the disease do not indicate this 
measure, yet if the constitution of the patient and his puhe justify it, I should still 
have recourse to it. 

Local Applications. — For the relief of the parts themselves, which are tingling 
and itching, the chlorides of lime and soda answer better than any thing else. — 
Many persons use vinegar for this purpose; and it answers pretty well; but I think 
that, in all cases where there is itching of the skin, if that organ be sound, and the 
chlorides be properly diluted, they are by far the most serviceable. I have known 
some persons relieved by the application of prussic acid, of the strength of a 
drachm* to eight ounces of water; — sometimes stronger. I had an old man at St. 
Thomas's Hospital, with great inflammation of the legs, connected with varicose 
veins; — which is certainly not exactly this disease; but nothing relieved him except 
prussic acid; — one ounce* to a pint of water. Sometimes, however, this will pro- 
duce heat and tingling; and it is best not to use at first more than a drachm* or two 
drachms* to a pint; but, if this produce no effect, increase it. Occasionally there 
is great heat and dryness induced by applying it in greater strength. 

Bleeding at the arm, low diet, and purging, are the best general means, and, as 
local remedies, either vinegar, prussic acid, the chlorides, or plain water, warm or 
cold. 



SECTION III.— PRURIGO. 

Symptoms and Progress. — In prurigo,'' the papulae are very little discoloured; 
— being nearly the same colour as the skin; but they are larger than in lichen. 
They are particularly characterized by itching; which is a far more striking symp- 
tom then the eruption itself. That is not the case in the two affections already 

a Of the officinal preparation, — " Acidum Hydrccyanicum Dilututn." 
b From "prurio," tp itch. 



PAPULiE. 371 

described; except in that form called "lichen tropicus^ In the latter there is a 
very severe eruption; whereas, in prurigo, the eruption differs but little from the 
adjoining skin. The papulae also vary from those of lichen, in not being so pointed. 
So severe is the itching, that people scratch themselves, till they rub off the surface 
of the papulce. A little blood exudes; — a very minute portion; and then it forms a 
little black crust; so that the papulae will have an artificial black top; and, from 
scratching them, water will ooze as well as blood. This, however, is incidental; 
and has nothing to do with the complaint. If the patient will continue to scratch, 
he may cause these papulae to be converted into vesicles; if he scratch still more, 
suppuration will take place, and he will have pustules; and the skin may even be 
brought into such a state, that it will crack, and become indurated and hypertro-- 
phied. This is a chronic disease. Lichen and strophulus are sometimes chronic, 
and sometimes acute; but prurigo usually lasts a considerable time, unless properly 
treated at an early period. 

Prurigo Mitis. — If the disease occur in the mildest form, it is called "prurigo 
mifis.^' This chiefly affects the young. The disease altogether, in every variety, 
affects both the young and the old; but that called "prurigo mz/is" principally 
affects the young; and occurs particularly about the spring or beginning of summer. 
It is said, by some, to degenerate into the itch; but others deny this. Sometimes 
the eruption is scarcely visible at all. There is intense itching; but it is rather 
difficult to find out any eruption. It will remit; and sometimes it will intermit, — 
come and go entirely. 

Prurigo Formicans. — If it be very severe, there is an epithet added to the word 
^^ prurigo,'''' to signify great intensity; and, from the itching resembling so much 
the bite of an ant (" formica"), it is called "prurigo /brwicans;" which is a very 
severe, — I may say, a dreadful disease. It affects adults at all periods, but not 
children; and it occurs in every part of the body, except the palms of the hands 
and soles of the feet. Occasionally it is preceded by feverishness, pain of the head, 
and sickness. 

Prurigo Senilis. — There is a third form, which is confined to old age; and 
which is called " prurigo senilis;" and this is likewise a very severe form of the 
disease. I should sometimes be at a loss to distinguish between " prurigo /or- 
micans" and " prurigo senilis; for the former only occurs in old people. I think 
it would be better to say, that prurigo is a disease which sometimes is mild, but 
now and then severe. If it attack old people, it generally continues very obstinate, 
for a great length of time.* There are no scales, or scabs, or water; nor is there 
any pus. 

Local Varieties of Prurigo. — This disease is sometimes local; attacking a par- 
ticular part of the body only; and not being diffused. It affects, particularly, the 
scrotum of the male, and the pudendum of the female. The scrotum, from constant 
irritation, — from the patient everlastingly scratching himself, becomes scaly, and 
very much indurated. It will attack the prepuce; and then it is called "prurigo 
prseputii." Sometimes it has occurred within the urethra; — " prurigo urethralis." 
It will sometimes affect the extremity of the rectum; — " prurigo pof/?"cis." The 
worst seat of it, however, is in the pudendum of the female; — "prurigo pudendi 
muliebris;" and there it is sometimes very violent, — very distressing; so that a 
woman cannot go into society at all. She cannot appear before men; nor, indeed, 
can she appear before strange females; in consequence of her being under the 
necessity of scratching herself. I have known women driven almost mad, with 
the vexation of finding that they were not able to pass five minutes without scratch- 
ing themselves violently. I saw one woman, who was obliged to get up several 
times in the night. She was unable to go to sleep; for, at last, the heat became so 
great, that she was compelled to get out of bed, and wash herself with cold water; 
and so she had passed every night, for months, when I saw her. The vagina and 

» These forms of Prurigo are well shown in Willan's Work on the "Description and 
Treatment of Cutaneous Diseases;" Plate 7. 



372 PAPULA. 

the inner surface of the labia, in very severe cases, become thickened; and small 
indurated masses are formed here and there. The latter are not properly tubercles; 
but have a tuberculated appearance. When this occurs in females, it excites a 
desire of copulation; which, as they have told me, relieves it for a lime; but, in a 
little while afterwards, they are worse than ever. It is impossible for them to get 
relief, in this way, every moment; and I advised the woman to whose case I had 
just referred, and who told me that she lived separately from her husband, to use 
nothing- but cold water. It is really, though not dangerous to life, a distressing 
disease; and women will cry, and absolutely wish for death, when they are labouring 
under it. I cannot conceive any thing more lamentable; and, if itoctjur to a modest 
woman, it is the most horrid sort of case that can come before us. It rarely occurs 
in females before the middle period of life. Dr. Willan* says, that aphthae may 
appear on the nymphse, and internal part of the labia; and may be communicated 
to the glans penis, and internal part of the male prepuce; that they are easily cured; 
and that these aphthae, as well as. "prurigo pudendi muliebris," often occur after 
the fourth month of pregnancy. 

Causes. — [Dr. Willan" attributes the milder form of prurigo to " sordes col- 
lected on the skin, producing some degree of irritation, and also preventing the free 
discharge of the cutaneoi^o exhalations; the bad consequences of v/hich must 
necessarily be felt at that season of the year, when the perspiration is most copious." 
Hence he considers, that those who have originally a delicate or irritable skin, will 
in such circumstances be the greatest sufferers. The more severe form of prurigo 
(*' prurigo /ormica/2«") is generally, according to Dr. Willan,'' attended with an 
unhealthy condition of the system, consequent on grief, watching, fatigue, and poor 
diet. As, however, the concurrence of these circumstances will not, in all cases, 
produce this disease; Dr. Willan conceives'' that it must, in part, be referred to the^ 
original texture of the skin, or the state of the cutaneous glands. In support of this 
opinion, he states'" that *'lhe greater number of cases had a more than usual coarse- 
ness or roughness of the skin; which seemed often to have been communicated 
hereditarily; and that when the itching and papulae disappear at the termination of 
the disease, the cuticle is left dry, scaly, and thickened." Want of proper clean- 
liness is also a frequent cause of this disease among the lower classes. " Certain 
modes of diet" (according to Dr. Willan'') "have likewise a considerable effect in 
aggravating or exciting the prurigo formicans. Many persons are affected with it, 
who in the summer season live much upon fish and other stimulant animal food; 
at the same time drinking freely of wine or spirituous liquors. Some of the white 
Spanish wines excite, in particular habits, an eruption of itching papulae; which is 
excessively troublesome for many hours afterwards; but does not become permanent, 
if the beverage be discontinued."] 

Effects and Duration. — This disease is not dangerous to life; but it is some- 
times really a most dreadful disease; — "dreadful," I mean, so far as suffering is 
concerned; and, for what I know, it may injure the general health. I have known 
imbecility of mind sometimes caused by the intense suffering it occasions. The 
intense suffering has continued, month after month; and, indeed, year after year; 
and has produced such depression of spirits, and such exhaustion of mind, that 
persons have become imbecile, — really worn down; and a sort of fatuity has arisen 
from mere exhaustion. I once had a man come to me, in this state, at St. 
Thomas's, when I attended the out-patients. He pulled off his coat, uncovered 
his bosom, and showed me every part in an instant; — he was so quick in all his 
movements. He then pulled a comb from his pocket; and assured me that was 
the second comb he had bought; — having worn out the first in scratching himself. 

a See his "Description and Treatment of Cutaneous Diseases;" Order 1; Genus 3; 
Species G. 

^ See las " Description and Treatment of Cutaneous Diseases," Order 1; Genus 3; 
Species 1. 

c See his "Description and Treatment of Cutaneous Diseasesj" Order 1; Genus 3; 
Species 2. 



PAPULA. 373 

I have no doubt this was true. The itching was most intense; and he had been in 
this state two or three years. Some years a^o, I had a man who came to the 
hospital; and whose sufferings had been nearly as intense. The idea had not 
occurred to him of buying a comb; but he used his nails well in scratching himself. 
His mind was as much gone as that of the other patient. He was really falling 
into childishness. 

Prurigo Mistaken for Itch. — The mild form of prurigo may be mistaken for 
itch. I will not point out the diagnosis now; but advert to it when I speak of itch. 
I may mention, however, that it will occur in every part of the body. It will occur 
in the face, as well as other parts; but the itch, I believe, will not. Prurigo, too, is 
not a contagious disease. 

Treatment. — With regard to the treatment, supposing it to be the mild form of 
the disease, it is right to make the patient avoid stimuli of every sort; — pepper, 
mustard, wine, beer, &lg. Many persons have a tingling, immediately on taking 
certain articles. If I take a grain or two of pepper, or taste vinegar, I have an 
itching of the scalp; and, wherever I am, I must begin to scratch my head. If I 
take opium, I have a violent tingling of the nose, for many hours afterward. Now 
all these matters, especially mustard and pepper, are likely to increase the affection. 
If a patient will bear it, it may be right sometimes to take blood. At any rate, it 
is proper to purge him moderately; and I should advise alkalies; — as there is often 
acidity in the stomach. But there is a remedy from which I have found greater 
relief, than from any other; not in the mild form only, but also in the severe; and 
one of the men I have just mentioned, was cured by it; — at least, he was so far 
relieved, that I could keep him no longer in the hospital. That remedy is col- 
chicum. I am sure that purging with colchicum will produce more benefit than 
any thing else. In the mild form of the disease, undoubtedly, this is the best 
remedy. Patients should avoid going near the fire, or taking much exercise, so as 
to irritate the skin; but I am quite satisfied that colchicum is the best remedy we 
can employ internally. 

Local Applications. — As to the itching itself, that is very much mitigated by 
diluted acids, such as vinegar; and also by the chloride of lime, or of soda. These 
produce a very great mitigation of the itching. We also find relief, sometimes, 
from a fomentation of prussic acid. The woman who was so bad from " prurigo 
pudendi rnuliebris," found great relief, for a time, from applying prussic acid. 
She used it, at length, to such an amount, and of such a degree of strength, that it 
produced giddiness and fainting; — so .that she could not stand it; and yet it did not 
cure her complaint. It appeared, at last, that the best thing was a cold application; 
and, therefore, she had a pail of water brought into her room at night, and used it 
very frequently. I believe this local prurigo will arise, occasionally, from some 
local cause of irritation. Worms in the rectum, will produce " prurigo podicis;'* 
and a stone in the bladder, is sometimes attended with a violent itching of the pre- 
puce. In women, it sometimes attends structural disease of the womb. It is right 
to endeavour to ascertain whether there is a local cau^e; and, if there be, we must 
endeavour to remove it; but if we cannot find a local cause, then (I believe) the 
application of the chlorides, or prussic acid, or cold water, is the best thing. Some 
tell me that they have seen great relief from what is called "the yellow wash;" — 
bichloride of mercury and lime water. It is much about the same thing as using 
the chloride of lime. The French use sulphureous baths, and emollient baths 
containing gelatine; but I have no experience of them, 



374 EXANTHEMATA. 



CHAPTER 11. 
EXANTHEMATA. 

We now proceed to another class of diseases; — a class in which the redness is 
not confined to spots, but forms patches. Such diseases as these are called "ex- 
anthemata,"* or (in English) "rashes;" — a "rash" being an extensive redness of 
the skin. In these diseases there are not pimples or spots, but patches; — the same 
thing precisely, only of greater extent. They are defined by Dr. Willan'' to be 
" red patches, variously figured, in general confluent, and diffused irregularly over 
the body; leaving interstices of a natural colour. Portions of the cuticle are often 
elevated in a rash; but the elevations are not acuminated. The eruption is usually 
accompanied by a general disorder of the constitution, and terminates, in a few 
days, by culicular exfoliations." The former class of diseases (" papulae") it will 
be remembered,'' either terminated without any thing following, or induced a scurf. 
These being a more extended redness, — being patches instead of pimples, are fol- 
lowed, not by scurf, but by an exfoliation of the cuticle. Large portions of cuticle 
separate; and therefore, instead of being branny or scurfy, it is in plates. These 
exanthemata often render the surface uneven, by elevating the portions afTected. 
The brightness is variable; and sometimes, Willan"^ says, extravasation occurs. 

The chief diseases of this description are, in the first place, " erythema" and 
" roseola;" which I will unite together (or endeavour to do so), as I did lichen and 
strophulus. The next is " measles;" the next " scarlatina;" and then comes 
" urticaria." Some of these are contagious, and others not. None of the first 
class were contagious; but two of these are; — namely, measles and scarlet fever. 
These two usually occur but once during life. The two first of these affections 
are very slight; just like lichen and strophulus; and are not contagious. 



SECTION I.— ROSEOLA. 

Characters of the Eruption. — Roseola^ is described as consisting of rose-coloured 
patches, without wheals, little bumps, papulae, or minute elevations of the skin; and 
these patches are circular or oval.' It occurs at all ages, but especially affects 
children; when it is called " roseola infantilis.''^ There is sometimes an itching 
attending it; and sometimes only a tingling. The patches are of all sizes, and are 
sometimes diffused very generally over the body; but if not, still they are pretty 
numerous. If the patches be round, it is called "roseola annulata.''^ Sometimes 
there is a little feverishness, or a little irritation of the bowels; and those symptoms 
generally occur from two to seven days before the eruption appears. It is usually 
a superficial complaint; very innocent to the body; very short in its duration; and, 
after it, there is scarcely any exfoliation. The character of this eruption is said 
(by Rayer) to be that, after pressure, the redness returns at all points. In scarlet- 
fever, if we press the rash, the redness, on removing the finger, returns from the 
circumference of the part; but, in roseola, every part recovers its redness at the 
same time. I never made the observation myself; and therefore cannot answer for 
its accuracy. Now and then it might be mistaken for scarlet-fever; but, he says, 

* From e^avQsiw, to effloresce. 

^ See his " Descripiion and Treatment of Cutaneous Diseases;" Definition 6. 

See Page 366. 

^ See his " Description and Treatment of Cutaneous Diseases;" Order 3. (Pages 213 and 
214.) « From " rosa," a rose. 

1 It is well shown in Willan, Order 3; Genus 4; Plates 25, 26, and 27. 



EXANTHEMATA. 375 

that we may distinguish between the two affections, by noticing what I have just 
stated. 

Duration and Varieties of Roseola- — It is a trifling eruption, and seldom lasts 
more than four or five days; so that it never becomes chronic, unless there be many 
attacks of it; — unless it be remittent. If it come and go, a patient may be troubled 
with it for a length of time; but the disease never remains incessantly, for any long 
period. In the spring and summer, it will no doubt frequendy arise from the heat 
of the weather, but frequendy it happens without any evident cause whatever. 
If it occur in the summer, it is calleil "roseola xstivaf^ but if it occur in the 
autumn, it is designated " roseola autumnalis.'^ If it occur in small-pox, it is called 
" roseola t;ano/os«;" if in cow-pock, "roseola vaccina.^^ It has various names, 
according to these circumstances; which names it is unnecessary to remember. 
Occasionally we see such rosy patches in continued fever; but still it is called 
" roseola." The redness of the skin observed in gout, is also called " roseola;" 
and the redness of the skin sometimes observed in rheumatism, especially of the 
fingers, bears the same name. Occasionally the mucous membrane of the throat, 
more particularly of the pharynx, suffers the same degree of redness. It would 
appear that, occasionally, something of the same nature occurs in the stomach and 
intestines. At least when there is this eruption of the body, there will be a violent 
degree of heat in various parts of the abdomen. After inoculation for small-pox, 
this litde redness will sometimes take place before the pustules appear. This is 
said to have happened in one out of fifteen cases; and inoculators used to imagine, 
that it betokened a mild form of the disease; while, if the redness was general and 
deep, and there was much pyrexia, they supposed it indicated that the disease 
would be severe, — would be confluent." The roseola which occurs in cow-pock, 
generally appears on the eighth or ninth day. 

Treatment. — This disease requires no treatment whatever; unless it be thought 
right to lower the child's diet, and give it a dose of physic. The great importance 
of knowing this rash, is not for the sake of curing it, but in order to distinguish it 
from another disease; for many children have been said to labour under measles, or 
scarlet-fever, when they have only had this redness of the skin. We hear of 
children having had measles, or scarlet-fever, half a dozen times; whereas they had 
merely this little redness of the skin, called " roseola" (or " rose-rash.") 



SECTION II.— ERYTHEMA. 

Identical with Roseola. — The next disease is, by some writers, separated from 
roseola, and is called " erythema." It is said to consist of red patches or diffused 
redness. It often affects the subcutaneous tissue; so that there is a slight swelling. 
To show the absurdity of separating these two diseases, I may mention that one 
is called "red patches, variously figured and irregularly diffused;" and the other is 
called " red patches, or diffused redness." I am sure it is frequend}'- impossible 
to distinguish between these two diseases. The different varieties of erythema are 
much more unlike each other, than matiy cases of erythema and roseola. All that 
we have to remember is, that a litde redness is called either " roseola" or " ery- 
thema;" that roseola occurs particularly in infants; and that erythema* occurs some- 
times in rather a severe form. 

Varieties. — Erythema may be transient, and last only about a week; and then 
there is furfuraceous (branny) desquamation. Sometimes it is local, arising from 
friction; and then it is called "erythema intertrigo.'''' If the skin in the groin or 
arm-pits be irritated, the motion of the parts increases the irritation; and if they be 
accidentally irritated by the dress, then the redness will increase; and this is some- 
times called " intertrigo." However, when this redness is slight, it is called " ery- 



* Rayer entertains a different opinion. *> Sometimes called "red-rash. 



376 



EXANTHEMATA. 



ihemdi fugax.^^ If the skin be very smooth, it is called "erythema Isevey If it 
have a distinct margin, it is named "erythema marginatum,'''' If there be small 
papulae, it is designated "erythema papulatum.^^ If, instead of papulae, we have 
slighdy elevated tubercles, it is called "erythema tuberculatum.^^ If we have 
large bumps, it is then designated "erythema nodosum.^' 

Causes. — [Rayer has primarily divided erythema into " idiopathic," and 
"symptomatic;" — divisions far more comprehensive and practical in their nature, 
than those proposed by Willan; who has classified appearances^ rather than causes. 
Idiopathic or local erythema (" intertrigo") generally arises from some obvious 
cause of irritation; — such as friction, pressure, distension of the integuments, 
extremes of heat or cold, the slings of insects, chemical irritants, or the presence 
of various eruptive diseases, wounds, or ulcers. Symptomatic erythema, which 
embraces six of Willan's varieties, is contingent on and associated with various 
inflammatory affections (especially those of mucous membranes,) continued fever, 
dysentery, and other affections.]* 

Accompanying Signs. — This disease is now and then preceded by a little ill- 
ness, which disappears when the eruption occurs; and now and then there may be 
a little feverishness during the attack; but, for the most part, it is a trifling com- 
plaint, or is consequent upon some other affection. Rayer considers, that when 
there is an internal affection, the disease is the sympathetic effect of the internal 
irritation; — that an irritation of the stomach or intestines is the real cause of the 
disease; and not that this disease itself is at all capable of affecting the constitution. 
When persons are out of health, there will be an external inflammation, not 
attended with any secretion; and that inflammation is called " erythema." 

Erythema Nodosum. — But there is a form of this disease which is very obsti- 
nate. It appears in great patches, chiefly on the legs, and particularly in females. 
If we draw our fingers along the legs, we find very hard and red bumps. It is 
called (as I before said) " erythema nodosum.'*^ We are frequently consulted 
respecting it, and asked to give it a name; and if we cannot, we are considered 
deficient in skill. Patients place the more confidence in the physician, if they 
fancy he knows what is the matter with them; and it is very natural that they 
should do so. It is very easily cured, if treated properly at first; but if it be 
neglected, it is a very obstinate affection. Now and then, instead of bumps, we 
have tubercles (in the common acceptation of the word;) and then the affection is 
called " erythema tuberculatum.'*''^ The tubercles are like peas. This variety is 
worth knowing; because patients frequently die when they have it, though I do 
not know that they die of'ii. 

Treatment. — The best treatment for this disease, is anti-inflammatory; — in fact, 
just the same as for all the others that I have mentioned. If the patient's strength 
will bear it, we may take away blood with advantage; and generally it -is buffed 
and cupped. It is proper also to purge the patient. In fact, we may treat him on 
the antiphlogistic plan; either purge him alone, or bleed him at the arm as well. 
If there be anasarca of the legs, we may favour its removal by the recumbent pos- 
ture. We cannot expect the erythema to disappear, while the leg is hanging 
down, as it arises from the distension of the part; and if the distension of the part 
be allowed to remain, nothing will remove the erythema. The general rule, how- 
ever, is to treat erythema as we should any other inflammation. In the erythema 
which occurs in the legs of females, we shall derive very great benefit from these 
measures; — that is to say, bleeding in the arm, the application of leeches to the 
neighbourhood of the part, and active purging; but we shall derive more benefit 
from colchicum than from any thing else. I have had great experience in the 
treatment of this disease; and I know the comparative efficacy of combating it by 
purging with common cathartics, and by purging with colchicum. I find that col- 

■ "Cvclopaedia of Practical Medicine;" Article "Erythema;" Volume 2; Pages 115 
and 119, 

b These forms of the disease are very accurately delineated in Plates 31 and 32 of Willan's 
work. 



EXANTHEMATA. 377 

chicnin is the best medicine that can be employed, not only in severe prurigo, but 
also in this species of erythema. 

Erythema Tubercidatinn. — I mentioned tliat, in one variety of this affection, 
there was great redness of the skin, with hard lumps; — not so large as in "ery- 
thema nodosum;'''' but small lumps about the size of peas, or small-pox pustules. 
This is a state of the parts which I have never seen but once; and then I con- 
founded it with "erythema iw do 811711'' and thought nothing of it; — imagining that 
I could cure it. The lumps had no sooner disappeared, than the man became 
paralytic, then hectic; and died in an extraordinary way, with symptoms of various 
diseases. I was not then sufficiently aware of the distinction between "erythema 
nodosum'' {\\\\'\c\\ is an innocent disease,) and "erythema tuberculatum;" but 
Dr. Willan says, that he had seen only three cases of "erythema tuberculatum;''' 
and all of them proved fatal. ^ Two of his patients died of heciic, — ^just as mine 
did; and one died of subsequent hydrocephalus. My patient died heciic; and if he 
was not hydrocephalic, he had affection within the brain; for he was paralytic. Dr. 
Bateman says that he never saw the affection. The treatment, I presume, would 
be the same as for " erythema nodosum;" — bleeding to a certain extent, and col- 
chicum. I gave it to this man; but, to my astonishment, he did not get well. It 
is not the erythema that gives rise to paralysis or hectic; but (I presume) it takes 
place only in constitutions which are strongly disposed to some internal disease, 
and when the patient is on the eve of labouring under it. 



SECTION III.— URTICARIA. 

The next of those diseases in which the inflammation is extended in patches 
over the skin, is " urticaria." I select it as the next because it is not a contagious 
disease; and, indeed, is almost always a disease free from danger; — ^just like the 
three I spoke of in the class of papulee, — namely, strophulus,^ lichen,'' and pru- 
rigo;'' and just like the two of which I have already spoken in this class, — roseola® 
and erythema;^ except " erythema tuberculatum;" wdiich, although it will not 
itself prove fatal, occurs in persons who usually soon die of something else. 

Characters of the Eruption. — This disease, urticaria, is (in plain English) 
the " nettle rash." It is so called because the appearance is precisely that of a 
person stung with nettles; — ''urtica" being the Latin for '^nettle." It is de- 
scribed by some writers under the \%vm '■'■ essera;" which, I understand, is the 
Arabic name. Dr. Heberden (I think) speaks of nettle-rash under that title. In 
this disease there are " efflorescences" (as they are called), — extended patches; 
but besides that there are wheals. I need not say that a wheal is a pretty hard 
elevation of the skin; such as occurs from a horse-whip applied to the surface of 
the body; — but it is defined particularly, by Dr. Willan,^ to be a "round, oval, or 
longitutlinal elevation of the cuticle." One ought to comprise more in it than that, 
however. We might say, in general terms, — " a round, oval, or longitudinal ele- 
vation of the skin;" but still we must add — " not permanent; not containing fluid; 
and not tending to suppuration." Of course, if the cuticle be raised (according to 
Dr. Willan's expression), there must be something under it. One would imagine 
there must be a vesicle, water, or pus; it is, therefore, improper to say, — " eleva- 
tion of the cuticle." The cuticle is raised; but it would be wrong to say, — that 
the cuticle is raised from the other component parts of the skin. The cellular 
membrane indeed is raised, as well as the cutis; and there is a hard bump, and an 
extended efflorescence (or patch) around the bumps. This efflorescence is of a 
vivid red, — a very intense red; — sometimes really of a damask hue; almost the 

^ See Dr. Willan's " Description and Treatment of Cutaneous Diseases;" Order 3; Genus 
4; Species 5. 

b See Page 367. « See Page 3G9. <» See Page 370. 

e See Pajje 374. f See Page 375. 

s In his " Descripiion and Treaimeot of Cutaneous Diseasesj" Order 3; Genus 3. 



378 



EXANTHEMATA. 



appearance which we observe in those persons said to have "claret marks." Oc- 
casionally there are a few very small wheals, but not always; — the efflorescence 
being ihe character of the disease; lliongh, in the greater number of cases, in the 
midst of this efflorescence, we find these wheals; which appear white in the midst 
of the red patches. There is an extreme itching; — that sort of itching which is 
©ailed " tingling;" exacdy as if a person were stung with nettles. To the eye of a 
bystander, and to the feelings of the patient, the state is just that of a person stung 
with netdes.* 

Varieties. — If the bumps" be very hard indeed, they are, at the same time, large; 
and that variety of the disease is called "urticaria tiiherosa.^^ It is sufficient to re- 
member, that sometimes the bumps are pretty large and hard, and very painful. 
This variety chiefly occurs in the loins and legs, and is generally worse at night; 
subsiding in the morning, and leaving the patient weak. If it happens that these 
■wheals and patches are numerous, and of irregular form, and coalesce, it is called 
"urticaria conferta;'''' and these are said to occur chiefly in persons of a dry, 
swarthy skin, above forty years of age. If the disease has been preceded or is 
accompanied by headache, nausea, gastrodynia, drowsiness, and pyrexia, it is 
called " urticariay*e^?77is." Very frequently, \v]\ei\\e,v preceded hy these symptoms 
or not, it is attended by them when it does appear. If they precede it, they will 
still continue; but frequently they will come on only when it appears. Generally, 
in severe cases, there is heat and thirst. The tongue is while, yellowish, and 
loaded; the epigastrium is tender; the pulse is full and quick; and now and then 
the disease will come on, like any other inflammation, with shivering. Now and 
then the internal symptoms, which occur before the eruption, are relieved by its 
appearance; or, at least, are diminished, or disappear; but they reappear when it 
ceases again. Frequently, however, these will all exist together; — the internal 
symptoms (feverishness); and the external symptoms (efflorescence and wheals). 

Sometimes the disease is chronic; and is called " urticaria /9ers/«?25." It is suffi- 
cient to remember that urticaria may be a chronic disease. The redness will go; 
but the wheals, perhaps, will remain. Now and then, instead of remaining 
chronic, it comes and goes for many months; — vanishing and recurring; and then 
it is called "urticaria evanida.^^ But it is unnecessary to remember these ex- 
pressions. It is sufficient to know that it comes and goes, or stays; — without 
knowing how authors arbitrarily choose to designate these varieties. Dr. Bateman 
says there is no pyrexia; but I know that there frequently is; and also an inflam- 
matory state of the head and of the abdomen. It sometimes happens that the 
eruption disappears, or only comes from time to time; and when the tingling 
comes between the appearances of the disease, it is then called " urticaria sub- 
cutanea." It is, perhaps, difficult to imagine a disease of the skin to be under the 
the skin; but so it is called. It lies underneath; and teazes the patient without 
showing its face. 

Attendant Symptoms. — This disease is sometimes so active, that persons can 
hardly see out of their eyes; and, in fact, we can see but little of their eyes. Every 
part around is swollen; — the cheeks, lips, and scalp are tense, — the nose among the 
rest. The eruption will vary in intensity, and vary in situation, not only on different 
days, but at different hours of the same day; it will come and go several times in the 
twenty-four hours. Warmth will aggravate it; and, on the other hand, exposure 
to cold will do just the same. When a person undresses, and there is an appli- 
cation of cold air to a part of the surface which before w^as covered, it will fre- 
quenUy bring out the rash, and make it worse. On the other hand, if a person go 
into the other extreme; — if he stand near the fire, or take stimuli, he will be worse. 
Rubbing and scratching make things a great deal worse; but people will do so; and, 
on account of the pain, they really can hardly help it. This disease is often not 
confined to the surface. It affects the internal mucous membranes next the sur- 

* The appearance of this affection is well shown in Plate 25 of Willan's work. It is 
sometimes mistaken for measles or erysipelas; and therefore its characters should be studied 
with great aiteulion. 



EXANTHEMATA. 379 

face; and the submncous cellular membrane. We often find the tongue, fauces, 
and throat swollen; — so that the patient can perhaps hardly swallow. The irrita- 
tion of the mucous membrane, in the upper part of the throat, sometimes occasions 
a degree of cough. I have frequently seen patients unable to swallow, and nearly- 
unable to breathe. It is said (though I have never seen it) that, now and then, 
there is an irritation of the bladder, producing strangury; and sometimes diarrhoea 
is induced. The internal affection, in this complaint, is sometimes said to end 
fatally; but I presume this internal affection does not arise from the eruption. On 
the contrary, I imagine that it is the general state which gives rise to the eruption. 
The disease will last for a few days, perhaps a fortnight; and now and then there 
is a slight scurf afterwards. The cuticle, in consequence of the irritation, is sepa- 
rated from the parts beneath, and comes off in the form of slight scurf. This oc- 
currence, however, is not general. 

Causes of Urticaria. — I believe that the most frequent cause of urticaria is the 
application of cold; especially when the body is heated. It will frequently arise 
from cold applied to the surface; — sometimes cold and wet; but especially when 
the body is over-heated. It is, perhaps, sometimes induced by sudden heat. It 
will frequently arise from an emotion of the mind, from teething, and from certain 
ingesta. Some have it through one kind of food; and some through another. In 
some persons, almonds will occasion it; or rather the skin of almonds. It is not 
the blanched almonds that cause it, but the unblanched; — so that it is the external 
part that produces the disease; and this it does in consequence of the skin of the 
almond containing hydrocyanic acid. The latter, in its medicinal form, will now 
and then have the same effect. Various kernels of fruit will give orig^in to it, in 
some people; — in consequence of containing the same substance. Mushrooms, 
also, will sometimes occasion it. I suppose the mushrooms must be of pecular 
kinds. Herrings, particularly " red herrings," and shrimps, will likewise occasion 
it. Shell-fish are very often the cause of the disease; but I believe muscles pro- 
duce it more frequently than other kinds. We hear of persons being poisoned with 
muscles; and they are said to swell. I imagine the idea of swelling from being 
poisoned, arises from this circumstance; — that urticaria is produced by different 
substances; and, when it is produced, the face often swells prodigiously, and some- 
times even the whole body; and if persons have previously eaten muscles, they 
are sure to say they are poisoned; but it hardly amounts to that. So intense is the 
idiosyncrasy of some persons, as to muscles, in reference to this disease, that a 
gentleman mentioned to me the case of a woman, in whom urticaria was induced 
by one tea-spoonful of the water in which muscles had been boiled. She always 
had urticaria if she tasted muscles; but, having boiled some for her husband, and 
being extremely fond of them, she thought she might indulge herself with a little 
taste of them; and so she took a tea-spoonful only of the liquor; but it had the 
same effect as if she had partaken of the muscles. Crab-soup, which (I suppose) 
is much the same as the liquor in which muscles are boiled, will also induce the 
disease. Malt-liquor, white-wine-vinegar, and common spirits, will, in some people, 
produce it. A medical man told me, that his wife always had it if she took gruel. 
One of the most common causes, among medical agents, is copaiba. Many per- 
sons, on taking copaiba, are covered with nettle-rash. I had a patient in whom it 
was produced, in the greatest intensity, I ever saw it, by the sulphate of quinina. 
I never knew this before. His eyes were closed; his face was so swollen, that his 
friends did not know him; he was in a most intense burning heat; and could 
scarcely breathe. Swallowing was impossible. His brother came to me, and told 
me of the circumstance. I wished to ascertain whether it was the sulphate of 
quinina; and I begged him to take only a grain. He complied with my request, 
and it had the same effect, only in a less degree. He then took a mmuie fraction 
of a grain. There was not more quinina than (as is sometimes said) was " suffi- 
cient to swear by;" and even that produced a degree of uneasiness in his throat, 
and a certain tingling in his skin. I have known several persons, in whom the 
disease has been induced by laudanum; — in fact, by opium in any common form. 



380 EXANTHEMATA. 

I mentioned* that, in my own case, whenever I take opium, I am sure, in two or 
three hours to have an itching of my nose; which will not leave me quiet for 
several hours. The same substance, in other persons, will induce universal tinglmg 
of the skin, with bumps; — in fact, nettle-rash. Pepper, and various spices, will 
have the same effect. Pepper and vinegar occasion in me a great itching of 
the scalp. I once saw the disease induced, very violently, by a mixture of sub- 
carbonate of iron with treacle: whether it was the iron or the treacle, I do not 
know. 

External stimuli will induce it: and it may spread along the skin, so as to prevail 
to a considerable extent. Dr. Willan says^ he knew a person, in whom it was 
produced by a slight application of Unguentum Hydrargyri; and another who had 
it from rubbing the hands with oatmeal. It is worth notice that, when an irritant 
is applied to the skin, the effect is not always limited to the spot; but other parts, 
either around, or to some distance, or at some distance, may suffer. Croton-oil 
often causes redness and vesicles, far beyond the spot of application. Tartar- 
emetic, applied to the legs, often causes pustules in the genitals." 

Treatment. — With regard to the mode of treatment, the shortest way, if the 
patient's strength will bear it, is to take blood from the arm. Even if any thing 
improper has been taken into the stomach, bleeding in the arm produces almost 
instantaneous relief; and the patient will speedily get rid of the complaint. A friend 
of mine was taking copaiba, in consequence of his misdeeds; and next day, was 
seized with an eruption all over his body. His face was swollen and burning; and 
his lips were so stiff, that he could scarcely move them to eat. The aperture of his 
eyelids became very small; his pulse was about 100, and full; he was in a great 
heat, and red all over. Before I saw him, he had taken an emetic to empty his 
stomach; but it was quite in vain. The copaiba had entered his system; and was 
there causing irritation. When I went to him, I immediately saw it was nettle- 
rash; and begged another friend, who was by, to put a lancet into his arm, and 
detract a quantity of blood. Before the basin was half filled, he felt relief; and as 
the blood continued to flow, he felt more and more benefit. He became paler and 
paler; the swelling of his face declined; and before evening he was tolerably well. 
He took a dose of physic to assist the bleeding; but I dare say he would have 
done without it. The venesection, notwithstanding the emetic had been fruitless, 
instantly relieved him. A short time afterwards, he found it necessary still to go 
on with the copaiba; — his otiier troubles not having ceased; and the same effect 
was again produced. He took no emetic that time, but was again bled; and the 
disease instantly disappeared. He had no further trouble. 

Evacuants. — However, if we are sure that the cause is still in the stomach, in 
consequence of the short time which has elapsed since it was taken, it would be 
but common sense to empty it; but I confess, if the person were of a full habit, I 
should take away blood first; for we shall find that a most speedy mode of cure. 
We must, as in all other inflammatory complaints, regard the constitution of the 
patient on the one hand, and the intensity of the disease on the other. If we take 
away blood, we shall cure the disease in perhaps a twentieth part of the time that 
will be required, if we trust to low diet and purgatives. I would, in every case, 
back bleeding by low diet and purging. In the chronic form of the disease, the 
patient should avoid stimuli, and adopt the antiphlogistic regimen. He should 
avoid eating any thing that can excite either his body or his mind; and if the pulse 
be strong, he should unquestionably lose a small quantity of blood. The warm- 
bath is said to relieve the affection; and in some cases bathing has done good. 
Bark and acids are praised. All the cases, however, that I have seen, whether 
acute or chronic, have been best and most successfully treated by venesection, and 

« See Page 373. 

^ In his "Description and Treatment of Cutaneous Diseases;" Order 3; Genus 3; Spe- 
cies 2, 

^ For this fact I beg to refer to a paper of mine, on Subcarbonate of Iron, in the thirteenth 
volume of the " Medico-Chirurgical Transactions." (Page 241.) 



EXANTHEMATA. 381 

common antiphlogistic measures. In the case of the lady who had nriicaria from 
takinff the subcarbonate of iron in treacle,^ for a couple of days, the eruption began 
one Sunday morning; and it was supposed that she had got scarlet-fever. The 
eruption was of a damask-red colour, with bumps; and it came out suddenly. She 
was in the greatest agony. Her countenance expressed great distress; but, though 
I imagined it arose from the medicine, I did not give her an emetic. I had her bled; 
and while her noble blood flowed (for she was a peeress) the symptoms declined; 
and when the arm was tied up, there was no redness to be seen. No pains were 
taken to get rid of the offending matter; which, in all probability, was tiie cause of 
the disease. I did not know the use of bleeding, in this complaint, when I began 
practice. But, finding it mentioned by several authors, it seemed rational; and I 
adopted it in every case afterwards, where the pulse would allow it. 

Treatment of the Chronic Form. — In the chronic form, if we find any other 
disease be present, we must endeavour to remove that. The urticaria may arise 
from chronic enteritis or gastritis; and that ought to be remedied in the usual way; 
which usual way is to apply leeches to the abdomen, or adopt general bleeding, &c. 
We may get great and deserved credit for curing this disease; wliich is sometimes 
very obstinate. The secret of the cure generally lies in bleeding, and adopting 
antiphlogistic means. Among local applications, the chlorides, prussic acid, or 
nitric acid, best alleviate the itching. 



SECTION IV.— RUBEOLA. 

Various Names and Derivations. — The next disease of which I shall speak, is 
"measles;" — a severe affection, which is frequently fatal. It is called, among the 
medical men in this country, " morbilli," or "rubeola." We have adopted the 
expression '-^ morbilW from the Italians; who so named the disease from its being 
a less kind of plague; — the " minor plague," — the " little disease." The expression 
*'n<6eo/rt" was formerly applied to scarlet-fever and measles in common; as well 
as to other diseases. In fact, it was Sauvages (the first writer on Methodical 
Nosology) that restricted the term '■'rubeola''' to measles. The word "rw^io" 
('• red"), from which it comes, is Spanish; and it was written " ruhiolo,''^ as it is 
pronounced; — the accent being placed on the o. 

Its Nature. — This is a contagious and infectious disease, chiefly affecting 
children; and is more severe in them than in adults. There is very rarely an in- 
disposition to it; for we seldom meet with any one that will not take it. The 
indisposition is less frequent than the indisposition to small-pox. It rarely occurs 
more than once; but sometimes it does. Dr. Baillie* describes eight cases of its 
occurrence more than once. When it does occur more than once, it generally 
prevails as an epidemic disease." It chiefly prevails in winter and spring. It is 
very well characterized; — having very peculiar symptoms, which hardly any one 
(I think) can mistake.*^ 

Progress of the Disease, — It is almost always ushered in by catarrhal symp- 

* See Page 380. 

b In the ''Transaclions of a Society for the Improvement of Medical and Chirurgical 
Knowledge." 

° By " epidemic," I do not mean contagious. The word "epidemic" has been atiempled 
to be restricted to those diseases which prevail over a number of persons, without any con- 
tagion in the atmosphere; but the word relates to diseases that prevail temporarily over 
many people, without a local cause, — be it contagious or not contagious. 

d Dr. Montgomery (in the " Cyclopsedia of Practical Medicine") gives the following clear 
and concise definition of rubeola: — "A contagious inflammatory disease, affecting at once 
the skin and gastro-pulmonary mucous membrane; in which, after catarrhal fever has con- 
tinued about three days, a rash appears on the skin, at first in small stigmatized dots, not 
unlike flea-bites; which, presently coalescing, form patches of a crescentic or semilunar 
form; first on the face, and thence spreading gradually downwards over the whole^of the 
body and limbs, at the end of four days disappear by desquamation of the cuticle." (Volume 
3; Page 625.) 



382 EXANTHEMATA. 

toms; — that is, by flushing of the face, redness of the eyes, heaviness of the 
countenance, a " running of the eyes and nose, soreness of the throat, sneezing, 
and a hoarse and sounding cough; — a cough which old women, who have been 
much amongst children, describe as the " measle-cough." I cannot describe it. I 
can only say it is a hoarse cough. 

These catarrhal symptoms will sometimes last two days, and sometimes ^i^eri/y, 
before the cutaneous affection shows itself. But, in general, it appears on the 
fourlh day; — sometimes as early as the third, sometimes on the fifth, and some- 
times on the sixth. It is generally upon the fice that the cutaneous affection pre- 
sents itself. It appears as a rash on the forehead and the chin; and thence it 
spreads all over the face. The next morning it is found to have spread, not only 
over the face, but over the breast and trunk, and upon the extremities. On the 
fifih day, the disease has pretty well covered the body; and it is on that day 
that it is most vivid on the face. On the sixth day, the eruption is pale on 
the face, and most vivid on the body; and on the seventh day, it begins to 
disappear in the latter situation. The disease altogether is of about seven days' 
duration. The catarrhal symptoms appear for four days; upon the fourth day the 
cutaneous disease appears; and this lasts three days; — makmg seven altogether. 
But, now and then, children have catarrh for two or three weeks; and then, in the 
midst of the catarrh, without any previous additional symptoms, except perhaps an 
increased intensity, the cutaneous disease shows itself. Now and then, there are, 
on the back of the hand, patches, which did not appear before the sixth or seventh 
day of the fever; and, in the remote parts of the body, the redness occasionally 
does not come on till that time; and then the eruption in these situations does not 
decline, perhaps, till the eighth day. On the ninth day, there is only a slight dis- 
coloration left; — a sort of brownish appearance. The colour, in this disease, is 
by no means so vivid as in roseola, and as in scarlet-fever. When it subsides, if 
the inflammation have been pretty extensive, there is a furfuraceous desquamation. 
This, then, is the course of the disease. 

The longer the premonitory symptoms and the general indisposition occur, 
before the appearance of the eruption, and the more severe they are, the more 
severe, generally speaking, will be the disease itself. The affection, too, is usually 
more severe in the cold than in the warm months. Sometimes, in the severe form 
of the disease, there are, about the fourth day, small dark patches in the mouth, on 
the hard and soft palate, upon the tonsils, and upon the uvula; — the mucous mem- 
brane being affected, as well as the skin. 

Characters of the Eruption. — When the affection first appears, there are only 
(at the utmost) little red dots, nearly circular; which are scarcely perceptible, and 
rather less than the spots of flea-bites. They become more and more numerous, 
however; and coalesce into patches. All the exanthemata begin and extend in this 
way. The patches which are formed in this disease, are of an irregulnr figure; 
and frequently assume a semicircular or crescentic form. This is characteristic of 
the disease, and is worthy of notice; — not that the diagnosis is often at all difficult; 
but, if it be difficult, we may be assisted by remembering, that the patches in 
measles affect a semicircular or crescent-form; that, in the midst of these patches, 
there are circular spots; and that, around the patches, are spaces of the natural 
colour. The disease is most severe upon the face. The skin of the face is finer, 
and more abundant in red vessels, than that of many other parts; and there it is 
that the effects of inflammation are most severe, — from these circumstances. The 
skin is not smooth, but roughened; so that, by passing the finger along it, a little 
roughness is observed; — hardly worth the name of roughness, perhaps; but an 
inequality. Occasionally, if the inflammation be severe, this is observed in other 
parts of the body. Occasionally the red dots are more or less hard and elevated. 
Although the disease is characterized by patches, the inflammation may be so in- 
tense as to cause the face to swell, and the eyes to be closed; nay, the symptoms 
may be so severe as to cause litfle collections of water, the size of millet-seeds, 
which are called " miliary vesicles;" and sometimes there are papulae on the hands, 



EXANTHEMATA. 3S3 

wrists, and fingers;— elevations of the cuticle, having a distinct roughness, in the 
midst of the patches; so that while the patches give to the feel a sensation of being 
elevated above the surrounding skin, in the midst of these there will be another 
rouffhness, arising from the papulae. 

Diagnosis. — When we hear a child sneeze and cough, and see these crescentic 
semicircular patches, we may be sure it is the measles. It is on the face we usually 
see the disease best characterized. We may mistake it on the arms, hands, and 
body; but we can hardly do so on the face. It is very important to make a cor- 
rect diagnosis here, although the disease may be of a slight character; because the 
man that tells a parent that the child is about to have the small-pox, when it is 
going to have the measles, will of course be deemed ignorant. Sometimes the 
spots will go down as fast as they appear. 

Continuance of the Catarrhal Symptoms. — It is almost constantly observed, in 
this disease, that the catarrhal symptoms are not much lessened on the appearance 
of the eruption. It is often said by authors, that when the eruption comes out, in 
cutaneous diseases, the internal symptoms are relieved. "We all meet with this 
occasionally; but, in a great number of cutaneous diseases, I have seen the internal 
symptoms not alleviated by the appearance of the external. In measles, however, 
it is a well-known fact, that, so far from there being an alleviation of the internal 
symptofns, they are more frequently aggravated than not; at any rate, in general, 
they are not mitigated. When the eruption comes out, the catarrh is confined 
perhaps to the bronchia. It appears that the catarrh is more or less bronchitic; 
lor there is an affection of the superior parts of those tubes. But frequently the 
irritation of that part of the membrane below the larynx increases; so that we have 
decided bronchitis. Sometimes there is an aflection of the substance of the lungs 
(pneumonia); and sometimes of the investing membrane (pleuritis). 

Seqiielse. — Frequendy, when the measles are over, they leave chronic bronchitis, 
chronic pneumonia, chronic pleuritis, or even phthisis. They frequently seem to 
give rise to tubercles. Frequently, too, there is left after measles a chronic diar- 
rhoea (generally of an inflammatory character); frequently inflammation of the eyes 
(ophthalmia): ear-ache; running of the ears (otorrhoBa); deafness. Frequently there 
is disease of the mesenteric glands; and frequently, after the disease, we see various 
chronic cutaneous affections; such as ecthyma, rupia, porrigo, boils, aphthae, &c.* 
In fact, there is no end to the mischiefs that measles leave behind. They may 
recede suddenly; and then we may have internal inflammation of the lungs, or 
within the abdomen, or in the head; but it is chiefly in the chest that inflammation 
occurs, when the disease recedes. It is not by any means certain, that the retro- 
cession of the measles causes these symptoms. It is just as probable that, in many 
instances, the occurrence of the internal disease puts a stop to the external. It is a 
great mistake to suppose, that the retrocession of an eruption causes internal dis- 
ease, in every case where such internal disease occurs. There can be no doubt 
that the occurrence of another disease, in the internal part of the body, will put a 
stop to, or suspend, a disease which has previously been going on in an external 
part; but it is a fact that, when measles suddenly disappear externally, for the most 
part there is some internal afTection. 

Predisposing Causes; Age. — Infants, or at least children, are considered to be 
much more susceptible of the disease than adults; but infants at the breast are cer- 
tainly not so susceptible of it as others. It is not at all an uncommon thing to 

* Dr. Montgomery (" Cyclopaedia of Practical Medicine'-') says, — "In a few instances, 
gangrene of ihe inside of the cheeks, gums, and lips has been observed; in other instances, 
moriihcation has affected the uvula. Anasarca has been known to appear after measles, 
as it very ofien does after scarlatina; but this is so rare an occurrence, that where it doef; 
occur there is much reason to suspect, that the previous disease has been scarlatina. Dr, 
Harty, who has had extensive opportunities of observinsr this disease, informed the writer, 
that he has very frequently found, during convalescence from measle.^-, that the pulse became 
unusually slow (about forty or fifty in the minute); but it did not appear to be connected 
with any thing unfavourable in the condition of the patient, whose recovery was uninter- 
rupted." (Volume 3; Page G31.) 



384 EXANTHEMATA. 

notice the disease in a family of children; all of whom have it, excepting one which 
is at the breast. There is no doubt that extreme infancy is not so disposed to the 
disease, as later periods of infancy. It is considered, however, that infancy at 
large, childhood, and the young adult period, are more subject to it than the full 
adult period; and much more so than old age. In considering this question, we 
ought to reflect on the circumstance, that although fewer adults have it than children, 
yet it is a disease that occurs generally but once; and it is possible that the reason 
why it is not seen in adults is, that almost all adults have had it when children. 
To ascertain the hci fully, we ought to have a number of adults who never had 
the disease; and expose them with an equal number of children who never had the 
disease; and see how many of each are affected. But even if a smaller number of 
adults escaped than of children, still that might not be satisfactory; because those 
adults probably did not have the disease in infancy, — owing to a positive indisposi- 
tion; and that indisposition might still prevent them from taking it. We can draw 
no inference from the number of persons who have the disease in childhood; as is 
usually the case. Dr. Babington, I have heard say, has seen measles occur after 
sixty years of age; and it is a fact that we may see small-pox after seventy. Some 
children are said to have been born with measles;* and others have had it at a very 
short period after birth; but, as a general rule, the extremes of age are very unfa- 
vourable to this affection. 

Exciting Cause. — The exciting cause of the disease is, indisputably, a peculiar 
contagion; and this has been communicated by art; — the disease has been conveyed 
by inoculation. Experiments of this kind were made, many years ago, by Dr. 
Home," Professor of Materia Medica in the University of Edinburgh. Many have 
thought but little of these experiments; but, in 1822, an Italian physician (Dr. 
Speranza) in the territory of Mantua, repeated them. He inoculated six cases, and 
afterwards himself, with the blood taken from a slight scratch in a vivid papula. In 
a few days the measles appeared; and went through their course mildly and regu- 
larly. This encouraged him to make further experiments; and he says they were 
all successful. Occasionally the measles do produce little vesicles; and it is cer- 
tainly likely that these vesicles contain the contagious matter in a concentrated form. 
Many who have attempted to inoculate for measles have failed; but that measles 
have been communicated by inoculation, there can be no doubt, and as the disease, 
when produced naturally, is so severe; while it is slight when produced artificially; 
and as most children have the disease, I think it a pity the subject has not been 
more attended to. There is not the same facility, of producing this disease, as 
small-pox; but it is possible to communicate it; and there can be no harm in scratch- 
ing a few children, and attempting to give them the measles, during the favourable 
period of the year. Nor do I see why, as most children have it, they should not 
be exposed to the contagion, by having the clothes of others labouring under measles 
placed near them, during the warm summer months. 

Period of its Occurrence after Exposure. — With i^gard to the time at which 
the disease occurs after exposure, Willan says that he knew a person who ha4 
had the measles, and became convalescent; and his clothes infected a child in the 
country; and that the child had the eruption sixteen (Says after being first exposed. 
I suppose the usual period is from five days to a fortnight; but most probably this 
varies, as in most other contagious diseases. 

Varieties: — 1. Rubeola sine Catarrho. — The measles sometimes occur, without 
any internal affection; — without any catarrhal symptoms, running of the eyes or 
nose, sneezing, heaviness of the head, or cough; and it is said, that when disease 

» "It is asserted by Rosen, Vogel, and others, that infants have been born with the traces 
of measles. Guersent (" Dictionnaire de Medicine," Tome 18, Page 513) mentions having 
seen an infant born with measles on it (having taken the disease from the mother); bat, we 
presume, such instances must be of exceedingly rare occurrence." — " Cyclopcedia of Practical 
Medicine-" Volume 3; Page 625. 

^' " Clinical Facts and Experiments;" published in the year 1758. He was the father of 
the present Edinburgh Professor. 



EXANTHEMATA. 385 

occrurs in this exceedingly mild form, it does not prevent a second attack. This 
was mentioned by Ur. Wilian;* and, as an accurate observer, he was, perhaps, 
never surpassed; but Rayer declares that this kind of disease is not measles at all, 
but only roseola. Dr. Willan,* however, says that he saw two distinct cases of 
measles, — indisputable measles, without any catarrh; and I myself attended a family, 
in which several of the children had had the measles, with catarrh; and One of them 
had, at the same time, an eruption exactly like the others, but without catarrh; and 
which was pronounced, by the medical attendant,- to be the measles. The rest of 
the family never had the disease again; but tliis one, a year afterwards, had regular 
measles. From this fact, occurring within my own knowledge, I cannot but think 
that Willan is rijrht. If any could distinguish between rubeola and roseola, it must 
have been Dr. Willan. Besides, all contagious diseases will occur in an imperfect 
form. The most intense contagious disease may be of unusual shortness, or of 
unusual mildness, or both; and may even want some of its symptoms. Pustules 
of small-pox sometimes occur without any indrsposition. Doubtless, measles is no 
exception to the general truth. When small-pox has so appeared, W' illan* says it 
may begin regularly, and be perfected on the eighth or ninth day from the first 
appearance of the pustules, ivithont indisposition. In the same manner, measles 
will sometimes appear, and proceed to perfection in a few days after the eruption, 
ivithout catarrh. It is well, therefore, to tell the parents, that the child may have 
an attack again; for a second attack of measles is possible in any case; but if they 
occur without catarrh, it is almost certain that the patient will have them again. 

2. Rubeola Nigra. — The measles are sometimes attended with a darkness of 
the skin. About the seventh or eighth day, the rash suddenly becomes yellow, or 
livid. There is langu.or or quickness of the pulse; but no inconvenience arises; 
and the whole ceases in a week or two. It does not appear that there is any danger 
from the mere lividness of the patches in this disease. Many eruptions of the skin, 
when they subside, become of a dingy or yellow colour, without any danger what- 
ever. There is merely a little change of colour, which is quite independent of the 
present indisposition. So it happens in measles. The dinginess is more intense 
than usual; the part becomes exceedingly brown and yellow; but this generally 
ceases after a week or two. Perhaps the blood is in a state approaching to stagna- 
tion; — the circulation not going on in the natural way. This species is called 
*' rubeola nigra.^^^ 

3. Rubeola Putrida. — But it is said that measles sometimes do occur in a really 
typhoid state of the body; — that "putrid measles" take place. Sir William Wat- 
son, who was physician to the Foundling Hospital, said that he saw this sixty 
years ago. Others think this was an error: because (like Morton, a cotemporary 
of Sydenham) he did not distinguish measles from scarlatina; and proposed to 
banish the latter word as superfluous. Indeed, the original writers on measles all 
consider it and small-pox as the same disease in difl^erenl forms. Dr. A. T. Thom- 
son, however, declares, that. he saw a case in 1804, where the languor and state of 
the pulse were alarming; and the skin rubbed off like a moist cobweb; but the 
patient recovered by the use of wine and cordials. I never saw this form; but the 
other (rubeola nigra) is not very uncommon. 

[^The prognosis in measles, during the early stage of the disease, is always 
favourable; but a mild attack of the proper symptoms is often suddenly converted 
into a most dangerous disease. It should be recollected that the eruption, or the 
mere disease, rarely puts the patient's life in hazard; — as we so frequently observe 
in scarlatina, in which the vital powers are so alarmingly depressed by the action 
of the poison; but in measles, the internal inflammation, particularly of the lungs, 
which frequently supervenes, is the chief source of danger. It is very generally 

"^ In his " Description and Treatment of Cutaneons Diseases;" Order 3; Genus 1; Species 
2. (Page 235.) 

b " Rubeola sine catarrho," and " Rubeola ni^ra," are well represented in Plates 21 and 
22 ofWillan's Work. 
VOL. I. — 25 



3S6 * EXANTHEMATA. 

admitted, that measles are more severe, and attended with more danger, in adults 
than in children. Dr. Montgomery dissents from this doctrine; and stales that, as 
far as his experience enables him to judge, he should pronounce exactly a contrary 
opinion.* The most severe cases of measles which have come under our notice," 
have certainly been in adults. The character of the prevailing epidemic, and the 
peculiar type of continued fever of the same period, should be carefully weighed in 
forming the prognosis, as well as in determining the treatment of measles. The 
season of the year has a more important influence on the issue, than in scarlatina 
or variola; the complaint is more likely to proceed favourably and safely in mild 
than in cold damp weather. When measles quickly succeed to other infantile 
disorders, as pertussis or remittent fever, the danger to be apprehended is greatly 
increased; the same may be said when it attacks children disposed to affections of 
the brain, or to scrofula. The following are the general circumstances which 
denote danger; — unusual violence of the eruptive fever, especially if attended with 
spasmodic twitches or convulsions; the eruption appearing late, and of dark livid 
colour; the supervention of thoracic or abdominal inflammation; severe headache, 
with nocturnal delirium; retrocession of the rash; extreme dyspnoea, coming on 
late in the disease, with a dusky flush on the cheeks, and livid lips; the accession 
of typhoid symptoms; the appearance of petechiae, or profuse haemorrhages from 
mucous surfaces. 

A favourable prognosis may be pronounced when the eruption appears at the 
usual time, and proceeds regularly over the whole body and limbs; by the mildness 
of the bronchial affection; by the appearance of moderate diarrhoea; by the softness 
of the pulse; by the uniformly warm and moist state of the skin; and by the return 
of sound refreshing sleep.''] 

Treatment. — In the treatment of measles, the first point is to attend to any 
internal symptoms of inflammation that may exist. A large number of cases will 
do very well, without any medicine at all. The child cannot eat; and therefore, 
if not recommended by the parent, will not take any thing injurious. He is more 
inclined to take plain water, milk, or milk and water, than any thing else. The 
patient should be kept cool; but it is rather dangerous to keep him cold. He 
should be kept in a moderate^ but by no means stimulating, temperature; for heat 
would do great harm, and aggravate any disposition to bronchitis; but I do not think 
there would be the same propriety in exposing the child to cold air, that there is 
in small-pox and scarlet-fever;- — owing to the great disposition to bronchitis. Some 
have recommended the cold aflfusion in this disease; but the tendency to bronchitis 
is such, that 1 have never practised it, and I would not recommend it. 

From the catarrhal symptoms in this disease, and their great disposition, on the 
appearance of the eruption, to become severe, it is always necessary to direct 
attention to the state of the chest; — to observe, carefully, whether there is peri- 
pneumonia, or bronchitis, or pleuritis, or any other aff'ection of the chest; and to 
treat it just as if no measles were present; — to take blood from the arm or the 
jugular vein, or apply leeches, as the case may require. It is not requisite to pay 
such great attention to these symptoms before the eruption occurs; but if they be 
severe when the eruption comes out, blood should be taken. Leeches generally 
answer; but if the child be large, blood might be taken from the jugular vein, or 
the arm. Moderate purging is proper, and low diet. The patient must be treated 
on the antiphlogistic plan, according to the degree of inflammation. 

Recession of the Eruption. — If the eruption does not come out, or recedes, we 
should put the patient into the warm-bath; but we must remember that this is most 
likely produced by some internal disease; and that internal disease, in nine cases 
out of ten, is inflammatory; and in eight out of that nine it is situated in the chest. 
The Internal affection may be the consequence of the measles receding; but, in a 
great number of cases, it is the internal aflfection that puts a stop to the progress of 

» " Cyclopsedia of Practical Medicinej" Volume 3; Page 630. 

^ That of Dr. G. Burrowes. 

<= " Library of Medicine;" Volume I; Page 33L 



EXANTHEMATA. 3S7 

the disease on the surface. The best mode to bring out the measles again, is to 
lessen the internal disease. The measles will sometimes be suspended for many, 
many days, after appearing on the surface. They will recede in consequence 
of the internal inflammation; which we must subdue; and then, frequently, they 
will re-appear. This is a very curious circumstance. Now and then, there may 
not be internal inflammation. There may be mere debility; and then it is neces- 
sary to give stimulants; — ammonia and wine. When there is diarrhoea, it generally 
requires antiphlogistic treatment. 

Diarrhoea. — The diarrhoea is generally troublesome, when the disease is over; 
but it is important, in all cases, to press upon the abdomen, and see if there be any 
tenderness. In a large number of cases, there is tenderness; and the diarrhoea is 
only to be subdued l3y sinapisms, leeches, (fee. Sydenham pointed out that the 
diarrhoea was inflammatory; that opium and opiates were improper; and that vene- 
section ought to be resorted to. Venesection is out of the question, in many cases; 
but it is sometimes proper. However, this is no general rule. We see cases 
where there is so little inflammation, that astringents and opium will cure the 
disease; but frequently they are not to be trusted to alone. In some we must unite 
this plan with the remedies for inflammation; in others we must solely treat inflam- 
mation, and the diarrhoea will cease. This is a most important point in practice, 
although it is simple; and unless it be carefully attended to, we may do harm when 
good might be eflfected. 

. Measles are very apt to leave after them an obstinate diarrhoea, which ends in 
disease of the mesenteric glands; and a bronchitis, that is apt to leave a disposition 
to the formation of tubercles. We have chronic bronchitis, and then tubercles; so 
that children frequently die of phthisis; but measles often set up scrofula, both in 
the abdomen and chest. 

Putrid Measles. — In the putrid form of measles (which I have never witnessed), 
the opposite plan must, of course, be adopted; only we must take care not to mis- 
take a blackness arising from extreme congestion of the lungs, for a putrescent state 
of the body. When there is congestion of the head and chest, wine and tonics 
would be exceedingly improper; but I should think that a careful practitioner would 
not make the mistake to which I have adverted. 



SECTION V.~SCARLATINA. 

Formerly Confounded with Measles. — The next disease among the rashes of 
which I will speak, is scarlet-fever; which is called, in medical Latin, "scarlatina." 
Till the close of the eighteenth century, this disease was confounded with measles. 
Morton, who (as I before observed"") was a contemporary of Sydenham, thought 
they were mere varieties of the same disease.'' In the middle of the seventeenth 
century, Sennertus asks why the disease is sometimes " small-pox," and sometimes 
*' measles;"*^ and Diemerbroeck, who published in 1687, asserts that measles and 
small-pox diff'er only in degree.'^ Such were those days of diagnosis. In 1769, 
Sir William Watson did not distinguish measles from scarlet-fever.^ On this 
account, some have aflSrmed that Sir William did not see the putrid form of 
measles; — that what he saw was putrid scarlet-fever; and that, as he did not dis- 
tinguish between the two aflJ'ections, he called it "measles." Indeed, Morton, 
who confounded the disease, wished the appellation " scar/eZ/eue?-" to be banished 
altogether. He conceived that the two diseases (measles and scarlet-fever) were 

» See Page 385. 

^ " Opera Medica; nimirum, de Phthisi; de Morbis Universalibus Acuds; de Febribus 
Infiammatoriis. Auctore R. Morton, M. D." 

<= His " Opera Omnia" were published in 1641, at Paris, in three folio volumes, 

d " Opera Omnia Anatomica et Medica, Isbrandi Von Diemerbroeck; emendata et aucta 
ab auctore; el recogniia per Inn. de Diemerbroeck (Isbrandi jfilium)." 

e An Account of Experiments on the Inoculation of Small-pox. By William Watson, 
M. D." 



3S8 EXANTHEMATA. 

but one; and he thought it a pity to use both terms; — the won] " measlea^'' being- 
quite sufficient to designate the whole disease. Bateman thinks that the year 1793 
Avas the first in which an accurate diagnosis was made. Dr. Withering published 
an essay on scarlet-fever, in 1788; of which essay the second edition appeared in 
1793;* and Dr. Bateman considers, that the latter was the accurate date of the first 
correct division of these diseases. This must appear to us strange; now that the 
diagnosis between the two diseases is established with the most perfect facility. 
But so it is; and I trust that those who live a hundred years after us, will be satis- 
fied that we were an ignorant set; — that science will so advance, as hereafter to 
make our knowledge appear perfect ignorance. At the present momp;nt, people 
cannot settle how long cholera lias existed;— whether it is a new disease or an old 
one. Some say that it sprung up a ^^vf years ago; and others assert that it has 
been known from time immemorial. It is just the same with scarlet-fever. Some 
say that it was not known more than two hundred years ago; that it is not men- 
tioned in the Arabfan, not to say the Greek, writers; and that it came from Africa, 
and broke out (for the first time in Europe) in Spain, in 1610. Willan says'* it 
was known to the Neapolitans, before 1500, under the name of " rossalia," or 
" rossania;" and that Ingrassia describes it under that name; that others called it 
*'rosalia," " robelia," "rubiola," "rubeola," " rubiolae," and " rubeoli" (from 
" robia," madder; and " morbilli," measlea;) and that the French used all these 
words for scarlatina; and, in addition, even " rugeole;" — terming measles " sene- 
pion." The word " scarlatincC^ was formerly " scarlatiina;^^ and is derived from 
" scarlatfa,^^ — " a red-coloured cloth." 

Symptoms. — This disease is characterized by a close and diffuse scarlet-coloured 
efflorescence of t!ie skin, and likewise of the mouth and fauces. There are the 
usual symptoms of pyrexia, for about two days; and, on the second day of the 
pyrexia, the eruption generally appears in some part. In the greater number of 
casps, I believe this is true; but occasionally the eruption will not take place till 
the third, fourth, fifih, or sixth day; and when the eruption does take place, it con- 
tinues about five days. The interval between exposure and the appearance of the 
affection, is greater in adults than in children. 

Varieties. — [There are several forms of scarlet-fever; each of which requires a 
separate description. The poison of scarlatina usually exhibits its effects upon 
two membranes; namely, on the skin and the mucous membrane of the fauces; to 
one or other of which, however, its action may be restricted. Hence arise the 
varieties of scarlet-fever; — in accordance with a well-established law of the action 
of other poisons, — " that they may exhaust themselves on one or more of the tis- 
sues they usually affect, without involving the whole series; and that they act with 
greater or less intensity, according to the pecular idiosyncrasy of the patient."'' 

In the most simple form of scarlatina, the fever is seldom of an active kind. The 
cutaneous efllorescence appears in the usual manner; but there is no inflammation 
of the mucous membrane of the throat ("Scarlatina Simplex^^). 

In the second, there is greater febrile excitement; and the general symptoms are 
farther complicated by inflammation of the fauces ("Scarlatina Anginosa'''). 

In the third, the symptoms are of a more severe description. The fever — which is 
of a typhoid type, with great depression of the vital powers — is sometimes accom- 
pinied with diphtheritis,*^ sometimes with gangrenous inflammation of the throat, 
and generally with tumefaction of the parotid and cervical glands, and acrimonious 
discharge from the nostrils and ears ("Scarlatina Maligna'''). 

In a fourth variety, the efflorescence does not appear upon the skin; but is con- 
fined to the mucous membrane of the mouth and throat. Although this form has 
not been described by Dr. Willan, as a distinct variety, it was often witnessed by 

* " Account of the Scarlet-Fever and Sore-Throat; by William Withering, M. D." 
*> See his "Description and Treatment of Cutaneous Diseases;" Order 3; Genus 2. 
(Page 289 of the First Edition.) 

c l)r. R. Williams's " Elements of Medicine;" Volume 1; Page 131. 
^ From S'i<;)9E;a, skin (or membrane)^ and " itis," inflammation. 



EXANTHEMATA. 389 

nim.* Dr. Tvveedie, in his valuable essay on scarlatina,'' has designated this va- 
riety "Scarlatina /awcmm." Dr. Williams'' has described it as "Scarlatina sine 
Eruptione.'"^] 

I. Scarlatina Simplex. — In the most simple form of the disease (that called 
" scarlatina simplex^''^) the feverishness is very moderate. On the day after the 
commencement of the feverishness, innumerable red spots appear on the face and 
neck; and these, in twenty-four hours, will spread all over the surface; — coalescing 
and multiplying". They thus increase and multiply; enlarging the redness, and 
uniting together, till they form large exteiisive patches over the trunk and ex- 
tremities. On the third day, there is almost one diffuse and continuous efflo- 
rescence over the body; and especially around the fingers. The scarlet hue is 
usually most vivid on the flexures of the joints; — the skin there being very fine; 
and likewise on the loins. The patches are seldom universal on the trunk; but 
upon the extremities they are very continuous. If we turn aside the bed-clothes, 
we perhaps observe a continuous redness from the groin down to the foot; — the 
patient looking almost like a boiled lobster; and towards evening the redness is so 
intense, that the patient looks as if he had been smeared with raspberry-juice. On 
passing our finger carefully over the skin, we may find exceedingly minute aspe- 
rities (resembling the "cutis anserina" of the cold stage of ague);— far more so 
than is observed in measles; but we do not observe the irregularity that occurs in 
measles. In measles the whole skin is raised in patches; and besides that, we 
frequendy feel small papulae; but, in scarlet-fever, the patches are not at all 
elevated. The distinction between the sensations given to the touch, in the two 
diseases, is very obvious. 

It is usually upon the fourth day, that the eruption is at its height. On the 
second it comes out; and on the third it has spread all over the surface; if the lower 
parts were exempt before, it reaches them now; and, on the fourth, it is at its height 
of redness. On the fifth day it declines; and it declines by interstices; — so that 
the patches reappear. While the disease was increasing, the patches were lost 
in one continuous redness; and then, as the disease declines, the continuous redness 
becomes again divided into patches; — that is to say, there are intervals of paleness. 
On the sixth day, the eruption becomes very indistinct; and it is gone, generally, 
before the end of the seventh. Now and then, if the disease be severe (and some- 
times when it is not) between the fourth and seventh day there are (as is sometimes 
observed in measles) little miliary vesicles. In acute rheumatism, also, I have seen 
the fingers beset with vesicles. About the eighth or ninth day, the cuticle comes 
oiT. in the form of scurfy desquamation 

The disease attacks the interior of the mouth and fauces; and it even affects the 
conjunctiva.* The papillae of the tongue become enlarged; and we may see them 
through the white crust of dry mucus with which it is loaded. The tongue looks 
as if It had been slightly sprinkled with Cayenne pepper. If there be any cough, 
it is not that peculiar cough which I mentioned' as occurring in measles. In 
measles, there is a peculiarly sounding cough, — such as experienced women and 
nurses know to be the cough of measles; but that does not occur in scarlet-fever. 
If there be any cough at all, it is merely a short irritating cough; arising from irri- 
tation of the fauces, without any expectoration or hoarseness. The conjunctiva 
beiuff affected, there is a redness of the eyes; but no intolerance of light, and no 
overflowing of the tears; and the ciliary glands are not affected. 

If scarlatina be at all severe, we may have a discharge from the ears, both within 

• See his "Description and Treatment of Cutaneous Diseases;" CrJer 3; Gcnjs 2; Spe- 
cies 2. (Pa^es 273 and 274 of the First Edition. 

• In the "Cyclopedia of Practical Medicine;" Volume 3; Page G4J. 
c s' EleiTieuis of Medicin.-" Volume 1; Pa^e 131. 

d " Library nf Medicine;" Volume 1; Pa?e 335. 

• See Dr. Willan's" Description and Treaimeat of Cutaneous DLscases;" 0.der3; Genus 
2; Species 1; Plnie 23. (Page 254.) 

' From "con," together; and "jango,"^<3 jtf/7i. 
6 See Page 382, 



390 EXANTHEMATA. 

and without; — a discharge both from the Eustachian tube, and the external meatus. 
It may also give rise to sores behind the ears; — and to glandular suppuration in 
various parts; as in the parotids, and the glands of the neck. It may give rise to 
pulmonary disease, or to diarrhoea. It may be followed by chronic pustular dis- 
eases of the skin (called "rupia" and "echthyma"); but they are much more 
common after small-pox. After mild scarlet-fever, there is very often general 
dropsy ("anasarca"). The other symptoms which I mentioned (such as discharge 
from the ears, suppuration of the glands, &,c.) all occur after the most severe forms 
of the disease; particularly that called " scarlatina maligna;^^ but after the mildest 
form we may have dropsy. This dropsy usually occurs at the end of the second 
week; and after the rash declines. It occurs particularly in spring and in autumn; 
and, if I be not very much mistaken, it is generally owing to the patient having 
caught cold, in some way or other. 

2. Scarlatina Jinginosa. — Now and then scarlatina is accompanied with little 
or no affection of the throat. Perhaps there may be a slight affection; though fre- 
quently it is so slight, as to deserve no notice; but if it be very obvious, the disease 
is called "scarlatina anglnosa.^^^ There is then more violent inflammation of the 
fauces; which inflammation increases and decreases with the eruption; the general 
disease of the system, and the eruption, are altogether more intense; the heat may 
be 106 or even 112 degrees; and there is sickness, headache, restlessness, and deli- 
rium. The throat feels sore and straitened; and, on inspection, in various instances, 
a dark red line is seen along the velum, reaching down to the lower part of the 
uvula.'' The patient is hoarse; experiences a difficulty in swallowing; and the 
tongue is very red, especially at the sides and the extremity. The papillse are 
particularly afl'ected; so that they are greatly increased in length. 

In this more severe form of the disease, the eruption often does not appear till 
the third day; and very often the eruption is not so universal, but is in scattered 
patches; and very often it does not come out fully and remain so, but appears and 
disappears. Thus the whole disease is lengthened. From the eruption not coming 
out permanently, the disease is protracted. I mentioned'^ that when the measles 
recede, the eruption may last for some weeks. So, in scarlet-fever, if the disease 
comes and goes, then the period of the eruption is increased; although I do not 
know that it can be increased to the period to which I have seen measles extend. 
When the disease thus goes off, the desquamation is less regular; and, if the rash 
have been slight, (as it sometimes is, even when the throat is much affected,) there 
is perhaps no desquamation at all. Sometimes we see exfoliations of large portions 
of the skin, for m.any weeks; and these are usually upon the hands and feet. The 
nails have been known to crack and separate; and, now and then, superficial ulcer- 
ation will take place on the tonsils. For the most part, there are shreds of viscid 
secretion; which are sometimes mistaken for sloughs; but they are merely vitiated 
secretions; — excessively thick portions of lymph. Now and then we have real 
sloughs; with great debility after the disease. 

3. Scarlatina Maligna, — But we have another form of the afl^ection; in which 
there is a great disposition to sloughing, to mortification of the throat, and to pu- 
trescency of the body; and this is called "scarlatina malignay^ With respect to 
scarlet-fever, the names of the species are not (as is the case in many other cuta- 
neous affections") unworthy of being remembered. The distinctions of this disease 
are very proper; but we have only to remember that there is a mild form of the 
disease; another in which the throat is much affected; and another where there are 
typhoid symptoms. In this violent typhoid form of the disease, the efflorescence 

^ See Dr. Willan's " Description and Treatment of Cutaneous Diseases;" Order 3; Genus 
2; Species 2; Plaie 24. 

^ From " uva," a grape. 

= See Page 387. 

^ See Dr. Willan's "Description and Treatment of Cutaneous Diseases;" Order 3; Genus 
2; Species 3; Plate 24. 

e See Pages 3G7, 308, 375, and 378. 



EXANTHEMATA. 391 

is dark and livid. It comes out even still later than in " scarlatina anginosct'^ 
(vi^here the disease is attended by an inflammatory sore-ihroat); and it is of uncer- 
tain duration. It is continually ^oing and returning; and there is less heat of the 
body. In "scarlatina anginosa,^^ I said the heat might be 112 degrees; but here 
there is less heat; and the pulse, although perhaps very quick, is languid. There 
is great affection of the head; — great delirium or coma. In fact there is encepha- 
litis; — inflammation within the head; and sometimes other inflammatory affections 
are present. The eyes are red, and the cheeks darkly flushed. There are sordes 
of the tongue and mouth; dark sloughs (the basis of which are livid) in the throat; 
and great fretor from the nose and mouth. There is an acrid discharge through the 
nostrils; — a discharge which irritates the skin upon which it flows. There is 
diarrhoea; and frequently there are petechias; — black specks on the surface of the 
body. Haemorrhage occurs; and death often takes place in two or three weeks. 
Sometimes the patient sinks suddenly, within the first four days. Occasionally the 
disease does not show this malignant character at first; but goes on pretty mildly; 
and then, all at once, puts on these malignant symptoms. When the body is in- 
spected, there are found to be various internal congestions, inflammations, and 
efTusions; and inflammation of the surface (not of the interior) of the skin. 

It is this frightful form of the disease which, when recovered from, leaves very 
severe complaints; — as ulceration within the ears, chronic diarrhoea, and such dis- 
eases of the skin as rupia and ecthyma. I do not know that this form of the dis- 
ease is more frequently followed by anasarca than the others. So comparatively 
rare, however, is this species of the affection, that [ have never yet had occasion 
to treat a patient with it. It is, perhaps, a singular thing, that I have yet lost only 
two patients with scarlet-fever. But it has solely arisen from this circumstance; — 
that they have always been mild cases which I have treated; — such cases as required 
cold washing, cold air, and occasionally the local application of leeches. I have 
heard other practitioners say, that they never lost a case of scarlet-fever. 

We sometimes see that form of the disease which is called " scarlatina maligna," 
occurring generally throughout a neighbourhood; — at least generally during an epi- 
demic. Sometimes we see one person in a neighbourhood affected with it; while 
other persons, or other children, are aflfected with other forms of the disease. 
Sometimes, even in the same house, we see all the three forms of the disease. 
It appears, therefore, that the cause of the disease's putting on this malignant cha- 
racter, is sometimes something general in the state of the season or place; and 
sometimes something altogether dependent upon the condition of the individual. 
It does not appear to be any thing peculiar- in the contagion. We shall find, in 
the case of small-pox, that matter taken from a person labouring under a mild 
variety, will sometimes give to another person a malignant, confluent, violent form 
of the disease. So, in scarlet-fever, the 7Dild form of the disease, is sometimes 
caught from a person labouring under a malignant form; and vice versa; and 
although we see numerous cases of malignant scarlatina, during a particular epi- 
demic, — and especially in a particular neighbourhood, — yet, at other times, v/e 
shall see tlie malignant form occur sporadically. It may occur only in one or two 
individuals in a neighbourhood; while the rest have the mild, or merely the inflam- 
matory form; and we even sometimes see this peculiarity cease in one place, while 
another becomes filled with the inflammatory or mild form. I believe that the 
malignant form is more common in winter, than at any other period. The circum- 
stances that give rise to it are not well known. 

4. Scarlatina Fancium. — There is, however, another form of the disease, in 
which the throat is affected, and not the surface. Some, indeed, have denied 
this; — just as some have denied that measles are occasionally seen without catarrh. 
As, however, this disease aflfects both the surface and the throat; and as some have 
asserted that it frequendy aflTects the surface, while there is little or no afl'ection of 
the throat; so there is no reason whatever whv the throat should sometimes not be 
sore, while the surface is scarcely or not at all afli'ected; — while there is nothing 



392 EXANTHEMATA. 

upon the surface worthy of the name of an eruption. Dr. Willan mentions,* that 
in epidemic scarhitina, there are always many cases wliere the throat only is 
afiected; and that these cases will communicate all forms, of the disease, just as if 
the skin were affected. This, I think, is not at all surprising. In that form in 
which the throat particularly suffers, if we were to look over the skin from head 
to foot, two or three successive days, we might perhaps discover an eruption; but 
it would be so little, that we should be almost justified in saying there was none; 
and 1 have seen several in a family affected with the sore-ihroat only; and that 
mildly. Those who fortnerly had scarlet-fever, and even those that are recovering 
from it, if they be exposed to the contagion again, will sometimes have a little sore- 
ness of the throat, and even patches on the skin. 

// may Occur more thari Once. — It is a disease that usually occurs but once 
(Turing life; but I believe the exceptions to this rule are more frequent, than in the 
case of small-pox. Small-pox occurs twice, more frequently than measles; and I 
believe scarlet-fever occurs twice, more frequendy than small-pox. But I am not 
certain; for some persons do not make a sufficiently accurate diagnosis, between 
such a rash as roseola and scarlet-fever. Still, however, it is by no means uncom- 
mon for persons that have had scarlet-fever, to have a sore-throat, if they be exposed 
to the infection of an individual labouring under this disease. It is by no means 
unusual for those who have about them children labouring under scarlet-fever, to 
have a sore-throat, characterized by intense redness; and that sore-throat is some- 
times very severe. Occasionally, persons who have had scarlatina formerly, or 
are recovering from it, have not only sore-throat (if strongly exposed to the conta- 
gion), but even spots like flea-bites, sometimes of a dark colour. Dr. Willan says, 
that he never saw the disease occur more than once; although he had witnessed 
two thousand cases of it. When I was a pupil, it v/as denied that small-pox or 
measles ever occurred twice; but now that there are so many persons capable of 
making good observation, cases have been sufficiently multiplied to settle that point. 

Persons are not so liable to it. — It differs, however, from measles and small- 
pox in this; — that persons generally are not so liable to it. Almost every body 
has the small-pox, unless they have had the cow-pock, and are thus prevented; but 
we find a great number of persons that never had scarlet-fever. It is common to 
find persons that never had the scarlet-fever, although they have been exposed to 
the contagion; but it is very uncommon to find persons that have not had the 
small-pox (or the cow-pock) and measles. I have, been exposed to scarlet-fever 
often enough; but I never had it; though I have hatl small-pox, measles, and hoop- 
ing-cough; and the rest of the diseases which people usually have. 

Causes. — Scarlet-fever arises solely from contagion. I use the word " confa- 
gi07i''^ in its generic sense. The disease may be caught by being near a person 
labouring under it; and therefore it is infectious. It may be caught, too, by touch- 
ing any thing that the individual has touched; and it may be caught from a second 
person. If an individual visits a person labouring under the disease, and then visits 
another, the second person visited may catch it from him. It may be communi- 
cated too, it is said, by the exfoliated portions of cuticle. It may be conceived, 
that these are so abundantly impregnated with the perspiration, as to communicate 
the disease; but I do not know, from observation, whether this is the case. It 
occurs more frequently in children than in adults; but extreme infancy is least liable 
to it; — ^just as it is least liable to measles. Being of an infectious nature, the dis- 
ease is often epidemic; but it is more prevalent at the equinoxes, than at any other 
period of the year. 

Diagnosis. — [The only diseases with which scarlatina can be confounded, are 
measles and roseola. From measles it may be distinguished by the precursory 
symptoms; by the time intervening between the first accession of fever, and the 
appearance of the rash; by llie character of the eruption; and by the sequelae. 
Measles commences with coryza, sneezing, suffusion of the eyes, cough, slight 

» See Note (r) to Page 389., 



EXANTHEMATA. 393 

dyspnoea, and other catarrhal symptoms; wliile, in scarlaiina, the first sensation of 
uneasiness is referred to the throat. The eruption in measles shows itself on the 
fourth day of the fever; but in scarlatina it may usually be distinguished on the 
second. In measles, the rash is disposed in irregular portions, of a crescentic 
form,' and is slightly elevated, — so as to be sensible to the touch; in scarlatina, the 
eruption assumes the appearance of broad patches, of an intermediate shape. The 
rash has a different tint in the two diseases; it is of a vivid red in scarlatina, but of 
a darker or raspberry-hue in measles. In scarlatina, the fever does not abate apon 
the appearance of the eruption to the same extent as in measles, the former is fre- 
quently succeeded by anasarca, inflammation of serous membranes, deposiiions in 
the joints, &;c. The sequelae of measles are principally affections of the respiratory 
organs; as bronchitis, pneumonia, croup, &c. 

Roseola is distinguished from scarlatina by the partial and regularly defined rash, 
by the absence of angina, by the mildness of the febrile disorder, and by the short 
duration of the complaint. Deep rose-coloured patches, exacdy like roseola, some- 
times appear intermixed with the rash of scarlatina. 

Prognosis.- — The only danger to be apprehended in " scarlatina simplex,''^ is the 
occurrence of some internal local inflammation, or the supervention of anasarca, 
when the desquamation of the cuticle is completed^ It must also be borne in mind, 
when scarlatina prevails epidemically, that a mild case sometimes suddenly assumes 
a malignant type. The prognosis in "scarlatina anginosa'^ is influenced, chiefly, 
by the extent and severity of the local inflammation; — bearing in mind, however, 
that there is a natural tendency in angina to terminate in resolution. A bright florid 
appearance of the inflamed mucous membrane, is a more favourable symptom than 
when it presents a dark livid aspect. But if there is excessive tumefaction of the 
throat and surrounding parts, and especially if the inflammation has extended to tlie 
air-tubes, the disease is to be considered dangerous, and will probably terminate 
fatally. In some cases of this kind, oedema of the glottis* supervenes, and rapidly 
destroys the patient. The prognosis is also unfavourable if the delirium com- 
mences, as it frequently does in children and young persons, a few hours after the 
seizure: in these cases a fatal result often ensues in the course of two, three, or four 
days. Our prognosis may often be formed from the character of the eruption. A 
bright red efflorescence is more favourable than a pale rash, or a dusky red, or one 
of a raspberry tint. When tjie eruption is partial and evanescent, or when its re- 
trocession takes place suddenly at an early stage without reappearing, there is 
much cause for apprehension. Complete desquamation of the cuticle is a favour- 
able sign. *' Scarlatina maligna''' being always attended with great danger, a 
guarded prognosis should be given. 

Of the circumstances indicating a minor degree of danger, the following are the 
more important. It is generally supposed, that children withstand the virulence of 
this disease belter than those of more advanced aae. The absence of visceral in- 
flammation, or of structural disease of any important organ, will also lessen the 
danger. A plentiful and florid eruption, a bright red colour of the fauces, and a 
disposition of the exudations on the throat to separate, universal desquamation of 
the cuticle, the pulse falling in frequency and rising in power, the breathing be- 
coming gentle and free, the countenance resuming its natural expression, and gende 
perspiration, are indications of a favourable result. 

Among the unfavourable signs are the existence of inflammation in an important 
organ, for the subduing of which active remedies cannot be employed; a dark or 
livid appearance of the eruption, more especially when intermixed with petechice; 
the sudden disappearance of the efflorescence; a small frequent pulse, uiih great 
prostration of strength; hurried respiration, not depending on active inflammation 
of the lungs; acrid discharges from tlie nose and ears; the admixture of blood in 
the urine or stools; involuntary evacuations; subsultus tendinum; hiccup; mut- 

» From yx*TT*, the tongue. 



394 EXANTHEMATA. 

teving delirium and coma; the appearance of gangrene of those parts subjected io 
pressure, or in the extremities. 

In conclusion, it may be remarked, that it is often a fatal disease when it attacks 
pregnant or puerperal women; and that it is generally of a milder character in the 
spring and summer, than in the autumn or winter months/] 

Treatment. — The treatment of this disease is, for the most part, very simple. 
If we take care to do the patient no harm, he in general will do very well. In this 
disease, cleanliness and fresh air should be particularly attended to. If the season 
will allow it, the windows and doors should be opened; and only the slightest 
covering placed upon the patient. Cold water (or something nearly as simple as 
water) is the most eligible drink. No food beyond this, except it be milk-and- 
water, should be allowed. The bowels, of course, should be kept open. It is 
said that an emetic, given early, alleviates the disease. Some are of a different 
opinion; but many contend that, at the beginning of the disease, it is very good. 

Cold Effusion. — The disease certainly has been cut short, by taking a patient 
out of bed, and pouring cold water upon him. The heat of the body is so great, 
in this disease, that no danger is to be apprehended from cold affusion. It is true, 
there are cases in which the patient is more or less chilly; but if, in this affection, 
the general rules which I laid down in the case of common fever be followed, there 
is no danger whatever, but the greatest advantage, in taking the patient out of bed 
(however hot he may be) and pouring cold water upon him. Those rules are, — 
that the temperature is steadily above 98 degrees; that there are no profuse general 
sweats; that there is no chilliness; and no inflammation of the chest or abdomen. 
I presume this would be done oflener than it is, were it not for its appearing a vio- 
lent measure to take a person in fever out of bed, put him into a washing-tub, and 
souse him w^ell with cold water. But, at any rate, no friends will object to wash- 
ing a patient with cold water. It is a great comfort to the individual; and, as long 
as it is comfortable, it should be had recourse to. Sponging the hands, arms, face, 
and trunk, with cold water, is grateful to the patient; and is an excellent practice in 
the disease. 

Bleeding. — If the inflammatory symptoms run high, it will be necessary to 
bleed in the arm. In general, it is only requisite to give the patient fresh air; to 
give him little better than water to drink, and nothing to eat; to keep him clean; 
let him have but few clothes upon him; and to keep his bowels open. But if the 
symptoms should be violent, — that is to say, if any local inflammation come on in 
the head, chest, or abdomen, — it may be necessary to take blood from the arm. 
We are not to neglect local inflammation, because the affection under which the 
patient labours is scarlet-fever. For the most part, this inflammation may be sub- 
dued by local bleeding; and it is best to remove it by that means, if we can; be- 
cause it produces less debility, than if we take blood from the arm with a sudden 
shock. It is to be remembered, however, that the case may be so severe, as to 
render general bleeding imperative. 

Relieve the State of the Throat. — The chief parts that suffer, in this disease, 
are the throat and head. The throat suffers, because it is one of the seats of the 
disease. The application of leeches around it, is exceedingly useful; — far better 
than a blister; as I shall mention when I come to speak of common sore-throat. In 
that affection, blisters are frequently very severe; but leeches afford immediate 
relief; and plenty of leeches about the throat, or about the head, are often valuable 
in scarlet-fever. The tongue may be particularly foul in this disease; and that 
might give rise to the belief that there was great disturbance of the digestive organs; 
and therefore that emetics, calomel, and remedies of that description, were par- 
ticularly necessary. But this, I think, is a wrong inference; for the tongue is one of 
the seats of the disease. It is not foul because there is intense feverishness of the 
system; but foul because it is in a state of inflammation. The papillae are exceed- 
ingly red; the tip is red; and the secretion on the back of the tongue is diseased, 

"'Library of Medicine;" Volume 1; Pages 343 and 344. 



EXANTHEMATA. 395 

both in quantity and quality. We may have, in fact, (besides the redness of the 
papillae,) just such a tongue, with respect to the dorsum, that we have when a 
person is fully under the influence of mercury; — a tongue covered with a thick, 
yellow mucus. The tongue itself is swollen. 

This state of the mouth is much alleviated, by allowing the patient cold drinks; 
or, if it be agreeable, he may have them iced; for the heat of the throat and 
mouth is very great. We continually see sloughs formed upon the throat. I 
mentioned* that it is not every thing which looks like a slough, that is one; be- 
cause the disease produces the eflusion of shreds of lymph; and they lie there as 
though it was a little ulcer; but occasionally we have dark and ash-coloured 
specks, which cannot easily be removed; and which are neither more nor less than 
so many sloughs. In the malignant form we have very considerable sloughs. 
These — whether they be mere shreds of lymph, or sloughs — are always best 
treated by gargles of the chloride of soda or lime. The more intense the gan- 
grenous tendency, the stronger must be the gargle. In ordinary cases of scarlatina, 
a gargle composed of two ounces of the common solution, to half a pint of water, 
is found strong enough. It will produce a pricking sensation, and is even some- 
limes too strong; but in other cases, where the sloughs are very considerable, we 
may employ it much stronger than this. In the merest specks of the throat, this 
is one of the best applications that can be employed. However, there is frequently 
a difficulty in the application of gargles; and then it is belter to use a syringe, and 
squirt the gargle at the throat; if any of it be swallowed, it is a good internal 
medicine, and will do no harm. I know no gargle to be compared with a diluted solu- 
tion of chloride of soda or lime; both in cases of scarlet-fever, and in cases of thrush. 

Stimuli. — If the disease show a very considerable gangrenous tendency in the 
throat, and the pulse be very soft and feeble, we have only to treat it, generally, as 
we would treat any case of typhus-fever. Among the internal stimulating medi- 
cines, which it is found necessary to give in the latter stages, sesquicarbonate of 
ammonia is the best; with the exception, perhaps, of wine; which generally 
answers better than any thing else. Patients will sometimes take a great quantity 
of wine, in this disease. Dr. Withering, who wrote on this disease, says that, in 
an epidemic which prevailed among a number of children (about twelve years 
before he wrote), each must have taken a bottle of the best port-wine in twenty- 
four hours, for several successive days. A quantity of wine is borne, on these 
occasions, which would intoxicate and destroy at other periods. The treatment is 
the same as for typhus-fever, where there is great debility, or a tendency to putres- 
cency, or mortification. 

Ammonia. — Some persons think that ammonia has a peculiar power in this dis- 
ease; and they say they have given it in every case of every description, whether 
inflammatory or not: and that they never lost a case in their lives. I presume that 
very few of the cases which these gentlemen treated, were of a malignant charac- 
ter; and that if they had merely given all the children a piece o{ sugar once in the 
twenty-four hours, still the greater number would have done almost as well. This 
is a disease which, for the most part, terminates favourably, if the practitioner does 
no harm; and a litde ammonia can do none; but, by rational treatment, it runs its 
course. more mildly; and saves the patient a great deal of suff'ering. 

Recession of the Eruption. — If the eruption recede, the best treatment is to put 
the patient into a hot-bath, several times a day: to rub the body with stimulants; 
and to give stimuli internally. But it is necessary here, as in other similar cases, 
to observe whether an internal inflammation has come on. It may be t/iat which 
prevents the patches from coming out; and, in such a case, we must be careful not 
to give internal stimuli; but rather apply leeches, to remove the internal congestion 
and inflammation. We may stimulate the surface at the same time; but the great 
point is to alleviate the internal aff'ection, which prevents the external. 

Frop/njlactics. — As this is a disease which children do not necessarily take, as 

» See Page 390. 



396 EXANTHEMATA. 

ihey do measles and small-pox, it is but fair to endeavour to prevent them from 
catching it; and, besides free ventilation and cleanliness in the house, the use of the 
chlorides may be proper, with a view of destroying the contagion. I do not know 
whether they do destroy contagion; because I have recourse, in addition, to fresh 
air, plenty of water, and cleanliness; and, as I feel it my duty to use the chlorides 
at the same time, it is impossible to say what is done by the one, and what by the 
other. 1 have nO means, therelore, of drawing a conclusion. But it would be well 
to throw the dirty linen, taken off the patient, into water in which the" chlorides 
have been introduced; to put the chlorides into various utensils which are used; 
and to sprinkle them about the room. In this way, we may possibly prevent other 
persons in the house from catching the disease. 

Belladonna. — A German physician, however, recommends a medicine for the 
purpose of preventing the disease, which appears to me of a very fanciful cha- 
racter. Dr. Hahnemann, of Leipsic, says that belladonna will prevent the disease 
He says, that if we take two grains of the extract of belladonna,* and dissolve them 
in one ounce of cinnamon-water, or pure water (which is much the same thing), 
and give two minims of this solution to a child a year old (or another minim or two 
according to the age of the child), we may prevent the disease. I never thought 
it worth while to try it; because I hardly think the observations which are pub- 
lished conclusive. I know that foreign physicians have since published accounts 
of the disease being so prevented; but it ought to be from hundreds of observations, 
that any one says the disease has been prevented; because it is an affection that will 
not attack every one in a house; and, every now and then, when the disease has 
been spreading for some weeks, all at once it will disappear, and no other persons 
have it. Inferences, theref )re, ought not to be drawn without very numerous facts, 
— numerous coincidences, well ascertained. 

Treatment of the Anasarca. — With regard to the anasarca which follows this 
disease, I have no doub^, that it frequently arises from cold; for it either bejjins in 
the face, or the face is affected as soon as any other part. It may be attributable to 
exposure to cold when the disease is over, or declining; because it is an affection 
that does not take place during the disease, but subsequently to it. Rayer con- 
demns the application of cold in the disease; because it is likely to produce anasarca. 
Now I have generally used cold ablution [not- affusion) in this disease; and never, 
when I treated the case myself, has anasarca occurred. I do not believe that, if a 
low temperature be applied properly (that is to say, when the heat of the body is 
too great), there is any danger of the patient catching cold; but if it be used when 
the patient is not hotter than he should be, or after the disease has declined, then I 
have no doubt that it would lead to anasarca. However, this anasarca- appears to 
be inflammatory; and for this reason it resembles the anasarca which is the effect 
of exposure to cold; — especially cold united with wet. It begins in the face; or it 
particularly affects the face; or it is seen in the face as soon as anywhere; and, in 
the next place, the urine is often albuminous. It will no.t merely contain albumen^ 
however, but sometimes blood. In rnost cases of anasarca which I have seen,, (and 
perhaps I have seen them only because they were intense,) there has been more or 
less internal inflammation, in the head, chest, or abdomen; — just as in acute ana- 
sarca from cold. In almost every case, it was in the chest; generally pneumonia 
or pleuritis. 

The treatment of this anasarca is best conducted by antiphlogistic means; — by- 
purging the patient well (which is an anliphlotristic remedy); and some say by 
giving digitalis;" but I know that it recedes best by purging; and by attending to 
any internal inflammation that may exist. It would be in vain to purge, in severe 
inflammation of the chest, unless we made use of leeches at the same time; ami 
the same remark applies to the head. It is important, in all these cases of anasarca 
supervening on scarlatina, to examine whether there be inflammation; for if we 

* From "bella donna" (Italian), Jine lady, — .so named from its employment by the Italian 
ladies, as a ccsnietic. 
b From "digitus/' a finger;— ivom the shape of its flower. 



EXANTHEMATA. 397 

neglect that, the anasarca will generally be tiresome, but if we treat that, it will go 
away. Occasionally the anasarca goes away of itself; but we may always expe- 
dite it by purging, or by briskly applying antiphlogistic measures, directed towards 
some internal part. I do not know whether it is mentioned by any autlior; but, 
besides, phrenitis or arachnitis, rheumatism is not an uncommon sequela of scarla- 
tina. 



SECTION VI.— ERYSIPELAS. 

The next disease which I shall describe, is one that I hardly know where to 
place;—- 1 mean erysipelas.'' Kayer places it with the rashes, because there is a 
conlinuovis redness of the skin; but VVillan places it among those which have a 
large collection of water (" bullae.")^ The truth is, this disease may exist with- 
out the formation of any secretion, — without any collection of water, or even 
watery vesicles, yet I think that, in a great number of cases, it does produce an 
elevation of the cuticle (of smaller or larger size) containing water. Upon the 
whole, it may be right to place it with the rashes; — as the redness is diffused, and 
always exists, whereas vesicles, or bullae, do not. But it is a matter of no very 
great importance. 

Essential Characters. — Erysipelas is a very intense affection; of the same de- 
scription as roseola and erythema. What roseola and erythema are mildly, erysi- 
pelas is severely. If there be a diffused redness of the skin, with heat and more 
or less smarting, without disturbance of the constitution, and without any swelling 
of any consequence, we may call it " erythema;" if the symptoms be equally mild, 
and live rash is rose-coloured, we may call it "roseola;" but if the part be much 
swollen, the inflammation ver}'- intense, the pain and heat very great, and the con- 
stitution be disturbed; — ^ihen we call it " erysipelas." It differs from erythema in 
this: — that while the inflammation of erythema may be chronic, (as in "erythema 
nodosum," or "erythema tuberculatum,'-') erysipelas is always an acute febrile 
disease; — attended with heat, swelling, pain (which erythema and roseola may not 
be), redness of some part of the skin in patches; and often united with vesication. 
The swelling is irregularly circumscribed; and is generally soft. Generally the 
redness disappears on pressure, and instandy returns when the pressure is removed; 
as in erythema and roseola. 

Progress of the Disease. — Very often, before this inflammation comes out, 
tliere is a previous excitement of the constitution; as is the case in measles and 
scarlet-fever. Before tenderness of the skin is felt, the patient may be feverish; 
or he may have headache, nausea, vomiting, drowsiness, vertigo, or tenderness of 
the eoigastrium; or he may have rigors. After these symptoms (more or fewer of 
them) have existed in greater or less intensity, for two or three days, some part of 
the skin will feel sore; and, on being looked at, it will be found a little swelled, 
and a Utile red and hot. All this increases. The skin becomes more swelled; very 
red and very hot; the patient experiences pricking or smarting pains; and the 
general excitement and feverishness are increased. Occasionally the local symp- 
toms appear first; — the feverishness taking place exactly in the same degree that 
they do; but sometimes we have the feverishness first, and then the redness appears. 
Very frequently, after a liiUe time, minute vesicles are seen here and there, in the 
inflamed part. Frequently there are no vesicles at all; and when vesicles do appear, 
they frequenUy occur only in some particular parts of the red patches. Sometimes 
they are not very large; — they are really vesicles; but sometimes they are as large 
as walnuts; and are then called "bullae" in Latin, and "blebs" in English. Tliese 
contain, at first, a clear fluid; but sometimes, after a day or so, it becomes turbid; 
and is more or less yellow. These burst, and the fluid oozes out; so that a yellow 

a From s^v(a,to draw; and -rfKac, near or adjoininc^ :—Uom its teti'Iency to affect the neigh- 
bouring parts. Its c()iniT;on designation is—" St. Anlhuny's fire."' 

b See his "Description and Treatment of Cutaneous Diseases;" Order -1; Genus 1. 



398 EXANTHEMATA. 

crust form?; — a crust which is made of this secretion dried, and the exfoliated 
cuticle. If the disease decline without forming any of these vesicles, or bullae, 
the cuticle is sure to come off, and we have a scurf; but if there be vesicles, or 
bullae, then we have crusts. Sometimes the surface imder the elevated cuticle, 
after the bursting of the bladder, secretes pus; — more or less suppuration will take 
place; and sometimes the secretion, be it pus or mere lymph, is very acrimonious; 
so that it produces great irritation of those parts over which it flows. 

It has a tendency to Spread. — This is a disease which has a great tendency to 
spread. It will sometimes spread over half the body. I have seen it spread from 
the occiput down to the toes. As it spreads, sometimes the part first affected re- 
covers; at other times it does not; — so that we then have one immense sheet of red 
colour. It is sometimes very curious to see, as it spreads along, how the parts first 
affected become well. 

Metastasis. — Now and then it will suddenly cease, and some internal p'Srt suffer. 
This change of situation is called " metastasis;" and if it only disappears in one 
part of the surface, to reappear in another, the French call the circumstance 
" delitescence;" but if an internal part be affected, it deserves the name of 
"metastasis." 

Varieties. — When it extends slowly from one part to another (whether the part 
affected recovers or not), it is called "erysipelas erraticum;^^ — wandering about. 
Sometimes there is very great swelling, and effusion of serum into the cellular 
membrane; and it is then called "erysipelas cedematodesf — being cedematous. 
Now and then, the irritation of the cellular membrane under the skin, is much 
more severe than to secrete mere serum. It is so severe as to secrete pus; and then 
it is called "erysipelas phlegmonodes;'^ — it being the character of phlegmon to 
secrete pus. When this occurs, — when the cellular membrane underneath the. skin 
becomes affected, as well as the skin itself, to a great degree, — there is extreme 
pain, extreme tension, extreme hardness. The limb feels as though it would burst; 
the patient is skin-bound; and the general symptoms, throughout the body, are 
excessively severe. Suppuration sometimes occurs only here and there; but some- 
times it is very extensive. It is by no means uncommon, in partial phlegmonous 
erysipelas of the face, to see the affection suppurate in particular spots; as, for 
instance, at the orbit. The cellular membrane under the eyelids, is disposed to 
run into suppuration; when there is no suppuration in any other part of the face. 
But, besides this local "erysipelas phlegmonodes,^^ a whole extremity will some- 
times fall into this particular state. 

Erysipelas Gangrssnosum. — The disease is very much disposed, in many cases, 
to produce mortification. Parts of the skin will often slough; the vesicles will 
become dark; and the fluid which is within them become bloody. But, besides 
that, the disease will frequently produce sloughing deeper in; and death will take 
place, to all appearance, from the gangrene. When this is the case, it is called 
" erysipelas grangrxnosum.^^ Infants are very liable to this gangrenous erysi- 
pelas. New-born infants will frequently have it about the umbilicus and the geni- 
tals. I have seen this occur without any vesication. Round the umbilicus or the 
pudendum, in young children and infants, the parts will become very red, hot, and 
hard; the red will become dingy; and then gangrene take place, and the parts be- 
come perfecUy black. In adults, this occurs very frequently in the extremities; 
but in the case of children, it is about the genitals and the umbilicus that it usually 
takes place. 

We see, therefore, that this disease, (like continued fever, or any common in- 
flammation, or like scarlatina,) runs from mere active inflammation with strength, 
on the one hand, down to the most perfect prostration of strength, and the most 
violent tendency to mortification, on the other. It is pretty evident, therefore, that 
no one mode of treatment can be adopted. 

Not confined to the Surface. — Erysipelas is by no means confined to the surface 
of the body. We continually see the throat affected. If the inner part ef the 
throat and mouth are the seat of the disease, the throat and tongue are red; the 



EXANTHEMATA. 399 

patient complains of the mouth being exceedingly hot; perhaps there is a short 
cono-h, and difficulty of swallowing-. In fact, there is a sore-throat. Very fre- 
quenllv, too, it will run down the membrane lining the tubes; so that there is a 
very severe cough, and a difficulty of breathing. We have more or less bronchitis; 
and" sometimes there is really severe bronchitis; but for the most part, it is only a 
superficial sort of inflammation; — erysipelas of the raucous membrane; and will 
go away without the adoption of any strong measures. 

Complications. — Very frequently, besides the sympathetic effect occurring at 
the beginning of the disease, there is great tenderness of the epigastrium;— the 
patient complaining of intense heat there; and sometimes the same is felt all over 
the abdomen, as if the inner surface of the intestines were in a state of erysipelas; 
and then diarrhoea occurs. I have seen the disease spread down the air-passages, 
and then down the alimentary canal. But, besides this spreading from the skin 
through the ramifications of the trachea and bronchia, and through the pharynx* 
and o35ophagus'' to the stomach, and down to the intestines, we continually see the 
membranes of the brain affected, when the head and scalp are the seat of the dis- 
ease. When the disease affects the inside of the head, (which it is much disposed 
to do, after it has attacked the face, neck, and scalp,) the danger arises from in- 
flammation of the membranes of the brain; so that, as the disease advances, we 
have extreme drowsiness. The patient complains of internal pain of the head; 
delirium comes on; and, at hist, there is more or less of an apoplectic state. 

When the patient dies with symptoms of inflammation within the head (such 
as drowsiness, delirium, &c.), I have always found, within the skull, certainly not 
inflammation, but the effects of inflammation; — effusion. I have always seen an 
effusion of serum upon the brain, or in the ventricles, or in both situations; and 
sometimes great turgescence of the vessels. 

Erysipelas of the Face. — When the face is affected, the eyes are closed and the 
features lost; — from the general swelling and effusion into the cellular membrane. 
The person becomes, in his appearance, as ill-looking a fellow as can be conceived. 
His nose is bottled, and i^ buried in his cheeks; — in fact, he looks as if he had 
been drinking hard, and had had a good drubbing. The features are set, the eyes 
closed; and there he lies; — not to be recognized by any one. I know this by m/ 
own case;— having myself laboured under the disease. My friends brought a 
looking-glass; and, on raising the upper eyelid, I took a peep at myself; but the 
sight was so abominable, that I begged the glass might be removed. 

Causes. — The common causes of the disease, are vicissitudes of temperature, 
and exposure to cold; — especially when the person is heated. But it very com- 
monly arises from some local cause; — mechanical injury, or any thing that irritates. 
It is much predisposed to by certain situations. There are certain situations, in 
which erysipelas is very common. There are hospitals, it is said, where erysi- 
pelas is more common than in others. It certainly appears to be dependent, in 
some measure, upon the season. At particular periods, in several hospitals in the 
same town, where there had been no erysipelas, the affection will, all at once, 
become very common. These circumstances may be so strong that, without any 
local irritation, patients will be seized with erysipelas; and the slightest local injury 
will sometimes cause it. Erysipelas, in these particular seasons, or in these neigh- 
bourhoods, may be followed by the most violent inflammation. Persons of bad 
constitution are also very liable to it. Those who have been in the habit of drink- 
ing spirits, or have ruined their constitution in any other way, are very likely, from 
the least injury (even from leech-bites), to fall into this disease. 

Is Erysipelas Contagious? — It is said, by some, that erysipelas is occasion- 
ally contagious. Dr. Wells (as I raentioired formerly*"), published a number of 
cases to prove it contagious.*^ It does appear that, in the cases lie mentioned, it 

* From c})s«a>, to carrij; because it conveys the food into the gullet, 
b From o:a), to carry; and 4)ay«, to eat; because it conveys the food into the stomach, 
c See Page 135. ' ^ ' ' ^ 

d In the " Transactions of a Society for the Improvement of Medical and Chirurgical 
Knowledge;" Volume 2j Page 213. 



400 EXANTHEMATA. 

was contagious. The instances were nnmerons; and they were casesof persons 
"who went to visit others who had erysipehis; and then went back, and gave it to 
oihers in their own houses. I cannot exactly say thai I have seen it contagious. 
In hospitals, I (in common, I suppose, with every other practitioner in similar cir- 
cumstances) have seen patient after patient, in a ward, become affected; but whether 
it arose from local circumstances, or from emanations spreading from one individual 
to another, Icannot tell. I recollect once having had it, five days after stooping 
down over a patient, who had the disease in so violent a form that he died of it. 
I was looking into the state of his skin; and his breath came into my face. I turned 
away with a feeling of disgust; and said, — "I hope I have not caught it;" but, five 
days afterwards, having forgotten the circumstance, I was seized with erysipelas. 
T felt ciiilly, and my head was sore; and I had the disease violently. This was in 
the winter, when a person is liable to catch cold; and therefore I am not sure that 
I caught the disease from contagion; though, , so far as I am aware, I never take 
cold. I have seen instances where the affection might have been contagious; but 
I am not sure that such w^as the case. 

Treatment.— The treatment of the disease must be totally different in different 
cases. In the country, and in young, strong, healihy subjects even in town, tliere 
can be no doubt of the propriety of taking away blood from the arm. I have often 
bled patients, and was repeatedly bled myself; and with the best effects. On the 
other hand, if a patient have a shattered constitution, either in consequence of being 
half-starved, or of intemperance, or any thing else, then we must employ bleeding 
with great caution. But still, in the greater number of cases, antiphlogistics are 
the proper remedies; though perhaps they should not be carried to a great extent. 
Purging, and the other parts of the antiphlogistic plan, are necessary. 

Cold Applications. — I have always found cold useful; and I never. saw^ the dis- 
ease recede in consequence of it, or internal disease produced by it. I employed 
it in my own case. The application of cold water, either directly, or by means of 
rags, is very uncomfortable to the patient, after a time; and as soon as this effect is 
produced, it is but common sense to leave off the application of cold. If fresh air 
can be obtained, it should be had recourse to in this, as in most other diseases. 

Local Bleeding. — Frequently local bleeding will answer every purpose; but I 
should never shrink from general bleeding, if it appeared desirable. There is 
nothing to fear from it. With regard to local bleeding, we may employ it by means 
of leeches around the part; or we may put them on the part itself. There is no 
harm in adopting the latter plan. I was not aware of this at one period; but I have 
tried it; and now I know it by experience. Some think it is more eligible to take 
away the blood by means of needles, or the point of the lancet; because then there 
is not that irritation, which is occasioned by the bite of a leech. I have never seen 
harm result from leech-bites, when they were applied around the inflamed part, or 
to the part itself; but it is said there never is any danger, if we withdraw the blood 
by means of acupuncture. There is a vast collection of blood in the erysipelatous 
part; and, by puncture, we may frequently unload it to a great amount. 

Nitrate of Silver. — We may put a stop to the progress of the disease, by the 
application of the nitrate of stiver. I have done so very frequently. If we rub 
the nitrate of silver on the healthy part around the disease, or make a strong solu- 
tion and apply it all round with a brush, we may generally prevent its farther pro- • 
gress. Some persons recommend blisters; but the nitrate of silver answers much 
better. I have stopped the disease, over and over again, by this means; and I 
should feel it right to have recourse to it, in every severe case. We .are indebted 
for a knowledge of its use to Mr. Higginbottom, of Nottingham; who has written 
a work to show the good effects of this remedy, not only around the part, in this 
way, but applied to the inflamed part itself.* It is necessary, however, that the 
application should be continuous; for if we allow a small place at which the disease 

* " An Essay on the Use of the Nitrate of Silver in the cure of Inflammation, Wounds, 
and Ulcers. By J. Higo:inboltom." Second Edition. 



EXANTHEMATA. 401 

can creep out, it will be sure to do so. I have seen cases where a portion was left 
unguarded; and I have seen the affection creep through there, and spread along the 
part. It is very important to stop the progress of the disease, if it be near the head; 
because if it should spread over the head, or even half over it, it is ten chances to 
one that we have delirium, and inflammation of the membranes of the brain; and 
the patient will die in an apoplectic state. 

Incisions. — If there be much tension in the part, there is no impropriety in 
doing something more than merely emptying it by leeches. Indeed, it is very 
important to make an incision in it, by means of a lancet; and the tension will then 
sometimes cease immediately. It is in ^' erys'ipehs p/ilegmonodes^^ that this is 
particularly required. Generally, if we take away blood, purge, starve, and apply 
cold, the disease will give way; but if there be this extreme tension, and we make 
an incision, the wound immediately stretches; — ^^just as it would if we had made a 
cut in a shoulder of mutton. The practice is now, I suppose, well established. 
Some surgeons make the incision a foot long; but others make half a dozen incisions, 
each an inch in length; — some doing it all at once; and others, as Mr. Lawrence 
once waggishly said, " by instalments." That, however, is a matter of surgical 
choice. But there can be no question, I think, as to the advantage of making 
incisions, for the purpose of letting out blood or pus; or (before pus is formed) 
merely to take off the tension, by allowing the blood to ooze from the part. 

Tr^alment of Mortification. — In case mortification is threatened or occurs, we 
have to consider whether it depends upon the violence of the inflammation. If 
the inflammation be violent, we must not, because there is mortification, give wine, 
bark, and opium; but must strive to subdue the inflammation by antiphlogistic 
means. Again: if we see or fear a sinking of the constitution, even if there be no 
mortification, then wine, porter, opium, bark, and good food must be given; — ^just 
as would be the practice in any common case of inflammation. 

In doubtful cases, when we hesitate whether to bleed and put the antiphlogistic 
plan into force, or to stimulate and support, the best plan is to apply cold effectu- 
ally; to unload the part by leeches or punctures; and to give beef-tea, milk, and 
quinina. I have never seen quinina do harm, even in active tonic erysipelas; and, 
in doubtful cases, I believe it always a safe and eligible medicine. In other cases 
of inflammation, I have thought that the time was arrived for this species of treat- 
ment, when it was not; and have been obliged to desist; but, in erysipelas, such a 
circumstance very seldom occurs. Dr. Heberden gave it as his opinion, that bark 
would not do harm in inflammation; and in a great many cases that opinion is true; 
but as to quinina, I have given it over and over again in inflammation, for some 
other reason, (for example, in ague,) and have not seen the inflammation increased 
by it; but in these cases I have always treated the inflammation, at the same time, 
by proper measures. Hence, in erysipelas, if we feel disposed, we may always 
give quinina, unless there should be vomiting; and even then, where the vomiting 
was not inflammatory, I have given it; and it has put a stop to the vomiting. 
Therefore, though this is a disease that is to be treated by decided antiphlogistic 
measures, yet it permits the exhibition of wine, bark, and porter; and though we 
adopt antiphlogistic measures, yet it does not bear those vacuations which other 
inflammatory diseases do. It sooner requires supporting measures, and a larger 
number of cases require support, than perhaps in any other inflammation. 

Bark. — Some old practitioners imagine (from having learned it in their youth) 
that bark is a specific for this disease; and in every case of erysipelas they give, 
or (as they call it) " throw in," the bark. It was at St. Thomas's Hospital that 
this practice was first established. Dr. Fordyce gave bark in erysipelas with very 
great success; and his colleagues and successors, down to within a very few years, 
all adopted the same practice, and extolled it highly. But I never fell into the 
practice of giving bark universally, without regard to the state of the patient. Very 
often there is tenderness of the epigastrium; very often there is vomiting: very 
often there is a robust constitution and a strong pulse; — in short, a decidedly inflam- 
matory state; and I could not, in my conscience, think of treating the case with 
VOL. I.— 26 



402 SQUAMA. 

bark. No doubt bark might be given, in many inflammatory diseases, v/ithoiit 
doing any harm, except so far as it prevented us from doing good; but there are 
many cases where antiphlogistic measures are decidedly required; and I could not 
bring myself to omit them. There are many gentlemen now in practice, who 
were educated under Dr. Fordyce — the principal medical lecturer in London at 
that time; and they regularly give bark in this disease. I have no doubt that a 
number of their patients get well, because many cases are assisted by the bark; 
and many cases will get well of themselves, if we do not adopt any measures 
which do serious harm. 

There is certainly a great peculiarity in erysipelas. Many cases do well, with 
little or no treatment; without those evacuations that other inflammatory diseases 
require. I have seen cases neglected, which, had they been pleuritis or enteritis, 
would have proved fatal without vigorous antiphlogistic treatment; but which, not- 
withstanding they were neglected, did exceedingly well. Erysipelas is considered 
a specific inflammation; not contagious, like small-pox; not limited in its occur- 
rence to once during life; but still altogether of a peculiar nature. It will bear 
stimulants, and bark, and nourishment, in a way that other inflammations will not; 
nor will these things do the same degree of harm that would ensue from their ex- 
hibition in other inflammatory complaints. We may omit antiphlogistic measures, 
to an extent that we dare not in other cases; and it will require on the nvhole 
(however violent the inflammation) much more moderate evacuations, an^jt- will 
bear great evacuations less easily than otiier inflammations. 

Local Applications. — Respecting local applications, I have found cold answer 
better than heat. Some practitioners sprinkle starch and other powders over the 
skin; and I do not know that it does any harm; provided the powder be of the 
lightest possible description, so as not to lie heavy on the part. If there be vesi- 
cation, it certainly is a good plan to sprinkle a litfle powder, for the purpose of 
absorbing any discharge that may have oozed out.* The oxide of zinc, or cala- 
niine-powder, either the one or the other, is as good an application as can be em- 
ployed: but this should not prevent the application of cold water; which may still 
be done bv means of cloths. 



CHAPTER III. 

SQUAMA. 

I NOW proceed to consider those inflammations which, although they are attended 
by no secretion under the skin, still cause such a disease of the cuticle, that a scale 
is produced. After those inflammations of which I have already spoken, — lichen,"' 
strophulus,*^ measles,'' (fee, — there is, for the most part, a degree of scurfy exfolia- 
tion. The cuticle is separated, more or less; either in fine grains (so as to form a 
scurf ), or in large portions. But the diseases we are about to consider, produce 
something more than a separation of thp cuticle. The latter becomes somewhat 
diseased; and lies in plates upon the inflamed spot. That is the only difi'erence. 
These thickened portions of cuticle are called " scales." Dr. Willan's definition 
Off a "scale" is, — "a lamina of morbid cuticle; hard, thickened, whitish, and 

■ a The late Dr. Fletcher, of Edinburgh, used to relate that, in an attack of erysipelas under 
which he suffered, he derived the greatest comfort from the application of blotting paper, 
to absorb the discharge. 

b See Page 369. «= See Page 3G7. 



SQUAMiE. 403 

opaque."* A ^^ scurf'' is only a little exfoliation of cuticle;^ — the cutis not be- 
coming diseased; but if the cuticle be not merely separated, but become *' hard, 
thickened, vvliitish, and opaque," then it is called " a scaled Still, however, there 
is no ulceration. There is neither pus, nor serum, nor any other fluid effused 
under the cuticle; but the cuticle is separated; and not only separated, as in com- 
mon inflammation, but thickened and diseased. In this order of diseases, there are 
three g'enera;*' and they are of common occurrence. None of them are contagious. 
They may occur twenty times during life; and are all disposed to become chronic. 



SECTION I.~PITYRIASIS. 

Pityriasis Capitis. — I shall describe pityriasis first; because the scales are ex- 
ceedingly thin, and the affection altogether very superficial. When it occurs in 
the head of children, it is called "pityriasis capitis,-''' — "dandriff of the head." 
Wlien a child's head has this disease, a fine powder falls off in all directions; — in 
fact, it is called '^ pityriasis'^ from its resemblance to bran (rti'tvpov). It is a very 
common disease of children. Now and then the inflammation under these scales 
is considerable; and then it is called " pityriasis rubra.''^ It is only worth while 
to remember that, according to the degree of inflammation of the skin underneath 
the scale, the part is either rather pale or pretty red.*^ 

Treatment. — This is a disease which lasts only for a time in children. For the 
most part, it gets well; and, I dare say, sometimes spontaneously. It is best 
treated as inflammation; — having the parts pretty well moistened, twice a day; 
keeping them exceedingly clean; and depriving the child of stimulants. Small 
doses of Hydrargyrum cum Creta, I believe, are the best internal means that can 
be used; the best, at least, that I have found. It is said, by Bateman, to be re- 
moved by antimonials, with the decoction of woods;^ but I have no faith in these; 
and I know, that the plan I have stated, answers better than any thing else. You 
may keep the parts soft by Unguentum Zinci, which is one of the best ointments: 
but it is well to know that, in diseases of the skin, ointment (however mild) may 
produce irritation. It is well to remember this; because we might imagine, that it 
was only something stimulating in the ointment that was injurious; and that a 
milder ointment would answer better; whereas it is the ointment z7se/f which pro- 
duces the mischief. I have seen the disease kept up entirely by the application of 
grease; and when the patients have exchanged it for calamine-powder, and kept the 
parts moist by rags laid on them, they have improved almost immediately. 

Pityriasis Versicolor. — Pityriasis is said to occur frequently in another form; 
but I am not sure that it is really the same disease. It occurs in young women, 
particularly about the breasts; and sometimes there are yellow patches of it on the 
neck. This disease is called by Willan^ "pityriasis versicolor;" — '•'•variegated 
pityriasis;" but Rayer does not place it under " pityriasis." Now and then there 
is a little redness, a little heat, and a little scurf. I do not believe that this varie- 
gated pityriasis is under the influence of internal medicine. At least, I have tried 
a great many prescriptions without any effect. We may destroy it by the local 
application of acids. This remedy is painful; but we may apply it to a portion of 

' " Description and Treatment of Cutaneous Diseases, By Robert Willan, M. D." 
Definiiion 2. (Page 12 of the first Edilion.) 

_ ^ " Scurf" {furfura)\ small exfoliations of the cuticle, which take place after some erup- 
tions on the skin.— Z?/-. Willan's " Description and Treatvmit of Cutaneous Diseases." De- 
finition 1 . {Pa^e 12 of the First Edition.) 

« Dr. Willan has four:— 1. Lepra. 2. Psoriasis. 3. Pityriasis, 4. Icthyo^is, (See his 
"Description and Treatment of Cutaneous Diseases;" Order 2.) Dr. Elliotson places 
Icthyosis elsewhere. 

d "See Dr. Willan's " Description and Treatment of Cutaneous Diseases;" Order 2; Ge- 
nus 3; Varieties 1 and 2; Plate 17. 

e " Decoctum Sarzae Compositum." 

f Order 2; Genus 3; Variety 3. 



404 SQUAMA. 

the affected part first; and if that be cured, and the patient has no objection, we 
may go over all the rest. It is a complaint not attended by derangement of the 
constitution; — any more than the "scurf" of children. The causes of these affec- 
tions, so far as I am aware, are not known. It may, now and then, arise in chil- 
dren from weakness; and it may be right to give tonics; — some preparation of iron 
or quinina; and good nourishment; but, for the most part, I believe the treatment I 
have mentioned (Hydrargyrum cum Creta, and mild diet) answers very well. 



SECTION II.~LEPRA. 

The two other diseases in this class occur every day. They are diseases to 
which a great number of young men and women are particularly subject; and I 
think they are more common in the latter, than in the former. These two affec- 
tions are very similar to each other; they run into each other; and, indeed, I think 
they might be considered as the same disease in different forms. 

The first of these is called "lepra."* "Lepra" does not sisrnify '* leprosy;^* 
according to the meaning attached to the ancient term. It is a different affection. 
It is by no means a loathsome disease; — consisting merely of red spots or patches 
on the skin, covered with scales. For the most part it does not affect the health, 
except so far as it may sometimes be connected with an inflammatory state; other- 
wise it is merely disfiguring and inconvenient. 

Distinctive Characters. — In the disease denominated " lepra," to distinguish it 
from " psoriasis,"^ the patches are circular, the margin is red, and elevated a little 
above the skin. The cuticle is sometimes very much thickened; and sometimes 
very white and silvery. The disease first appears in dots, varying in size from 
that of a pin's head to that of a pea; and these dots become confluent, and form 
patches. It is about the outer part of the elbow, and below the knee, that these 
are most conspicuous. We see it also about the occiput, and behind the ears; and 
it will affect, more or less, the face and the whole of the scalp. The character of 
the disease is shown more in one part than in another; and it is a good general 
rule, when investigating cutaneous diseases, not to be satisfied with looking at one 
part of the body; for the disease may be bad/y characterized at one part, and ex- 
tremely well characterized at another. It is best, in looking at cutaneous diseases, 
to examine the whole body; and, in doing so, we shall come to one part where the 
disease is so characteristic, that we may name it without any difficulty. The 
patches, in lepra, are sometimes as large as a crown-piece; and the disease much 
more frequenUy affects the extremities than the trunk; but we see it also very much 
about the head. 

Varieties. — The most common form of the disease is that which is called "lepra 
vulgaris. ^^ In this form the eruption usually assumes a circular form; the large 
patches, which are made up of an aggregation of small ones, being still more or 
less circular, and having around them a red margin, which is elevated. When 
they heal, they generally do so from the centre. This is the most common form. 
But I mentioned," that now and then, the scales are very silvery. They are really 
as silvery as the scales of a fish; and then the disease is called " lepra alphoides.^"^ 
Now and then the scales are a little dark; and then it is termed "lepra nigricans.'''' 
In other words, it is sometimes very white; and sometimes black. That will do 
as well as remembering '''•vulgaris,''^ '•'' alphoides,''^ and '•^nigricans.''^^ It is a 
great mercy that we have no other names given for the intermediate shades. 

Period of Life at which it occurs. — I do not think I ever saw this disease in 
an infant, or in a child. We seldom see the disease in patients under ten or eleven 
years of age; and even then it is not so frequent as in the first stage of adult life. 

a From xettjo?, scabby. t See Page 406. 

c See the previous Paragraph. ^prom a\<poi;, white. 

« For these three different forms of the disease, see Dr. Willan's " Description and 
Treatment of Cutaneous Diseases ;" Order 2; Genus 1; Species 1, 2, and 3j Plates 8 and 9. 



SQUAMA. 405 

From about seventeen or eijjhteen, up to thirty, the disease occurs more frequently 
than at any other period. Why this is I cannot tell. 

Causes and Duration. — As to the cause, it is very common to discover none; 
but now and then it may be traced to a person having drunk cold water, or some 
other cold fluid, when overheated. This is a common cause of lepra, and a va- 
riety of diseases of the skin which are not contagious. It is a disease which will 
last a very considerable time; — perhaps two or three years; though sometimes it 
will go off in a few monihs. It is an affection which will recur; and now and 
then there is very great tingling, and very great heat of the skin. 

Contagious? — I stated"* that these diseases are not contagious; and that is 
allowed to be the case; but, two or three times, I have met with the disease con- 
tracted, apparently, from communication with another person labouring under it. 
It has happened to me (I am quite sure twice,, if not three times) to see persons 
have lepra after sleeping with others affected with the complaint, or using their 
towel. These instances occurred in St. Thomas's Hospital. It might have been 
chance; but it so happened that a person had lepra, about a week or a fortnight 
after employing a towel which had been used by a patient affected wuh that dis- 
ease; and, in another case, a young woman slept with a female who laboured un- 
der it; and she had patches as large as a half-crown. I cannot venture, therefore, 
to say that the disease is not contagious. 

Internal Symptoms. — I always make it a rule to inquire in this, as in other 
chronic diseases of tlie skin, whether there are not some internal symptoms; and, 
in a large majority of cases, the patient complains of drowsiness, heat and pain of 
the head, and giddiness; and if we take away blood, we find it buffed, and perhaps 
cupped. This is an every-day occurrence; but it is by no means dwelt upon by 
Willan and Bateman as it should be. In fact, they were only forerunners to better 
writers on the subject. They were occupied, as historians, in pointing out dis- 
eases; rather than pointing out the pathology, or the rational mode of treatment. 
But if we make inquiry in cases of lepra, as well as of other diseases of the skin, 
we find the head affected at first, and frequently throughout the course of the dis- 
ease. There are cases where nothing wrong can be discovered about the head; 
but even there we find the irritation and tingling very much relieved by bleeding. 

Treatment. — In the treatment of this disease, it is improper to begin with any 
empirical medicine, till we have ascertained whether there is a sufficiently inflam- 
matory state of the skin, to justify the adoption of antiphlogistic measures. Many 
cases will be cured by putting persons on low diet, and bleeding them from time 
to time. I do not know that mercury is of any use. Lepra, however, is often a 
venereal affection; and so likewise is lichen; and, in such cases, we fail in doing 
good, unless we exhibit mercury. But when the disease is of a syphilitic charac- 
ter, the redness is of a coppery hue, and the spots are hard; — in consequence of 
the disease approaching to a tubercular state. When these appearances are seen, 
it is better, whatever may be the assertions of the patient, to give mercury; for, 
on this subject, patients will tell all sorts of untruths, without the least hesitation. 
The hardness of the parts, and the copper hue, are sufficient to make us suspect 
that the lichen,^ lepra, or psoriasis, is of a syphilitic nature. But when there is no 
decidedly inflammatory siate, sufficient to make us bleed the patient, or if we 
have already used antiphlogistic measures to reduce the inflammatory state, then 
other remedies may be employed; but of the mode of their operation I am 
ignorant. 

Dulcamara and Arsenic. — There are some of these remedies which, doubtless, 
deserve all the cliaracter that has been given them; and one of these is dulcamara. 
I have seen so many cases give way, under the persevering use of this medicine, 
that I have no doubt it is a remedy for the disease. A pint of the decoction may 
be given in the course of twenty-four hours; beginning with two ounces, three 
times a day, and then gradually increasing the dose. Arsenic, also, has very great 

» See Page 403. b See Page 369. 



406 SQUAMJE. 

power over the afTection. I have seen many cases yield decidedly, when a person 
took arsenic. I think that these two are, by far, the most useful remedies in the 
disease. 

Pitch. — Some mention pitch as being serviceable; but I do not know that it has 
any particular power over the afleclion. If it has, I have not observed it; though 
1 have made a patient swallow an ounce 0r two in a day. It is, however, perfectly 
harmless. 

Warm-Bath. — The warm-bath is very useful; but if there be much irritation of 
the skin, the heat is unpleasant; and then I have not persevered with it. If the 
warm-bath be used, it should be in a decided manner. The vapour-bath is likely, 
on the whole, to be more beneficial than the warm-bath; but if either of them be 
used, it should be every day, or twice a day. There is nothing- weakening in it, if 
patients do not keep themselves warm afterwards. The warm-baih is seldom used 
to the extent that is required. 

Local Applications. — With respect to local applications, many persons wash the 
surface with a decoction of dulcamara; but we often find that the tar- ointment is 
very useful. If, however, there be much irritation, it is not proper; and zinc- 
ointment is better. Tar-ointment is certainly one of the best applications that I am 
acquainted with, in this disease; — provided it is not of a syphilitic character; and 
that we have employed antiphlogistic measures, as long as the blood was buff'y and 
cupped, or the patient's pulse justified it. Dulcamara, or arsenic, should be united 
with it, as an internal medicine. 



SECTION III.— PSORIASIS. 

Characters. — The other squamous disease is called " psoriasis."* It bears a 
great affinity to lepra; and even runs into it. The difference between the two is, 
that in psoriasis the patches or spots are not circular, but more or less oblong; the 
margin is not raised; and it more frequently heals from the margin, than at the 
centre. In this disease the skin is very apt to crack; there are fissures in the skin, 
called " rhagades;'"" and there is, for the most part, much more inflammation than 
in lepra. It is easy, in a great number of cases, to distinguish between these aff*ec- 
tions. In lepra the patches are circular, the magin is elevated, and there are no 
cracks; whereas, in decided psoriasis, the spots are oblong, the margin is not ele- 
vated, and there are fissures or cracks. But in intermediate cases, it is almost im- 
possible to state, positively, whether it is lepra or psoriasis. They certainly run 
into each other. There is, very frequently, great irritation in this form of the dis- 
ease. It tingles and smarts severely. We have only, then, to discover whether 
the disease is attended by scales; and if it be, it is one of the three species to 
which I have now adverted. If it be "pityriasis," the scales are very minute, 
coming as near to scurf as possible. If the scales be thick, the patches circular^ 
the margin elevated, and there be no cracks, it is "lepra." If, however, the patches 
assume an oblong form, and there be cracks, it is " psoriasis." 

In one form, there is little inflammation, which occurs in dots; it is called 
*' psoriasis g-w//tt^«." If it occur in patches, it is called " psoriasis diffusa.''^ If any 
cause of irritation be applied to the skin, this may be aggravated. In washerwomen, 
for instance, the soap may produce this effect. Now and then it takes place, very 
locally, in the palms of the hands, or the soles of the feet; but chiefly in the palms 
of the hands; and it is then called " psoriasis palmaria.^^ The patches are oblong, 
and the margins not raised; and there are rhagades and fissures, which are so com- 
mon that we rarely see the disease without them. The more severe the inflamma- 
tion, the greater is the disposition to crack. Now and then this disease appears in 

» From 4wjrt, a scab. *> From ^nywfxt, to break. 



SQUAMA. 407 

a form like that of worms; and then it is called " psoriasis gyrata.^^^ I never saw 
this form of ihe complaint.^ 

Psoriasis inveterafa. — There is one form of the disease which might be con- 
sidered a pustular affection; namely, " psoriasis inveterata.^^ Psoriasis sometimes 
lasts a great length of time; — in fact, till the whole body is covered with scales; so 
that scarcely an inch is free from it. The disease being very severe, those cracks 
which are peculiar to it, or characteristic of it, become very large; and produce a 
degree of oozing. The irritation of the skin is sometimes so great, that it not 
merely produces a diseased cuticle, but perhaps an oozing of fluid under the cuticle; 
so that psoriasis runs into lepra, on the one hand, and into those diseases which 
are characterized by a morbid secretion, on the other. Still the cracks and the oc- 
currence of a scaly cuticle, show it to be a scaly disease. But we must look at 
these things as pathologists, and not as natural historians. 

Treatment. — In psoriasis, we shall find antiphlogistic measures, particularly 
bleeding, of the greatest use. Many cases will be cured by moderate bleeding 
and low diet. I do not know that dulcamara is of the same use in this form of the 
disease, as in lepra;*" but I have seen many cases cured by sulphuric acid, and by 
various other acids, perseveringly given. It is singular how large a quantity of 
the acids may be given. One would imagine that, being chemical substances, the 
quantity could not be increased to a great amount. It is commonly remarked how 
we may increase the dose of narcotics; but we know that the susceptibility of the 
body to any sedative agent, becomes less and less, the more frequently it is em- 
ployed; yet we should not suppose that it would resist chemical agents. We may, 
however, increase the dose of sulphuric acid, properly diluted, to a great extent; 
and I have frequently done so in psoriasis with the best effect. But what I am 
anxious to point out is, the importance of antiphlogistic treatment, in all cases of 
this description, where it is needed; and to insist on the necessity of looking out for 
inflammation. 

When the skin cracks, we sometimes find greasy applications of great use in 
softening the affected part; but, in a large number of cases, they cannot be borne. 
It is of great use, in the treatment of psoriasis, to prevent the patient from taking 
stimulants; for the disease is often kept up by stimulants taken as articles of diet. 
It is in vain to give acids, to bleed from time to time, or to give specific remedies 
(such as arsenic or dulcamara), unless the patient will submit to proper diet. If 
patients will take so many glasses of wine a day, they must expect the disease to 
be so much the worse. Alkalies, as well as acids, are said (and, I have no doubt, 
with truth) to be useful in this disease. The treatment of the disease, so far as the 
parts are concerned, is empirical. I have no idea how arsenic, and the other reme- 
dies mentioned, can act; but the treatment by bleeding (local and general), by low 
diet, and by the use of the warm-bath, is very rational. 

* From yv^o(:^ curved. 

^ For these different species of the affection, see Dr. Willan's " Description and Treat- 
ment of Cutaneous Diseases;" Order 2; Genus 2; Plates 11 to 16. In common language, 
the disease is called "dry or scaly tetter." 

c See Page 405. 



408 VESICUL-E. 



CHAPTER IV. 
VESICULiE. 

We now enter npon the consideration of those inflammatory diseases of the 
skin, which are characterized by the secretion of fluid under the cuticle. I shall 
begin with the description of those which are characterized by the secretion of a 
thin vmtery fluid: and, among these, of such as exhibit very minute collections. 
These diseases are termed " vesiculae." If the liquid be not water, but pus, the 
diseases are called "pustulae;" if the secretion be water, and the collections are 
large, the aff'ections are called "bullae." " Vesiculce" and "bullae" merely difl^er 
in point of size. The contents of a vesicle, therefore, are serous. They are also 
called "limpid;" but ^'limpid''' is an indefinite word; and it is therefore better to 
say " serous." 

Definition. — A vesicle* is defined, by Dr. Willan,'' to be " a small orbicular 
elevation of the cuticle; containing lymph [ye had better say — "serum;"] some- 
times clear, transparent, and colourless; but often opaque, whitish, or coloured." 
The serum may be quite clear, or it may be rather opaque, or purple; and such 
an eruption as this may be succeeded, either by scurf, or by a scab. If the fluid 
be absorbed, and the cuticle which is detached rub off" by degrees in minute por- 
tions, it is called " scurf;" if, on the other hand, the fluid be not absorbed, but the 
cuticle is ruptured, a "5ca6" is formed by the drying of the fluid, as it exudes. 
A scab may be formed either by serum, or by pus; therefore we may have a scab 
in vesicular diseases. A scab is defined, by Dr. Willan,'' to be " a hard substance, 
covering superficial ulcerations, and formed by a concretion of the fluid discharged 
from them." 

SECTION I.— MILIARIA. 

Characters. — The first disease among those which are characterized by a minute 
collection of watery secretion, and of wliich I shall speak as having the most minute 
vesicles, is the "miliary eruption;" called, in Latin, "miliaria." In this disease 
the vesicles are exceedingly numerous, and exceedingly minute, — about the size 
of millet-seeds (whence their name**}. There is a slight inflammation of the skin, 
and a slight rash; — sometimes a little more; and then the disease is called "r6(/ 
miliary eruption." If there be scarcely any, or what there is disappears, and there 
be only while vesicles, then it is called *'ivhife miliary eruption." Some imagine, 
that the red variety is neither more nor less than scarlet-fever. Formerly the diag- 
nosis was so imperfect, that many cases o^ miliary fever, were called scarlet-fever. 
However, if there is much inflammation, the skin will be red; if not, it will look 
white, from the number of these little vesicles. These miliary eruptions are, very 
frequently, nothing more than attendants upon other diseases. They will come on 
at an uncertain period of various cutaneous diseases. In measles,^ and in scarlet- 
fever,' we continually see a little miliary eruption. I have frequently seen it on 
the hands, in the case of acute rheumatism. This eruption is most abundant on 
the breast, neck, and back; on the face and extremities it is less copious; and it 
will appear and disappear in uncertain order. 

* The diminutive of " vesica," a bladder. 

*» See his " Description and Treatment of Cutaneous Diseases;" Definition 3; Plate 1; 
Figure 10. 

<= Definition 3; Plate 1; Figure 4. 
<i From " milium," millet. 
See Page 382. 



VESICUL.E. 409 

It is a thinff of common occurrence; and the disease is easily recognized, in 
consequence of the extreme minuteness of the vesicles. 

Progress of the Disease. — If the eruption be very copious, it is preceded by an 
unusual degree of languor and faintness, and a profuse perspiration; which perhaps 
accompanies it during the whole of its course; and which has a sour odour, or 
smells like rotten straw. There is sometimes a sense of heat, pricking, and tingling 
in the skin, before the eruption comes out; and even during its continuance. The 
vesicles at first are exceedingly small, and filled with transparent lymph; but, in 
about thirty hours, the lymph will become more or less opaque and milky. The 
tongue may be afi'ected. It may be dark and red at the edi^es: and the papillae* 
may be elongated. There may be aphthae of the mouth and fauces. The duration 
of the disease is very uncertain. It is said to last from seven to ten days, or longer; 
but crop after crop may come out, and protract the case for six or seven weeks. 

Causes. — This disease is supposed, by Bateman, to be nothing more than the 
effect of bad treatment. It was very common formerly, when lying-in women 
were kept in a heated room; when a number of blankets were placed upon them, 
thick curtains were drawn around the bed, and a fire was kept blazing in the apart- 
ment. Under all this it would have been strange if they had not sweated, and had 
a miliary eruption of the skin. It is supposed that there never was a specific dis- 
ease of this kind; but that it was the result of over-excitement of the body, when 
there was more or less feverishness. There can be no doubt, I think, that there is 
such a specific disease as " miliary /eL'e?^" besides the " miliary eruption,''^ which 
may be produced by improperly stimulating a person by heat. Formerly in this 
country, at difierent times, there was a disease called "sweating sickness," which 
was characterized by these very symptoms; and this disease now prevails, from 
time to time, in some parts of France; as in Languedoc, and Normandy. The 
disease has frequently prevailed in those places; — not sporadically, but as an epi- 
demic. These are moist places; and the disease is there thought to be (as old 
writers in this country declare it was) contagious. The fluid from a vesicle has 
been inoculated without success; but, in the places I have mentioned, people declare 
there is no doubt of its being contagious. It affects adults, and particularly women. 
It is said to prevail only between forty-three and fifty-nine degrees, north latitude. 

Progress of Epidemic Miliaria.— When it comes on in the epidemic form, it 
may (like most other diseases) be either mild or severe: so that it is divided into 
"benign" and " malignant." The " miliaria benigna'^ is preceded by lassitude; 
frequently by pain over tlie eyes, and loss of appetite; but sometimes persons go 
to bed well, and wake in a profuse sweat. Very soon vesicles appear; and they 
sweat on till they die, or the symptoms cease. Now and then, before the eruption 
comes on, they complain (as people do in this country) of a sense of heat along 
the skin; and the sweatings are so profuse, that the patient is actually steaming. 
In the violent form of the disease, all the symptoms are intense; but the stomach 
is found to be particularly affected. AVhat is called " gastro-enteritis" (an inflam- 
mation of the mucous membrane of the stomach and intestines) takes place; the 
sweats are very fostid, and the patient smells exactly like rotten straw. The erup- 
tion generally comes out on the second or third day; and continues from two or 
three days, to two or three weeks. There may be merely scurf afterwards; the 
contents of the vesicles being absorbed. Or there may be an oozing from the vesi- 
cation; and extensive desquamation may ensue. There may be violent headache, 
with giddiness and delirium. Such is the disease as it prevails in many parts of 
France. Several persoi:s, in Paris, deny that there is any such disease; — exactly 
as other people will sometimes deny the existence of things, which they do not 
happen to see themselves. 

Treatment. — The treatment of this disease, when it occurs (as ive see it) from 
the eifecl of hot regimen, or a violent inflammatory complaint, consists simply in 
keeping the patient cool; and the whole will then subside. But abroad^ when the 

* From " pappus," down. 



410 VESICUL^. 

disease prevails epidemically, — when ihey have what is called " the sweating sick- 
ness," then it is frequently necessary to take away blood, to give a patient fresh 
air, and (I should think) to sponge him well. It is also necessary to pay attention 
to the inflammatory state of the stomach and intestines; and to take especial care 
not to give any thing that will irritate those parts; — to give neither emetics nor 
purgatives. I should presume that other cases might occur, in which it was neces- 
sary to support the patient well. 



SECTION II.— HERPES. 

Characters. — The next disease of this description, is one of very common oc- 
currence; hut, as far as I know, is without any danger whatever. It is called 
*' herpes."* It is a vesicular disease, characterized by a great degree of inflamma- 
tion at the base of die vesicles. It may be distinguished from some other vesicular 
diseases, by the great degree of inflammation with which it is attended. It is a 
disease on which we are continually consulted. Patients are very much frightened, 
and fancy they have some terrible disease coming; but we may easdy quiet their 
fears. For the most part, very liule treatment is required. 

Progress of the Disease. — In most of its forms, it is an acute affection. It 
begins, perhaps, with general feverishness; and a great degree of smarting and 
tingling of the skin. The skin looks red, and clusters of vesicles then appear. It 
generally lasts from eight or ten days to a fortnight. There is not a large number 
of vesicles diffused over different parts; but they occur in clusters, and cluster after 
cluster will appear. Those eruptions which appear suddenly, on the chin (for 
example), are of this description. At first, the contents may be clear; but they 
soon become opaque and yellow. The scabs often seen about the mouths of 
children, are nothing more than herpes. Now and then it will occur around the 
whole body. 

Herpes Zoster, and Phlyctxnodes. — The patient is seized with a violent prick- 
ing, tingling, and smarting; and then there are seen vesicles, which form a cluster. 
This will go on, cluster after cluster being formed, till a belt is made. In common 
language this is called " shingles;" but in medical language it is called " herpes 
zoster.'''^ Now and then, the patient is a little indisposed at first; he has a little 
headache, and feverishness. But, frequently, there is no previous indisposition. 
The disease, when it occurs in separate clusters, is called ''\\ev}[)es phlyc/asnodes,^^" 
but when it extends round the body, it is " herpes zoster.''^ This is the only 
difference in the two forms of the disease. In that form which runs round the 
body, there is a high degree of redness, and the vesicles are larger than in " herpes 
phlyctsen.odes.^^ It can make no difference, as to the nature of the affection, whether 
it occur in clusters or mere patches. There is, at first, smarting and tingling in 
both; and when this is all over, there is great itching. 

Herpes Prseputialis and Labialis. — This disease frequently appears in a very 
local manner; for instance, about the prepuce of the male. On the pudenda of 
women, also, litde vesicles (which are herpes) will sometimes appear. They 
occur, too, about the lips and angles of the mouth; and children, from picking them, 
raise a scab; and thereby induce a sore, which lasts for a considerable time. If it 
occur on the prepuce, it is called "herpes prseputialis;^' but if it take place on the 
lip. It then receives the name — "herpes labialis.^' Moderate antiphlogistic treat- 
ment, purging, the application of cold water, and some moderate astringent powder 
(to absorb the discharge), is the best mode that can be adopted. On the prepuce, 
it is frequently mistaken for a venereal affection; and patients often go to medical 
men in a great fright. 

Herpes Circinatus. — Sometimes the patches wil 

a From Efwa;, to creep. b From i^ajj-rh^, a girdle. 

c From if-Kv-A.ta.^va.^ a -pustule. 



VESICUL^. 411 

the vesicles only on the circumference; and tlien it is called " herpes circhialiis.^^^ 
It is merely a number of vesicles spreading on the outward boundary. The great 
use of knowing the disease is, that we may not mistake it for a serious affection; — 
that we may be able to give a good prognosis.'' The patches heal in the centre, 
and are commonly round; and hence it is called, by the common people, " rmg- 
worm." The same treatment is applicable to this as to the preceding species; and, 
indeed, to every form of this disease. 

Herpes Iris. — There is one curious species of the disease, where all the colours 
of the rainbow are present; — for which reason it is called " herpes iri,5." I have 
not seen it above two or three times. , It occurs in circular patches; and each patch 
is of rather a different hue. It is generally seen on the back of the hands: and it 
occurred there in the cases that came under my notice. It is well described in Dr. 
Bateman's work. He says, — " The central vesicle is of a yellowish-white colour; 
the first ring surrounding it is of a dark or brownish red; the second is nearly of 
the same colour as the centre; and the third, which is narrower than the rest, is of 
a dark colour. The fourth and outer ring, or areola, does not appear until the 
seventh, eighth, or ninth day; and is of a light red hue, which is gradually lost in 
the ordinary colour of the skin. The iris has been observed only in young people; 
and was not connected with any constitutional disorder; nor could it be traced to 
any assignable cause." In fact, it is only inflammation of various hues. When 
speaking of inflammation in general, I said that it assumed different hues;*^ — a 
remark which is illustrated by the appearance of this affection. It is a very pretty 
sort of disease. There is no difference' in its cause from the others, and no difference 
in its treatment. Sometimes we can discover no cause for this affection; but it 
will come on after some little error in diet. There are concentric circles; — so 
that there may be a succession of these inflammations. Each of these forms of 
herpes may last a long time. 

Treatment. — There is not the least danger in this disease; and the patient would 
do well if we gave him nothing. In that species of the affection which encircles 
the body, however, I believe it is a very good plan to cut the patient off from a 
little of his diet, and to give him a gentle dose of physic. One of the best applica- 
tions to the part, is the oxide of zinc. It is well not to apply grease; for it irritates 
the part very much, but if we dust it with oxide of zinc, the fluid is generally 
absorbed, and the disease goes away. We may thus lessen the smarting-, and the 
irritation; and lessen the duration of the disease. It would go away of its own 
accord; but we may mitigate it, and give considerable comfort to the patient. 



SECTION III.— ECZEMA. 

Characters. — The next disease to which I will direct your attention, is very 
much like herpes; — so far as it is a vesicular eruption; but it differs from it, in 
having little or no inflammation. This disease is called eczema.^ The decided 
difference between the two affections is, that herpes has a great degree of inflam- 
mation, and eczema none. We frequenUy see an eruption of vesicles on the skin, 
without any mflammation; they are larger than miliaria; therefore they are not 
miliaria, but eczema; and if there be inflammation attending them, we call it 
*' herpes." That is all the difference. This eruption is very frequenUy seen on 
the neck or hands in summer. It may last only two days, or it may last a consi- 

* From " circus," a ring. 

b This variety of herpes, if it appear on the forehead and roofs of the hair, may be mis- 
taken for" porrigo scutulata;" but ihe vesicular character of the eruption, the regular course 
which it runs, and the hair not falling off, very readily enable us to distinguish it from the 
" contagious ring-worm of the scalp" (as "porrigo scutulata"": is called).—" Cyclopedia of 
Practical Medicine;'^ Volume 2; Page 422. 

e See Page 421. d See Page 74. 

e From EK^eaj, to boil out. 



412 ' VESICUL^. 

derable lime. Any irritation of the skin may produce it. Intense solar rays may 
give rise to it; and stimulatino- acrid substances will have the same effect. 

Eczema Riibrum. — The disease, how^ever, is sometimes very severe; — extend- 
ing over the wliole body, and proving fatal. Perhaps we should hardly say it was 
the same disease; however, it is so considered by Willan. 'J'his form, called 
"eczema rubrum,^^ is chiefly induced by mercury. Every now and then, when 
persons have taken mercury, they have been seized with great heat of the skin 
and feverishness. A number of vesicles, larger than the miliary eruption, have 
appeared. They have spread all over the body; the cuticle has come off; fluid 
has exuded; and the irritation been so great, as to make the patient quite wretched. 
At the sarne time, tiie mucous membrane has become affected; and there is almost 
always cough. This, however, is not all. I have seen more or less disease of the 
throat; and frequently vomiting and purging; — owing to the mucous membrane, 
which runs from the fauces down into the abdomen, having also been affected. 

Yreatment. — In this severe form of the disease, which generally arises from 
some peculiar susceptibility of the constitution to mercury, it is necessary (of 
course) to leave off that medicine. It is well to give the patient the utmost supply 
of fresh air; to open the windows and doors; and to ventilate the room as much as 
possible. The smell from the discharge is exceedingly disagreeable; and it is 
necessary to apply something to absorb it. Nothing answers better than powdered 
zinc or calamine.* The latter is exceedingly mild, and never produces irritation; — 
so that we may sprinkle the patient w^ell with it. It is also necessary to support 
the strength; to give nutritious broths, plenty of milk, frequently porter, and even 
wine. There is extreme debility of body induced; and I have seen several die 
from it. Inflammation will come on; and a difliculty arises between supporting 
the strength on the one hand, and subduing the local inflammation on the other; — 
so that we have to give, not wine or beer, but good broths; and to trust, on the 
other hand, to the depleting effect of leeches. The case is one which it is very 
unpleasant to treat; for, at^ter giving the patient the utmost support we can, — tran- 
quillizing his system by opium, and anxiously doing every thing possible, — after 
the lapse perhaps of six weeks, he dies; and it is not to be wondered at, when we 
consider the extent of skin which is in a diseased condition. It is not always 
mercury which produces this disease; but by far the most violent form is that 
induced by mercury. All the cases that I have seen, arose from that source. 
Other cases will occur, in which mercury has nothing to do with it. 

Eczema Impetiginodes. — This affection is sometimes ailended by the formation 
of a puriforra serum. The disease runs into a pustular form; and is then likely to 
be chronic, and may last a considerable time. The divisions of the disease, there- 
fore, are more or less arbitrary; for here we have a species of eczema which might, 
with equal propriety, be called " impetigo;" and therefore it is termed " eczema 
impetiginodes.''^^ There is scarcely any inflammation, compared with the intense 
redness of " eczema rubrumf^ and sometimes none at all. In this local form of 
the disease, occurring acutely, the only measure requisite is to give the patient a 
dose of physic that will do him no harm. This form of the disease is really so 
nearly allied to pustular diseases, that it will save confusion if I defer further men- 
tion of it till we come to impetigo." Every now and then we see a patient with 
vesicles in one part, and pustules in another; and therefore I thiidv it better to 
describe it under the head of "impetigo.'"' If we tliink proper, we may call it 
"impetigo eczematodes;" — just as we have " eczema impetiginodes." 



SECTION IV.— SCABIES. 

Another disease which occurs more frequently in the form of vesicles than other- 
wise is " itch." It is spoken of by Willan and Baleman as a pustular disease, and 

* From "calamus," a reed;-— so named from its appearance. 
" See Page 418. 



VESICUL^. 413 

it sometimes is so; but generally it is vesicular. Every body knows it by the 
waierv heads; and therefore it may come under the head of "vesicles." 

Parts of the Body most Liable to it. — The itch is called, in medical language, 
*' scabies;"* and occurs chiefly about the wrists and ancles, the roots of ilie thumbs, 
and between the fingers and the toes; but if it be anywhere, we are ahnost sure to 
see it about the thumb. It occurs, too, on the from of the body, on the chest, and 
in the axilla. I do not recollect having seen it in the face. These are all curious 
circumstances, and the reason of them I cannot tell; but it is far more frequently 
seen at the roots of the thumbs than anywhere else; then at the wrist; next be- 
tween the fingers, at the ancles, and between the roots of the toes; and next on 
the front of the chest. The disease is attended by an incessant itching. A Scotch 
king" is alleged to have said, that no subject deserved to have it, on account of the 
great pleasure derived from scratching the afi'ected parts. 

Its Progress and Symptoms. — ■! do not know how long the disease may last; 
it appears never to wear itself out. It is attended with no danger, except to young 
children. I have seen it excite such great feverishness in them, that if they had 
not been cured, it is possible that derangement of the alimentary canal, or of the 
head, might have been induced. If the patient scratch himself, the vesicles are 
ruptured. They then get dirty; a little blood (probably) exudes; and, between the 
dirt drying with the fluid, and a little blood oozing, we have small black heads. 
In children, we may often be mistaken as to this disease; for the irritation is such, 
that superficial inflammation to some extent occurs. Besides this, between and 
around the vesicles there is frequently common inflammation of the skin; and it 
will cause desquamation of the cuticle; so that the appearance of the disease is 
much disguised. In inf^mts, too, the intense itching makes them rub their legs 
against each other; and that occasions the disease to be recognized with difficulty; 
but by looking at the roots of the thumbs, we shall see the vesicular form of the 
disease, and ascertain its nature. 

Its Varieties. — If the eruption be of a watery character, the disease is called 
" scabies lymphatica;^^ if it be very rank, — resembling pimples, it is called " scabies 
papuliformis.^^ These distinctions are not very important. It is of importance, 
however, to know that the disease is sometimes characterized by pustules; — large, 
full, flat-looking pustules; resembling any thing but the litde vesicles which are 
seen in other cases. This is called, in common language, ''pocky itch;" and is 
well known to the common people. In refined medical language, it is called 
"scabies purulent a.''"' This is a species of the disease often mistaken; — from its 
being so unlike the common form of the affection. It occurs between the fingers, 
and at the back of the hands and wrists; where may be seen large pustules, of that 
description called " phlyzacious," attended with an inflamed base; and containing 
a thick yellow matter. When we have once seen the disease, there is no difficulty 
in recognizing it again. When there is great inflammation, we necessarily have 
suppuration induced. Even when the affection occurs in this severe form, it is 
generally found that, in other parts of the body, the vesicles are very small. It is 
only where there is great irritation, that this pocky form of the disease occurs. 
The general rule I formerly laid down,*' is here applicable; — that by looking all 
over the body, we shall see the true form of the disease, in some part or other. 

Occurring after Fever. — It is very common for itch to take place after fever. 
I have frequently seen this occurrence; but whether it came on spontaneously, or 
whether contagion had been applied before the fever occurred, I cannot tell. The 
lymphatic form is that which generally occurs in such cases. 

Causes. — Some have imagined that this disease arose from a small insect; but 
that is only a part of the doctrine, that all contagious diseases depend upon ani- 
malcules. Some deny that there is any insect; some declare that they have picked 
an insect out, and seen it through a microscope; but others declare that they never 

• From " scabo," to scratch. ^ James the First of England, 

e See Page 404. 



414 VESICULJU. 

could do so.* Though this is not a dangerous disease, yet it is a very troublesome 
one; and is held in great abliorrence. If we tell parents that their child has got 
the itch, they hold up their hands as if it had got the plague. 

It is Contagious. — This is a contagious afiection. The two last diseases which 
I have described (eczema'' and herpes*") are not contagious; but the itch is very 
much so. It is, however, contagious in the limited sense of that word; — it cannot 
be communicated by the atmosphere. We may go as near to a patient labouring 
under itch as we please, without the least fear of imbibing the affection; provided 
we neither touch nor handle him. But the itch is not so easily caught by contact 
as might be imagined. I have frequently touched people, — taken them by the hand 
or wrist (not knowing that they laboured under the itch), without catching it. I 
once caught the affection; but then I was a little boy, and obtained it from the 
nursery-maid. By washing my hands after touching patients, I have always es- 
caped contracting the disease. It is only by remaining in contact for some time, 
by sleeping with a person affected with it, or using something that the patient has 
touched for some time, that there is any chance of catching it. It is more com- 
monly caught by sleeping with a person labouring under it, than by any other 
means. It is common for working men who come to London, and sleep in beds 
where the sheets have not been changed, to catch the disease. It is very common, 
also, among children who sleep together. It is said that this disease is sometimes 
caught from brutes which have the mange. 

Treatment. — I need scarcely say that the great remedy for this disease is sul- 
phur; but why, no one can tell. I do not believe that it has any eff'ect when given 
internally. When I have employed it externally, I never found the cure accelerated 
by its internal exhibition. It may be employed in the form of vapour; or by means 
of baths, or in unction. In the latter form it should be rubbed in night and morn- 
ing; and if a person do that, he will soon get rid of the disease. Some employ 
sulphur-baths. Some have impregnated water with sulphur; and say they have 
cured the disease in that way rapidly, and in a more pleasant manner than by rub- 
bing in the ointment. It is said by some, who have had great experience in the 
disease among the lower orders, that it is more readily cured by what is called 
"sulphur viviim,^^ than by pure sulphur; if so, it is probably from the acrid mat- 
ters which the former contains. If there be no great inflammation of the skin, 
the sulphur produces more effect if we add hellebore, or some stimulating sub- 
stance. If the " sulphur vivum" answer better than pure sulphur, it is on account 
of some stimulating property. 

[Scabies never tends naturally to a cure, but may last for years. The treatment 
consists in destroying the acarus as soon as possible. According to experiments 
made by M. Albin Gras, a concentrated solution of the hydriodate of potash kills 
this insect in the shortest time. It lives sixteen hours in vapour of burnt sulphur; 
three hours in water; two hours in olive-oil; one hour in the acetate of lead; one 
hour in pulverized brimstone; three quarters of an hour in lime-water; twenty 
minutes in vinegar and spirits of wine; twelve minutes in a solution of sulphuret 
of potash; and only from four to six minutes in a solution of hydriodate of potash. 

* The immediate cause of the itch is now ascertained to be the presence of an insect, — 
the " acarus scabei;" — at least, the existence of this insect is now placed beyond doubt by 
the recent researches of M. Renucci; which confirm the former assertions of Avenzoar, 
Hafenreffer, Bonomo, Cestoni, Ingrassia, Joubert, and Moufet. The acarus is to be ibund, 
not in the vesicle, (as Gale asserted, and thus misled observers,) but at the end of a small 
reddish furrow, sometimes straight, sometimes crooked, about two lines in length; which 
begins at the vesicle, and finishes with the insect, A minute subcuticular spot is often per- 
ceptible near a distinct vesicle: on raising the cuticle with a pin, a small white corpuscle, 
which moves when lifted with the point of the pin, becomes visible; this is the acarus. 
The serosity contained in the vesicles does not appear sufficient to produce the itch, -whilst 
the acarus immediately produces the vesicles; but it yet remains to-be explained, why the 
itch is so easily caught by only touching the hand of a person infected with it; for it is 
difficult to extract the insect furrowed under the cuticle. — '^Library of Medicine;'^ Volume 
1; Page 885. 

» See Page 411. « See Page 410. 



VESICUL-E. 415 

The ointment of this latter substance, in the proportion of about half a drachm to 
an ounce of axunge, may therefore be considered as the best application to ihe 
affected parts. Half a drachm of the sulphuret of lime, mixed with a little olive- 
oil, and rubbed upon the palms of the hands twice a day, for ten or fifteen minutes 
each time, proves also an efficient remedy. Helmerich's ointment — composed of 
one part of the subcarbonate of potash, two of sublimated sulphur, with eight of 
axunge — generally effects a cure in ten or twelve days. The sulphur water-bath 
generally proves effectual in about twenty-five days, on an average. Tlie fumes of 
the sulphur should be avoided: they may, however, become a useful auxiliary in 
aged persons. Should much inflammation occur, or if vesicular or pustular erup- 
tions complicate the itch, all irritating frictions must be suspended, and tepid emol- 
lient baths employed. Even after the cure is effected, a few tepid baths will be 
useful. 

To disinfect the \voollen clothes of patients, they may be subjected to the fumes 
of sulphurous acid gas; — easily procured by the ignition of a rag dipped in melted 
sulphur.^] 



SECTION v.— POMPHOLYX. 

Classification. — The last disease which we have to consider, among those that 
are characterized by vesitication, is what is called "pompholyx'"' (" water-bleds"). 
"VVillan places this "disease in a separate order;'' and so does Rayer; while the only 
real- difference is that, in those of which we have been speaking,* tlie vesicles are 
very small; while here they are very large. I cannot myself see the reasonable- 
ness of making a distinct order of diseases, when the symptoms are precisely the 
same, and the only difference is a difference of size. One might as well call a 
tumour by one name if it be as big as a nut, and by another if it be as big as the 
head. However, if the vesicles be very large, they are called " bullae;"^ and be- 
cause there are sometimes large vesicles in erysipelas, Willan and Bateman have 
placed that disease in the order " bullae;" but as there are frequently only small 
vesicles (and indeed vesicles do not appear essential to erysipelas at all), 1 have 
considered it, as Rayer does, under the order " exanthemata."* 

Characters of. — When there is a very large elevation of the cuticle, — a large 
coUectionof water, the disease is called "pompholyx." A vesicle appears on the 
skin out of health; which, instead of being small, as in eczema,' — is large; and 
sometimes there is inflammation with a smarting and tingling sensation round it, as 
in herpes.^ AVhen it breaks, an excoriated surface is exposed; and a scab is formed 
of the fluid and cuticle together. 

Causes. — It was imagined, formerly, that there was a particular fever attended 
by aii eruption of large bullse; and it was denominated "pompholyx;" but it is 
now doubted whether there is a distinct fever of that description. In common con- 
tinued fever, and in other fevers well known, there may accidentally be a large 
bullae— just as, in other cases, there are vesicles not larger than a millet-seed (miliary 
vesicles''). However, this disease — which is characterized merely by large blebs 
of water upon the skin — is not very common; and yet it can hardly be called un- 
common. 1 may, probably, have seen about twenty cases of the disease. In 
many instances, it is really nothing more than large " eczema,"* or large herpes."*^ 
All at once, a person will have one of these on his face or head, or both; and be 
much frightened. Here there must be something more than an inflammatory' 
state; because I have treated them with antiphlogistic measures, and have failed 
entirely. 

» " Library of Medicine;" Volume 1; Page 386. 

^ From TTOfxtpQi, a bladder. c Order 4 (" Bullae")- 

d Miliaria (Page 408); Herpes (Page 410); Eczema (Page 411); and Scabies (Page 412), 

e From '-bulla," a iwMZe. f See Page 397. "s See Pages 410 and 411. 

h See Page 408. ^ See Page 411, ^ See Page 410. 



416 VESICULiE. 

Pathology. — [The pathological condition giving rise to this form of eruption, 
consists (as far as has been ascertained) in an inflammation of the rete mucosum^ 
or upper surface of the cutis; by which a more copious secretion of serous fluid 
takes place, than can be transmitted by the cuticle, — thus causing its separation and 
elevation. In proof of this we may mention, that the rete mucosum remains ad- 
herent to the cutis; and is not detached with the cuticle; — as happens when this 
latter is forcibly torn ofl". The inflammation which gives rise to the formation of 
bullae, may also be considered to exist in a higher degree than in erythema; for a 
higher degree of irritation converts erythema* into bullae.''] 

Varieties. — Bateman describes three varieties of this affection: — 1. "Pompholyx 
Benignus.^^ There is no great harm in that. 2. "Pompholyx Solitarius'^ — be- 
cause there is only one. 3. "Porapholyx Diutinus^^ — because it is chronic. It 
is almost a pity to make these names; for who would conceive that there was 
much difference between " pompholyx benignus^^ and solitarius?'''' If it be "soli- 
tarius," it is likely to be " benignus;" and it is not easy to see why sometimes it 
should have one name, and sometimes another. It is well to recollect, simply, 
that the disease may come on with only one vesicle; or that there may be several; 
and it may last for a short time only, or for a long time. It is very properly 
called " diutinus;" but we might as well call many other inflammations by the 
same term; for many last for a long time. I do not know why the term "• chroyiic'^ 
should not be employed. Remember, then, that large vesicles on the skin, occur- 
ring as an idiopathic affection, are called "pompholyx." Sometimes there is only 
one of these bullae; and sometimes a succession of them; and persons will have 
them month after month. I have seen all these forms of the disease. A patient 
in the hospital for some other complaint, all at once, has a great bleb on his foot; 
and we have only to prick it, and away it goes. There is no other treatment 
necessary. But "pompholyx diutinus''^ is a very obstinate sort of complaint; and 
I never saw any thing do good in it. I have seen it occur under two forms; — the 
one in a worn-out constitution; where bleb after bleb appeared on the skin, which 
cracked and oozed like a sore; and then, when the body was one mass of these, the 
health gave way, and the patient died. In the other cases which I have seen, it came 
on in regular succession. I recollect the case of a woman who, once a month, had 
some large bullae on her face. They were attended with considerable smarting. 
The fluid which oozed from them, produced inflammation wherever it went; it 
then dried up; and the cuticle healed. 

Treatment. — That form of the disease which occurs in a worn-out constitution, 
requires to be treated by soothing measures. We must exhibit opium and mode- 
rate astringents; sprinkle calamine (to suck up the discharge); and support the 
patient well, by means of wine, bark, and good nourishment. In other cases, where 
there is no debility, we should attempt to treat the patient on antiphlogistic princi- 
ples. I did so in the case of a woman, where the disease came out once a month; 
but the success was very limited. The irritation certainly was diminished; but 
the eruption came out again. By looking out for local disease, and attempting to 
tiure it; applying the warm-bath; and, if any phlogistic state of the system occurred, 
taking away blood, — we should be doing what reason dictated; but more than that 
I cannot say. 

* See Page 375. ^ " Cyclopaedia of Practical Medicine;" Volume 1; Page 334. 



PUSTULE. 417 



CHAPTER V. 

PUSTULiE. 

We now proceed to another order of diseases of the skin; in which the secretion 
that takes place under the cuticle, is pus.* Several important diseases are found 
in this order. There is one, for the most part, of a chronic nature; — "impetigo."* 
There is another like that I have just mentioned; only it is contagious; — " porrigo."" 
Then there is another, called " ecthyma;" and there are also " co?i'-pox," ^^ chicken- 
pox," and "sma//-pox." Thus we see that, except in tlie formation of pus, there 
is no agreement among these diseases. Some are acute, and some are chronic; 
some are simple diseases, and some are contagious; some of these contagious dis- 
eases occur but once during life, and others occur frequently. Porrigo may occur 
over and over again; but small-pox, as a general rule, does not occur more than 
once. 

a. Chronic Pustular Eruptions, 
SECTION I.— IMPETIGO. 

Characters. — The first disease of the order " pustulae," of which I will speak, 
is called " impetigo." I speak of it first, because it is closely connected with 
eczema.** Eczema, which is for the most part a chronic disease, is characterized 
by small watery vesicles; and frequently, instead of clear lymph, the fluid is almost 
puriform. Sometimes it is altogether puriform; and, in this latter case, we call it 
♦' impetigo." The two diseases run completely into each other.^ Neither eczema 
nor impetigo is in the least contagious. We may touch or sleep with a person 
labouring under them, or inoculate with the fluid; and no disease will arise from 
it; — at least, nothing more than irritation. 

Varieties. — This disease will occur, sometimes, in circumscribed patches, — ^just 
as in the case of herpes;^ and then it is called ^^ impeiigo Jigurata;^^^ and frequently 
there is inflammation around, — as in herpes. ^ Now and then the afl'ection is very 
much extended over the surface; and is called "impetigo sparsa^' ("sprinkled"). 
Now and then there is a thick scab; and then it is called " impetigo scabida.^^ The 
aflfected parts look like the bark of a tree; only it is not a diseased cuticle, but 
a real scab formed of dry pus. Now and then there is so much inflammation 
around, that it is called "impetigo erysipelatodes;^^ and, occasionally, there is such 
irritation, that it is denominated "impetigo rodens^^ ("gnawing.") It is only worth 

* Pustules are divided into four kinds; according to their size and figure. If a pustule 
be small and conically pointed, it is called "achor/' " Achor" is said to take its name from 
a)(yrt, bran; — on account of the branny scales thrown oflfin the disease; but probably (as sug- 
gested by Blanchard) it is derived from a, without, and x'^i'^fj space; — owing to the small 
size of the pustules. If, on the other hand, it be small, but flat, it is called "psydracium" 
(from 4u5'fa^, a small blister); if it be larger, and have a sort of cellular appearance, it is 
called " favus" (" a honeycomb"); but if it be a fat, large, well-fed pustule^ with an inflamma- 
tory base around, it is called " phlyzacium" (from <p\v^aij to injiame). See Dr. Willan's 
" Descripiion and Treatment of Cutaneous Diseases;" Definition 10; Plate 1; Figures 13, 
14, 15, and 16. 

b " Running Tetter." c " Scald-Head." 

d See Page 411. « gee Page 412. 

f See Page 410. s See Page 410. 

* This variety occurs most frequently on the face, and is identical with that form of 
eruption, known as crusla lactea, and confounded by some with the porrigos, but eniirely 
distinct from true contagious porrigo, according to Biett. T. S. 

VOL. I. — 27 



418 PUSTULJE. 

while to remember, that it may occur in clusters; that it may occur with scabs, 
with a great deal of inflammation; and that it may occur with ulceration. I men- 
tioned that, now and then, the fluid is watery, here and there, instead of purulent; 
and then it is called "eczema impetiginodes;"* and as there is pus in other parts, 
we shall be justified (if we think proper) in calling it "impetigo eczematodes."* 
These are the same diseases; only, according to the severity of the irritation, we 
have either pus or water poured out. 

Kind of Pustule in Impetigo. — In the disease that I am now describing, the 
pustules are small; — just as the vesicles are small in herpes.'' They are of the 
kind called " psydracia." It is of some use to remember this variety of pustules; 
because one disease has one species of pustule, and another a different kind. 
When the itch has pustules, they are of that description called " phlyzacia." The 
names given to these pustules are very hard words; and it would have been well 
had some others been devised; because it is sometimes difficult to distinguish the 
pustules of porrigo from these; and the difference in the pustules, is the principal 
means of diagnosis. 

Parts which it attacks. — This disease, which is easily recognized, — on account 
of its being a pustular affection, and being characterized by the formation of pus 
in small flat pustules, — occurs particularly on the extremities. We continually see 
both men and women with this disease on the front of their legs; sometimes run- 
ning all around, and sometimes upon the arm. If it be not properly treated, it 
will sometimes last for a very considerable lime, — even for years. Sometimes 
there is a great degree of inflammation attending it. 

Treatment. — The best mode of treating the disease, and the one that I have 
adopted, has been to regard it as an inflammation; — taking blood from the arm; 
applying leeches around the inflamed part, applying cold water, as long as that 
was agreeable; and then exchanging it for warm, and exhibiting mercury. This 
is an aflection, in which, I am sure, a moderate use of mercury is necessary. All 
this, however, will be of no use, if the patient do not limit his diet. If he do 
not leave off" wine and beer, and in some cases meat, the disease will not go away. 
It is a disease which, if not well treated, is exceedingly obstinate. If we adopt 
the plan I have laid down, although we may not eradicate the disease, yet we 
shall lessen it to a very g^reat degree. 

Local Treatment. — The chlorides are sometimes useful, and likewise the yel- 
low-wash; but I have frequendy seen them irritate the part. Altogether, the best 
local treatment is the application of some absorbent powder, (such as calamine or 
oxide of zinc,) and the constant application of cold or warm water. In the case 
of the leg, it is indispensably necessary that the patient should keep it, as much 
as possible, in a recumbent posture; — ^just as he would do in any other inflamma- 
tion of the lower parts of the body. In the way of medicine, I am quite sure that 
mercury, exhibited very gently, is exceedingly serviceable. 

Treatment of Impetigo Eczematodes. — In that form of the disease which is 
the link between impetigo and eczema,^ the treatment would be precisely the same. 
We frequendy see eczema of this kind behind the ears; running over the face, and 
down the neck; sometimes attended with a discharge of water, and sometimes 
with a discharge of pus. In fact, it may be either eczema or impetigo. When 
there is merely eczema, there is a great deal of scurf upon the part; so that when 
the secretion is stopped, the patient looks almost well; and then, when the part 
begins to run again, we have the neck looking moist and nasty; and having quite 
a diff'erent appearance. Whether it is eczema or impetigo, I believe antiphlogistic 
treatment, with the moderate exhibition of mercury, and the application of an 
absorbent powder, answers far better than any thing else. 

Impetigo cannot be mistaken for any thing else except eczema; and they run 
very much into each other. It is a common disease. We cannot go into an hos- 
pital, without seeing cases of it. We might almost as well give diff'erent names 

b See Page 410. 



L. 



PUSTULE. 419 

to rheumatism, if it ran down one shoulder, or occurred in hoth shoulders, or in 
one shoulder and one knee, as give different names to many of these cutaneous 
affections. It is very well to mention that they may occur in this way or that 
way; but to give them distinct names is quite absurd. In Plate 38, in Bateman's 
work, there is a representation of the disease called " porrigo;" which representa- 
tion is nothing more than one of eczenia; and the same may be said of the repre- 
sentation of "psoriasis," in Plate 1 1, Figure 2. If there be a watery discharge, 
it is called " eczema;" if it be matter, it is called " porrigo." Psoriasis,* ecze- 
ma/ and porrigo,*" run into each other. 



SECTION II.~ECTHYMA. 

Circumstances favoxiring its Occurrence, — I now proceed to describe another 
disease, which also is not contagious; and is characterized by pustules called 
" phlyzacia;" — the large, round, well-fed pustules, with an inflamed base.*^ This 
is a disease which frequenUy takes place in a bad habit of body. The disease 
which I last mentioned (impetigo) takes place, occasionally, in a cachectic state of 
the system; but frequently it takes place in persons who are in other respects very 
well. The disease which I now describe, (ecthyma,)^ is one which commonly 
occurs after small-pox, measles, and scarlet-fever; and now and then after syphilis. 
Occasionally, I believe, it is itself syphilitic. 

Characters. — It is characterized by pustules which are all distinct. In impetigo 
the pustules cluster; and when they are aggregated, they sometimes form clumps 
or clusters; and now and then they are diffused over a great extent. But in ecthy- 
ma, the pustules are all pretty distinct, and sometimes very large. "Without know- 
ing any thing of his history, we might think that the patient had small-pox. We 
continually see this affection in patients in the venereal wards; — it having come on 
in consequence of taking mercury. The pustules are all distinct, large, circular, 
and full of matter; not flat on the top, but globular. I have seen cases exactly 
like small-pox; and indeed I once knew a case sent to the hospital for small pox, 
raerely in consequence of the resemblance of the pustules. Now and then the 
♦pustules are remarkably large. When I say they are "/?///," I mean they are 
distended. Whether they be large or not, the discharge concretes into a dark- 
coloured scab. I recollect having had this disease when a child; — for I have had 
a taste of most diseases. I remember being very scabby for many months; — so 
that I was quite ashamed to be taken out for a walk. It is a disease which lasts a 
considerable time. Persons who say they have merely had gonorrhoea, frequently 
have an eruption exacfly of this description. 

Diagnosis. — It is very easily recognized. In the first place, there are pustules; 
therefore the affection belongs to the order " pustulae."^ We also see that they 
^re phlyzacia;^ that all of them are distinct; and that some of them run into scabs. 
For the most part they are not very numerous; but, when they are small, they may 
be so. In impetigo^ they are circular, and not so distended; and have little flat 
tops. Sometimes in impetigo, they will congregate into one large mass; but in 
ecthyma the scabs are all distinct, though they may be large. 

Varieties. — One of the varieties of this disease is called '* ecthyma vulgare;''"' 
and it certainly gives a person a very ^'ulgar appearance; but if it be a little darker, 
it is called " ecthyma luridum.^^ (If lepra be dark, it is called " lepra nigricans ^""^^ 
and it is a pity that the same adjective is not employed here.) If it occur in chil- 
dren, it is called " ecthyma irifantile.^^ We might as well apply a separate epithet 
to measles, accordingly as the affection occurred in infants or adults; — but this 
fondness for subdivision runs throughout Willan's arrangement. I mentioned that 

=^ See Page 406. »> See Page 411. « See Page 421. 

•» See Note (a) to Page 417. <= From «xfly«, to break out. 

' See Page 417. e See Note (a) lo Page 417. 

^ See Page 404. 



420 PUSTULE. 

the disease generally occurs in a bad habit of body; and if it take place in a very 
bad habit, it is called "ecthyma cachecticumy It will now and then occur (as 
is the case with almost all cutaneous diseases) with a sharp inflammation; and may 
last for a short lime; — just like herpes," or some other inflammations which pro- 
duce mere serum, or which cause no secretion at all, but constitute a mere redness. 
They begin with inflammation of the skin, and feverishness; but the result of this 
disease will be suppuration. For the most part, however, ecthyma is a chronic 
affection, and lasts a considerable time; — the patient being very much out of health. 
Treatment. — In these circumstances, the most eligible treatment is to strengthen 
the patient, in the best mode we can. Allow him wine, porter, meat, and fresh 
air, every day; and the warm-bath. If there be strength enough, I know that the 
employment of the coW-bath is very good. I would use the cold shower-bath in 
cutaneous diseases, when the patient's strength is able to bear it. Very frequently 
the disease is syphilitic; and, although the body is feeble, we find it necessary to 
give mercury, as well as to employ tonic medicines. Because we give mercury, 
it is no reason why we should not strengthen the patient, as much as possible. It 
is frequently a good practice to allow wine, porter, and meat in abundance; and to 
give tonics, — such as wine and bark; while, at the same time, we employ mercury. 
Sometimes we may alternate them. 



SECTION III.— RUPIA. 

Analogous to Ecthyma. — This disease* very much resembles ecthyma; and, 
indeed, it appears to me to be exactly the same; but it is placed by Batenian in the 
order " vesiculae,'"" merely because the disease is serous instead of pustular; and 
Kayer places it in the order "bullae," because the vesicles are large. It is called 
" rupia." It occurs in the same circumstances as ecthyma; the secretion soon be- 
comes purulent; and, after a time, there are the same large black scabs; and no 
one could then tell whether the disease was rupia or not. For the sake of consist- 
ency, it may be necessary to make two diseases of these; but I am satisfied that 
rupia is nothing more than ecthyma; — that they are varieties of the same affection. 
All that is necessary to be remembered is, that ecthyma sometimes begins with 
serum; which soon becomes thick and turbid. There is another reason for making 
the two the same. In rupia there is frequently a scab, which becomes conical; so 
as to have exactly the shape of those shell-fish which stick to the rocks. This 
form of it is called " rupia j9row?i?2ens." In ecthyma there is frequendy the same 
occurrence; the scab will assume exacfly the same appearance; and the treatment 
of the two diseases is exactly the same. I cannot but think it trifling to separate 
them in this way. Although Rayer finds fault with Willan for subdividing these 
affections, yet he is over minute himself. 

Characters. — The aflection will occur in little children, particularly if they 
have been thrown out of health by measles or small-pox; and sometimes it will 
even occur after cow-pock. The vesicles are circular, with inflammation around 
them; and they have a black scab. They are distinct, too (just like the pustules 
of ecthyma**); and they are globular; only the contents are watery. Where the 
disease has been purulent from the beginning, I have seen dark scabs. Rupia is 
as frequently syphilitic as ecthyma; and just as frequenUy requires mercury. I 
would put ecthyma and rupia together; — ^just as I would put together lichen and 
strophulus,^ erythema and roseola:^ and just as I would make no distinction- be- 
tween the orders " vesiculae" and "bullae."^ I would have some one word to sig- 
nify all the eruptions comprehended in those terms; from the size of a millet-seed, 
to that of a hen's egg. There are two kinds of rupia: — " rupia simplex,''^ and 

» See Page 410. •> Deriving its name from ^vTeoq, filth. 

<- Order 5. ^ See Page 450, ~ " 

f See Page 375. e See Page 408. 



PUSTULE. 421 

** mpia ;)romine??s;" but it is quite enough to recollect the word "■ rupia.'''' It is 
a very commou affection. 

Treatment. — When this affection occurs in adults, they require support; and 
now and then we have to give mercury. With respect to local applications, I have 
never seen them do any good. The parts should be kept clean; and, when the 
scales come off, it is well to use a dressing of oxide of zmc, or Unguentum Hy- 
drargyri. 



SECTION IV.— PORRIGO. 

The next disease that I will mention, and which is also a chronic affection, is of 
a contagious character. The three last mentioned diseases (impetigo, ecthyma, 
and rupia) are perfectly free from contagion;"" but there is another, — a chronic dis- 
ease, called " porrigo," which occurs particularly in the head; and is one of the 
most contagious diseases of tlie skin. 

Characters. — In porrigo, the pustules are different from what they are in the 
two former diseases. In impetigo they are little pustules, and flat;'' in ecthyma 
they are large globular pustules (phlyzacia);° but in porrigo (or "scald-head," as 
it is sometimes called) they are either small, with pointed tops; or large and flat; — 
that is, they are either acores*^ or favi.* I have no doubt that many diseases which 
occur in the head, are called " porrigo," which are not. I think I have seen 
enough to justify the opinion, that many cases of eczema are called "porrigo."® 
But this disease, though it usually affects the head, may occur in various parts of 
the body. 

iL is Contagious. — The disease is contagious, but not infectious. It is com- 
monly caught by children sleeping in the same bed, rubbing their heads upon the 
same pillow, or wearing the same night-cap. Frequenfly it is caught at school, 
by children putting on each other's hats or caps. Drinking out of the same mug, 
or giving a kiss (if any one could be tempted to do so) would, I should think, com- 
munica'e the disease. 

To show how very contagious these diseases are, I may mention the case of a 
barber, who had a child with a scald-head, and who kept a razor specially for 
shaving it. One day, by mistake, he shaved himself with it; and, although he had 
washed and stropped the razor well, and (like a true barber) put it into hot water 
first, yet, in consequence of using it to his own beard, the disease came out upon 
his chin, about a week afterwards. I saw it distinctly; and he told me the history 
of the case. Small circular pustules came out. We cannot too strongly impress 
upon the minds of people, the necessity of a child's dress being kept isolated in 
this affection; lest the disease should spread. 

Varieties. — It sometimes occurs in distinct patches, and is then called " porrigo 
scutulata. ''^^ Now and then it occurs, with a great deal of inflammation, in dis- 
tinct pustules, — not clustering together so muc!i; and, these pustules being favi,* 
it is called " porrigo/«uo.s«." Sometimes it has dry laminated scabs, of a yellow- 
whitish colour, containing a white scaly powder; and, from their resemblance to 
lupin-seeds, it has been called "porrigo lupinosa.''' In this form of the affection, 
the pustules are often very dry. The patches are full of hard grains, which are 
found to contain a great deal of lime; so that an earthy secretion takes place. They 
are not litde globular pustules, but large and flat; and therefore they are called 
" favi."** A variety is mentioned by Bateman, under the name of " porrigo /?/r- 
furansf' — where there are no pustules, but laminated scabs. I believe this is 
nothing more than eczema;" and I do not think it at all contagious. 

Porrigo Decahans. — This disease will sometimes occur without an eruption; 
so that we have an affection classed with those that are pustular; in which, never- 



» See Pages 417 and 419. ^ See Pase 418. <= See Page 419. 

d See Noie (a) to Page 417. « See Page 419. 

' From " sculeilura," a little shield. e See Page 411. 



423 PUSTULE. 

theless, there are no pustules; but this inconsistency we cannot avoid. The hair 
will sometimes drop off here and tliere in patches, leaving- the surface smooth; and 
this disease is said to be contagious. It is a very common affection; and is called 
" porrigo decalvans.''^ I believe it is very common in the West Indies; and I have 
seen it in children who have come from thence. It is said to spread in schools 
(just like the other forms of porrigo) from the children wearing each other's caps. 
There is a doubt as to whether this should be called "porrigo." The skin is 
smooth; and I am sure, in many cases, this is the entire disease. Here is baldness 
without any reference to pustules, or vesicles, or an inflammatory affection. Some- 
times half the head will be bared in this way; and sometimes the whole head. I 
once had a little patient, whose head was becoming perfectly smooth all over. I 
could do nothing with her."* 

Diagnosis. — When an eruption occurs in the head, of a pustular kind, and lasts 
some time, we may be almost sure it is porrigo; but if we ascertain that the pus- 
tules are small (acores^), or large and flat (favi''), then we may be sure of the nature 
of the disease. It is said to occur in other parts of the body; but I do not recollect 
seeing it. Impetigo,"" eczema, "^ and ecthyma,^ are common enough on the extremi- 
ties; but porrigo is much more particularly found on the head. 

Period at ivhich it Occurs. — Porrigo takes place far more frequently in children 
than in others; and it very often cures itself, when it is thought to be cured by 
medical means. It lasts for a certain time, and gradually declines. Children have 
it for a great number of years; and then, as they grow older, it ceases. There are 
diseases which are common to infancy, which gradually disappear as the subjects 
of them grow older; and scald-head is one of them; but I have seen persons labour- 
ing under it, who have attained their twentieth or twenty-fifth year; and who said 
they had had it all their lives. 

Treatment. — As to the treatment of this disease, it is one of the most obstinate 
that can be taken in hand. There is often great inflammation; — so that, on placing 
the hand near the patient's head, we find great heat. We should therefore com- 
mence our treatment with antiphlogistic measures; — taking blood from the neigh- 
bourhood of the head, and applying cold water. These things are certainly useful, 
and appear to be indicated by common sense; but they are only useful to a limited 
extent; and, as I just now said, the affection is very obstinate. It is sometimes of 
great service to give mercury. '* Plummer's pill"^ first obtained its credit by curing 
a disease of this description. Dr. Plummer (Senior) of Edinburgh, states,^ that 
he had a case of scald-head, for which he gave some common form of mercury; 
but the patient was no better. He then gave it mixed with a little guaiacum and 
antimony; and the patient presently got well. This pill was much employed by 
him afterwards, and others also used it; till at last it became well established; and 

» The case is described in the " Medical Gazette;" Volume 7; Page 639. 

The (lifficiiUies encountered in the study of the pustular diseases of the hairy scalp, have 
been greatly increased by the descriptions given by Willan and Bateman, under the titles 
of "porrigo" and "porriginous eruptions." They have described porrigo as a contagious 
pustule; and, at the same time, and under the same head, various eruptions, tnany of them 
noi contagious, are jumbled together. Biett, in his valuable oral lessons, delivered for the 
last twenty years, has unravelled the mystery. It is due to this eminent dermatologist to 
make this announcement; as others have not scrupled to publish, as their own opinions, 
the statements he delivered publicly many years ago. The "porrigo lupinosa'^ and " por- 
rigo scuiuUUa," as Biett rightly observes, are alone contagious diseases, with peculiarly 
formed pustular eruptions. The others, termed by Willan ^^ iporrigo favosa,''^ "porrigo 
larvalis," " porrigo decalvens," and " por r i^;o furfurans,^' are merely impetiginous or squa- 
mous affections of the hairy scalp. The denomination ''favosa,'^ was given by Biett to one 
of the varieties of contagious porrigo, on account of the remarkable honeyed yellow colour 
of the incrustations, much more striking than any other; and it corresponded also with the 
name ^Hinea favosa," given by Alibert to that disease. — " Library of Medicine;^' Volume 1; 
Page 400. 

b See Note (a) to Page 417. " See Page 417. 

J See Page 411. ^ See Page 419. 

f "Pilulae Hydrargyri Chloridi Compositoe." 

6 In the " Edinburgh Medical Essays and Observations;" Volume I; Page 46. 



PUSTULE. 423 

PJummer^s pill" is now as well known as '^Dover^s powder." T much doubt 
whether it has any efficacy beyond an equal proportion of calomel. At any rate, 
I do not think that a grain of guaiacum can make any difTerence in a pill; and as to 
antimony, I believe, unless it produces nausea, it does not deserve to be considered 
a medicine. I have made comparative trials with calomel and " Plummer's pill;" 
and can say that I never found the latter at all superior to the former. However, 
mercury is often useful, and so also is sarsaparilla; as well as other medicines of 
that description. 

External Remedies. — As to external remedies, besides antiphlogistic measures, 
astringents are very useful; — such as oxide of zinc and calamine. If there be but 
little inflammation, tar-ointment, united with that of nitrate of mercury,* is very 
serviceable; and sometimes an ointment of the red oxide of mercury.'' These 
stimulating applications are often exceedingly useful. I have seen cases get well 
under the use of cocculus indicus. It is used to destroy vermin in the heads of 
children; and a drachm mixed with an ounce of lard makes a stimulating ointment, 
which is often beneficial. Sulphur, too, has been employed. A wash of the sul- 
phuret of potassium is sometimes found advantacreous in this disease. But, among 
external applications, when there is no great inflammation present, tar and citrine 
ointment^ are among the best. I need scarcely say, that the head should be closely 
shaved, and kept very clean. 

[Internal remedies are generally useless, unless the state of the constitution 
should require some gentle tonic; — such as infusion of gentian-root, taraxacum,'' or 
hops, &c. When the disease has existed some time, blisters on the arm, and 
gende aperient medicine, may be advantageously employed. When it is recent, 
and there are few pustules, it has been immediately arrested by cauterizing (with 
the nitrate of silver) the slight erosions of the skin, after the favous scab has been 
detached. But when the disease is of long duration, and of some extent, the ap- 
propriate means are alkaline and sulphurous washes, and acidulous lotions. The 
alkaline washes are made stronger or weaker according to circumstances. Ten or 
twelve grains of the Potassa Fusa in an ounce of distilled water, or one or two 
drachms of subcarbonate of potash dissolved in a pint of tepid water, are the best 
alkaline applications. The first lotion should be applied for a short time only; and 
the latter by means of moistened linen, constanUy kept to the part. Alkaline oint- 
ments (one drachm of subcarbonate of potash to an ounce of fresh axunge) are 
also useful, and may be rubbed on gently after the wash. The ointment may be 
omitted, if it appear to soften the parts too much. Lotions of the sulphuret of 
potash,'^ containing one, two, or three dr chms to a pound of distilled water, with 
an ounce of alcohol, may be substituted for the alkaline washes, should these 
prove inefficient. Gende sulphurous douches, every morning, are also of great 
service. The acidulated washes consist of muriatic, nitric, or sulphuric acids, more 
or less diluted. 

Solutions of the sulphate of zinc, of copper, of the nitrate of silver, or of the 
deuto-chloruret of mercury,^ have been sometimes used with the best effects. 
The Unguentum Hydrargyri Nitratis, in some cases, improves the condition of 
the affected parts. Biett has lately employed, in " porrigo favosa," an ointment of 
the ioduret of sulphur, which merits the greatest confidence. We^have seen it, in 
long-standing cases, greaUy improve tlie state of the diseased skin, prevent the 
forniaiion of fresh pustules, and cause the hair to be reproduced with the same ap- 
pearances as that of the sound portions of the scalp. 

During the treatment, tepid baths, and sometimes sulphurous water-baths, are 
useful adjuvants. The greatest care is to be taken to prevent the fluid which is 
exhaled from the excoriations being carried over the adjacent parts; — the con- 

* "Unguentum Hydrargvri NiLraiis." '' " Hydrargyri Binoxyiium." 

■^ From ra^aa-at;, Lo alter. ' 

^ Now considered lo be a sulphuret of potassium;— \.\\e "Potassii Sulphuretum" of the 
Pharoiacopoeia, 
e Hydrargyri Bichluridum." f Dr. George Gregory. 



424 PUSTULJE. 

tagious nature of this fluid having certainly some influence on tlie obstinate re- 
appearance of the favous pustules; and this is only to be prevented by great 
cleanliness, and the repeated use of weak alkaline washes. Should the irritation 
be intense, all stimulant applications ought to be suspended, and emollients sub- 
stituted. . 

In very obstinate cases, the cauterization of the diseased surfaces, with some 
concentrated or rather diluted acid, has efl'ecled a cure. The acid should be passed 
over quickly with a featlier, and water poured immediately on the parts, before the 
action of the caustic becomes too deep. We have lately seen kreosote succeed, 
when many other means had failed. The diseased parts are to be touched with a 
small hair-pencil dipped in kreosote; and dressings, with an ointment of a scruple 
of kreosote to an ounce of axunge, afterwards applied.''] 

[The following aphorisms, by Dr. Graves, contain many valuable hints on the 
cure of this intractable disease: 

" 1. When the disease is of long standing, always insert an issne in the arm, 
before you attempt its cure. 1 have seen water on the brain, and other fatal con- 
sequences, from the neglect of this precaution. 

2. If this disease has clearly originated from contagion, and no other evidence 
of derangement of the general health can be detected, we must not, from the 
mere presence of the cutaneous affection, infer a constitutional taint; and must 
avoid the common error, of making the poor children undergo a course of alterative 
medicines. 

3. This afl'ection, originating in contagious matter directly applied to the skin, 
cannot, like some varieties of lepra and j)Soriasis, (to which it often bears a great 
resemblance,) be cured by internal medicines; such as mercury, arsenic, and iodine, 
given separately or in combination (as in Mr. Donovan's new preparation). 

4. When it occupies the hairy scalp, the common procedure of shaving the head 
is injudicious, for it adds to the irritation of the skin; and the scalp can be sufficiently 
exposed by cutting the hair as closely as possible, with sharp scissors. 

5. The great object is to get rid of the morbid action which is going on, and 
which consists in an inflammation of the external surface of the corium; — an in- 
flammation occurring in spots, and giving rise (in the first place) to an increased 
secretion of epidermis, which produces the scaly appearance of the parts affected; 
and (in the second place) to a very slight and scarcely perceptible oozing of mois- 
ture, which immediately dries into scales, and thus escapes notice; — being mingled 
with the scurf formed by the detached portions of morbid epidermis. 

6. The cure must be accomplished by removing these scales, as far as that can 
be done by diligent ablution, without using any irritating degree of friction; and 
when the diseased portion of the skin has been thus exposed, we must next have 
recourse to some application which will destroy the morbid secreting surface. For- 
merly this was attempted by means of an endless variety of complicated formulae, 
each of which had its advocates. The list may, however, be now reduced to a few 
simple remedies; and, in truth, with nitrate of silver, sulphate of copper, or strong 
tincture of iodine, every case of this disease may be cured. 

7. I never use the solid lunar caustic, or sulphate of copper; but prefer a solu- 
tion of ten, fifteen, or twenty grains to the ounce, — as the case may require. As 
to the application of this solution, it will not do to apply it (as is generally done) 
with a camel's hair pencil, for it must be strongly rubbed into each spot; for which 
purpose a small bit of sponge, covered with fine linen, and tied to the end of a 
quill or slender stick, should be employed. When a large portion of the scalp 
is afl^ecled, it will require some perseverance to apply tliis lotion in an eflectual 
manner. 

8. An application of this nature, when eff'ectually done, must not be repeated 
oftener than once a week. 

9. Immediately afier it, the whole scalp must be covered with a dressing of 

» "Library of Medicine;" Volume 1; Pages 401 and 402. 



pusTUL.^. 425 

spermaceti; which must be renewed at least four times daily; — so as to keep the 
head constantly moistened with it. The head is not to be washed for three days 
after the application of the caustic, or of the tincture of iodine; but then it may 
be well, but very gently, washed with yellow soap and water twice a-day; — taking 
care to cover (as before) with a spermaceti-dressing, after each washing. 

In scaly diseases of the skin, it is quite surprising how much tlie cure is facili- 
tated by keeping the affected parts constantly smeared with spermaceti, oil, melted 
suet, or even candle-grease. Without this aid, the use of caustics will often dis- 
appoint the practitioner. 

10. When the above precautions have been taken, the cure will advance rapidly; 
and each succeeding application of the caustic-solution, or of the tincture, may be 
less severe."^] 

Treatment of Porrigo Decalvans. — Stimulating applications are among the best. 
I should recommend the use of red oxide of mercury,^ and other remedies of a 
similar description; — in fact, to treat it like the other forms of porrigo.'' The head 
must be kept well shaved all round, and very clean; and, by applying stimulating 
applications, the hair will at last be brought on. It is said that there is no doubt 
as to its being contagious; but I have not seen it so. It is by no means uncom- 
mon; but, like the other forms of porrigo, it will cease after a time. I need not 
say that, in the various other forms of porrigo, when there is a scab, in order to 
employ the ointment with eflect, we sliould put on plenty of it; and the scabs, 
when softened, must be taken ofl". They should, however, be softened as much 
as possible at first; and, for this purpose, a poultice is sometimes necessary."* 

^^ciite Pustular Diseases. — These^ may be said to be all the chronic pustular 
diseases. Those which I mean next to speak of, are acute; and occur but once 
during life. They are diseases which we see every day; namely, chicken-pock, 
cow-pock, and small-pox. It is now believed, by a great many, that the two latter 
of these affections are one and the same; and some go farther, and think that even 
the chicken-pock is only a modified form of it. However that may be, these dis- 
eases are all exceedingly similar; — so far as they are pustular; so far as they are 
all highly contagious; so far as they are acute diseases; and so far as, for the most 
part, they occur but once during life. 



b. Acute Pustular Diseases. 

SECTION v.— VARIOLA. 

7/5 History. — I will now consider a very important pustular disease; called, in 
English, " small-pox;" but, in medical Latin, " variola." I understand that the 
word "jooc/:," or "/90.t," is of Saxon origin, and comes from the word '^poc- 
cadl;^^ which is derived from the word ''pocca,^' — a "bag" or "pouch;" or 
^' pochcha,''' which means the same thing, — a "little bag." The terms " s/^m//" 
was added to it in the third or fifth century; — I suppose to distinguish it from 
*'the great pox." Some etymologists say it is called "variola" from the word 
^^varius.^' — "spotted;" or else that it comes from the Latin word "-varus,^^ — 
"a pimple." How the point is to be settled I do not know. The disease is 
called, in Spanish " viruelas;" and some derive this from the Latin word " t'i/7^5." 
The etymology, like the disease, is a mass of corruption. Mr. Moore has written 

» "Dublin Journal of Medical Science;" Volume 18j Page 239. (November, 1840.) 

^ " Hydrargyri Binoxydum." 

f See Page 417. 

d We would here direct the attention of the reader to "A Practical Treatise on Porrigo 
(or Scald Head), and on Impetigo (Humid, or Running Tetter); with Coloured Engravings 
illustrative of the Disease. By the late Robert Willan. M. D. Edited by Ashby Smith, 
M.R.C.S." 

e Impetigo (Page 417), Ecthyma (Page 419), Rupia (Page 420), and Porrigo (Page 421). 



426 PUSTULiE. 

an admirable history of the small-pox,* and another of the cow-pook;'' both of 
wiiich works are exceedingly interesting, and well vvorih reading. He says that 
the word '■' vario/a''^ was first found in an old Saxon Chronicle, ascribed to Marios 
(Bishop of Vaux, in Switzerland): who says that a violent malady, attended with 
purging, hroke out in Italy and France, in the year 570. 

Premonitory Symptoms. — The disease, before the eruption appears, is marked 
by certain premonitory symptoms. The patient, first of all, is generally seized 
with languor, drowsiness, vomiting, and pain of the head and loins; — just as might 
occur in any other fever. Here the head is affected (" drowsiness" and " languor"); 
the stomach is affected ("vomiting"); and "the loins" are affected; as almost 
always occurs in common continued fever. There is pyrexia, universal feverish- 
ness, quickness of pulse, and also tenderness of the epigastrium; but the pain in 
the loins, and the tenderness of the epigastrium, are frequendy most intense; being 
ver}' marked in this disease. 

Appearance of the Eruption. — After these symptoms have prevailed a day or 
two, there appear, first on the face, and then successively throughout the body and 
extremities, small red spots (papulse;*^) and these rise into elevated pimples, and 
these again into hard tubercles, — in the common acceptation of the word.*^ So that, 
first of all, you have mere red spots on the skin; these spots rise into what are 
commonly called " pimples:" and then these pimples become very hard (tubera). 
These pimples become pellucid; and, on the fifih day (counting from the first 
attack of feverishness, headache, and so on,) they become pustules. From being 
pellucid, they have purulent contents opaque and white; and those which are large, 
are at first generally depressed in the centre. This is worthy of notice. They 
are not perfectly filled at first; but are filled in the circumference more than in the 
centre. 

When this eruption is taking place, if the individual be an adult, there is fre- 
quently a great tendenc)'' to profuse sweating; and if the patient be a child, there 
is a great tendency to epileptic fits. It is said that one fit forebodes a mild disease, 
whereas several forebode a severe one. Where there is but one fit, there is so little 
mark of severity of disease, that it often has been deemed a favourable symptom; 
but I should suppose, that if the child had no fit at all, it would forbode something 
better still. 

Period of Maturation. — On the eighth day, — counting always from the first, — 
if there be much eruption, the face swells from the inflammation. If the disease 
be pretty severe, the cellular membrane beneath falls into more or less irritation, 
and secretes abundantly; so the face swells on that account. The same circum- 
stance causes the eyes to close; and the continued extension of the irritation causes 
the mouth to " run," and the fauces to inflame. On the eleventh day, t!ie pustules 
are at their height; — as full and as numerous as they will be; and the swelling of 
the face, the "running" of the mouth, and inflammation of the fauces subside; and 
then the hands and feet swell; — first the hands, and afterwards the feet. The spots 
spread down the body and arms, towards the hands and feet; and, as these parts 
suffer the last, so they sfoell the last; and when the swelling commences in them, 
the irritation has already begun to suhside in the parts originally affected. The 
pustules are then said to " maturate;" that is to say, they grow ripe and perfect. 

Secondary Fever. — When this general suppuration has occurred, and the form- 
ation of pustules is perfect, then a fresh attack of feverishness occurs; and this is 
called the " secondary fever." That which occurs in the beginning, — ushering in 
the disease, and continuing for a little time, — lessens when the eruption comes out, 
and is called " the primary fever;" and when the eruption has gone on for a cer- 
tain number of days, and the general irritation is lessened, a second attack of fever- 
ishness takes place. The eruption is now perfect; — all the pustules having attained 

* " The History of the Small-Pox. By James Moore." 

b " The Historvand PracLice of Vaccinalion. P>y James Moore." 

•^ See Pa^e 36G. ^ See Pages 189 and 365. 



PUSTULE. 427 

their full development, and each pustule having become filled with matter, and of 
its full size. 

Decline of the Eruption. — When the pustules begin to diminish, and the matter 
to be absorbed, the common people, especially old women, call it " the turning^ 
We continually hear, in practice, that the disease has " turned;" and the meaning 
of that is, that the pustules have begun to subside. The pustules on the extremities, 
as I have said, appear later than those on the face and trunk; and their contents, 
I should also mention, are more limpid. There is not that excessive inflammation 
which produces pus; but only a puriform fluid is secreted; — a limpid fluid rather 
than perfect pus; and in them the fluid is frequently absorbed altogether, without 
any exudation occurring. In the other pocks, throughout the body and the face, 
the matter very frequently exudes; but those upon the extremities, particularly the 
hands and feet, lose their contents entirely by absorption; — so that the elevated 
cuticle remains flaccid and empty. The pustules on the extremities, as they come 
out last, also " turn" last. 

Pits and Cicatrices.— The pustules, too, when the matter escapes, generally 
dry into hard scabs. The matter exudes; a scab is formed of this dry pus; and 
frequently a little ulceration is found to take place; — so that a pit is left. The 
secretion is not merely superficial and cutaneous; but ulceration of the cutis, and 
even of the cellular membrane underneath, takes place; — so that marks are left. 
These pustules are nothing but so many minute abscesses; and, of course, there is 
more or less destruction of the parts, and a cicatrix is left on a small scale. If 
many of these run together, then a person is said to be " seamed." There are 
whole tracts of loss of substance. 

Critical Boys. — The days, then, on which the changes take place, are first 
according to the tertian type, and afterwards the qiiartan type. The day on which 
the (Hsease begins is the first day; then on the third (which is according to the 
tertian type) the pustules make their appearance; and on the fifth day (still accord- 
ing to the tertian type) perfect pustules are formed. The eruption begins as a 
little spot. This is succeeded by an elevation, which afterwards becomes hard, 
and contains a limpid fluid, which, on the fifth day, becomes perfect pus. From 
that time the quartan type commences; on the eighth day, if there be much erup- 
tion, the face swells, the eyes close, and the mouth " runs;" and on the eleventh 
day the pustules are all at their height, and there is no farther aggravation of the 
eruption. This enumeration will assist the memory. 

Variola Discreta. — The disease is generally divided into two varieties; the one 
called "distinct," and the other "confluent." In what is called " distinct" or 
" discreet" small-pox, the pustules do not touch each other. The pyrexia, or 
feverishness, is of that kind called "inflammatory;" and is attended with a pretty 
strong pulse, and great heat of the body. The pustules are comparatively few in 
number; and are all detached. Perhaps there may be very few pustules; — only 
one, two, three, half-a-dozen, or a dozen; but if there be more, still they are de- 
tached. They all look healthy, and have a rose-coloured base; — showing a healthy 
inflammation. Their contents are good, "laudable," "praiseworthy" pus.* The 
fever, in this form of the disease, lessens when the eruption comes out; and when 
the eruption is complete, the feverishness is nearly gone. The disease is mild but 
perfect. 

Variola Confluens. — In the other form of the affection, however, (which is 
called " variola confluens,'^) the pustules are very numerous, and run together. 
The feverishness is infinitely more violent, and rather of a typhoid character; the 
pulse is not so strong; the patient is exceedingly weak; and there is delirium. 
There is often so violent an aifection of the head, that it produces coma; and the 
eruption not unfrequently begins early, — even on the second day. The pustules 
are not only far more numerous, but they are smaller, flaccid, and not filled as they 
should be. Their quality also is bad; for, instead of containing a creamy " lauda- 

* See Page 100. 



428 PUSTUL.^. 

ble" pus, the contents are brown, — perhaps thin and serous; and perhaps there is 
a brownish ichorous fluid, rather than genuine pus. They not only run together; 
but, from not being well filled, they appear more or'less flat. 

Attendant Symptoms. — The feverishness, in this form of the disease, is very 
little lessened on the appearance of the pocks; and at the end of the eruption it is 
aggravated very much. Secondary fever, of a very violent character, comes on. 
The symptoms occurring in other parts, are also very severe. There is much 
more "running" of the mouth, and much more inflammation of the fauces, than in 
the distinct form; and, in infants, there is sometimes violent diarrhoea. In this 
I latter instance, the lower part of the alimentary tract sufl'ers great irritation. Fre- 

[j quently, too, between the pustules, there are petechias, vibices, and ecchymoses;— 

" there are, in short, red, dark-coloured spots, of various sizes. Sometimes there is 

bloody urine; and sometimes blood appears in the motions. The secretions are 
very unhealthy; and there is an exudation all over the body; so that the person 
emits a very offensive smell. Now and then, patients labouring under this form 
of the disease die rather suddenly. The consequences of this species of the dis- 
ease, too, are more severe than in the other form. In fact, it is " variola confluens'^ 
• that, for the most part, leaves such terrible consequences; such as blindness, phthisis, 
and diarrhoea; — the latter of which ends in ulceration of the intestines. 

In Negroes. — It is said (but I do not know the fact from experience) that ne- 
groes have a horny, warty, small-pox; and that the eruption is minute in size. 
Fibrin is efTused into the pocks; which give them a hard warty appearance. 

Complications. — [Such are the ordinary phenomena of the natural small-pox, 
in its distinct and confluent forms, when it occurs to persons previously in good 
health, and of sound constitution. But it must be remembered, that this disorder 
may attack those who may be labouring, at the time of seizure, under some other 
disease; — such as pneumonia, hooping-cough, hepatitis, or consumption; and, 
further, that these and oiher disorders may come on, unexpectedly, at any period 
(early or late) during the progress of small-pox. An infinite variety of accidental 
symptoms, may thus be superadded to those regular symptoms already enume- 
rated. Besides which, small-pox may occur to persons of a weak habit, or in 
constitutions exceedingly exhausted, and unable to cope with a disease of such 
severity. It may occur, for instance, to those who have but recently recovered 
from a severe typhous or scarlet fever. In these circumstances, we observe a very 
tardy eruption; collapse without advance of eruption; or, in a case somewhat more 
favourable, an abundant formation of large blebs, containing a thin ichor, with a 
very tedious and hazardous period of convalescence. To tliis latter form of the dis- 
ease, the old writers gave the name of the " watery or ^/cfcWer-pock.''] 

Occurs only once. — The disease rarely occurs more than once during life; and, 
although we may all see instances of its secondary occurrence, yet these are ex- 
ceptions to the general rule. Like measles, however, and scarlatina, it may occur 
more than once. 

Co-existent with Measles. — It was a dogma of John Hunter (an assertion with- 
out proof) that no two specific diseases could exist, at the same time, in the same 
body; but this is untrue. We see persons labouring under itch and syphilis at the 
same time; and there are plenty of instances on record, of small-pox co-existing 
with measles and cow-pock; though, in general, one disease runs its course in the 
body, and then the other. It is mentioned, in the " Edinburgh Medical Comment- 
aries," that measles and small-pox occurred simultaneously in sixteen children. 
Out of forty-three children who were inoculated, sixteen were at the time labour- 
ing under measles; and both the diseases went on together. This occurrence took 
place at the Foundling Hospital in Dublin. 

Effects. — Pustules frequently form around the eyes, and on the cornea itself; 
and there is often ophthalmia; — which not unfrequently (in the violent form of the 
disease) produces albugo, or staphyloma. Formerly, a great number of persons 

» " Cyclopaedia of Praciical Medicine j" Volume 3; Page 742. 



PUSTULiE. 429 

were rendered blind through the small-pox. When the disease is over, it fre- 
quently leaves scrofula. Persons may have enlarged glands of the neck; or they 
may have enlarged mesenteric glands; or they may have phthisis. Frequently it 
leaves rupia and ecthyma. Diarrhsea, too, is not unfrequently left after it; and the 
mucous membrane of the intestines sometimes falls into chronic inflammation. 

Among the mucous membranes, those of the larynx and trachea frequently 
suffer much. Many children die, from the upper part of the trachea being blocked 
up with a thick tenacious mucus, and much swoln. It is a point to which Mr. 
Alcock, the surgeon, has particularly attended; and in consequence of having had 
my attention directed to it by him, I have frequently examined the larynx of chil- 
dren wlio have died of this disease; and its state has been such as to astonish me. 
There has been great inflammation; and so great an effusion of thick stuff, as very 
nearly to block it up. 

Morbid Appearances. — [The following is a summary of the principal results 
deducible from the investigations of Dr. Petzholdt, into the morbid appearances 
found in the bodies of persons dying of small-pox: — 

" 1. There occurs softening of the undermost layers of the cuticle; and, at a 
later period, destruction of the connection with the cutis. 

2. Orifices are never observable in the cuticle covering pocks. 

3. What is called the ' pit' or ' umbilicus,' is produced by the retention of the 
quticle by the excretory ducts of the cutaneous glands. 

4. All pocks have not a pit or umbilicus. 

5. The pit, or umbilicus, never exists in pocks seated on the palm of the hand 
or sole of the foot. 

6. On the base of the pock, and consequently on the surface of the cutis, the 
orifice of the gland can be seen; except in the palm of the hand or the sole of the foot. 

7. The portion of the surface of the cutis not covered with pocks, is also in a 
morbid condition. 

8. The vessels at the base .of the pock exhibit marks of inflammation; those 
at its circumference, marks of congestion only. 

9. The (so called) ' 7Z-'z/if/- pocks' are by no means empty. 

10. The cutaneous glands are generally swollen in small-pox. 

11. The excretory ducts of the glands, when destroyed, as well as the hairs 
that fall out, are regenerated. 

12. The mucous membranes of persons affected with small-pox, often exhibit 
inflammation, with the formation of vesicles and ulcers. 

13. Vesicles and superficial excoriation are met with on the tongue. 

14. On the pharynx and back part of the mouth, there are never pocks; but 
the glands there seated are much distended, and have very wide orifices. 

15. There occurs softening of the epithelium of the oesophagus, rising into pus- 
tules. 

16. At a later period, the epithelium is completely destroyed. 

17. Ulcers are met with in the cesophagus; but never with perforation of the 
proper mucous coat. 

18. No pocks are found in the stomach and intestinal canal; but there occurs 
destruction of the papillae of the mucous membrane, particularly in the small intes- 
tine. 

19. There is often dendritic vascular injection of the mucous membrane of the 
alimentary canal. 

20. Ulcerated parts are occasionally found in the mucous membrane of the nasal 
fossae. 

21. Vesicles form in the trachea. 

22. Ulcers occur in both larynx and trachea. 

23. The mucous membrane of the genital organs is free from pocks; except at 
its junctions with the external skin. 

24. On the serous membranes nothing more is (in general) to be seen, than what 
is found after their inflammation in other diseases. 



430 PUSTULJE. 

25. In a few cases, an eruption was found on the serous coverings of the spleen 
and liver."*] 

Causes, — The cause of this disease, I believe, is in most instances a specific 
poison, generated by an individual labouring under the disease. Children some- 
times have it without there being any possibiliiy of tracing infection; but for the 
most part we can do so. It is a disease which is infectious as well as contagious.'' 
There is no occasion to touch the patient labouring under it, or any thing he has 
touched; to be near him is quite sufficient. One reason for thinking that it always 
arises from another individual labouring under it is that, in Denmark, the disease 
was made to disappear for many years, by practising vaccination on every indivi- 
dual; but at last the inhabitants grew careless; and, on their being visited by per- 
sons labouring under the affection, it again broke out. If, however, the two dis- 
eases be the same, the argument falls to the ground; for if the cow-pock be merely 
modified small-pox, then these are merely instances of the disease occurring but 
once. 

All Persons Liable to it. — Almost all persons are liable to take the disease;— 
so liable, that it is hardly right to say that a predisposition is required. From the 
few who escape if the poison be applied, it is a better mode of expression to say, 
with regard to those who will not take it, that " they are indisposed to it," than to 
say that " they are not predisposed to it." The only thing wanted, is the absence 
of an indisposition. Persons have been known to escape this disease for forty or 
fifty years, and then to have it. The same circumstance occurs with regard to 
hooping-cough, and other contagious diseases. It is supposed that the predisposi- 
tion to it, is strongest in early life; but I mentioned formerly, that this is hardly- 
proved; because most persons take the disease, if they have not had the cow-pock, 
in infancy or childhood; and therefore there are but {ew adults left to have it.*" 

Its Occurrence in the Fcetus. — Like syphilis, it may occur in the fa3tus. The 
mother may give syphilis to a child in utero, and also the small-pox; and, in the 
latter affection, it is singular that the mother may communicate it to the child, 
without having it herself. Dr. Jenner published* instances of two women who 
were exposed to the contagion of small-pox, a few days before delivery. Both 
women were, I believe, exposed to it by infection; but one woman had had the 
affection formerly, and the other had been inoculated; — so that both had acquired 
an immunity. Neither of the mothers had the disease a second time; and, there- 
fore, they served merely as transmitters of the poison to their children. In the one 
instance, the disease appeared in the child on the seventh day after birth; and the 
other female brought forth a child covered with the small-pox. Dr. Mead, in his 
*' Treatise on Variola," mentions a similar fact. However, this has not always 
been the case; for Sir George Baker mentions that two women, who took the dis- 
ease during pregnancy, brought forth children perfectly healthy; and the latter 
never had small-pox till they were inoculated; which did not take place till they 
were three years old. I do not know whether a woman can give syphilis to a 
child, without the disease affecting herself; — whether she can have the poison con- 
veyed to her system by a man, and yet have no symptoms of the disease, and 
nevertheless produce a child affected with syphilis. In my experience, wherever 
syphilis has appeared in a child at its birth, or soon afterwards, the mother has 
shown syphilitic symptoms, either then or soon after. It is to be remembered, 
however, that we have no immunity from syphilis. We have immunity from 
small-pox and cow-pock, in consequence of the disease having occurred previously; 
and when immunity can be produced from a poison, then the system may transmit 
it, though perfectly safe itself. 

Period of Incubation. — As to the period at which the disease appears after ex- 
posure to the poison, the late Professor of Botany in Edinburgh (Dr. Rutherford) 
used to say, that a party of soldiers were exposed to it, in the natural way; and 

» " British and Foreign Medical Review;" Volume 5; Page 479. 

" See Page 300. *= See Page 384. 

^ In the first volume of the " Medico-Chirurgical Transaclions;" page 271. 



PUSTULJE. 431 

that the interval between their exposure, and the appearance of the disease, varied 
from twelve to fourteen days. Dr. Fordyce, who paid great attention to this sub- 
ject, said that the period which 1 have now stated was the common interval. 
However, it is certainly known sometimes to come out earlier. 

It is frequently Epidemic. — Like other infectious diseases, it is very frequently 
epidemic; and it is more frequently so at the vernal equinox, than at any other 
time. It is said, by Sir Gilbert Blane, to resemble measles and hooping-cough, in 
being more fatal during an epidemic than at any other time. After it has been 
absent some time, it is also more severe than at other periods. It is also observed 
to be like all other epidemics in another respect; — those who have it first, have it 
most severely. 

Opinions of the Ancients on the Contagion of Small-Pox,— \i is said that this 
was not known by the ancients to be a contagious disease; and, indeed, they con- 
founded measles, scarlet-fever, and small-pox together.* Khazes, an Arabian, and 
one of the oldest writers on the subject, ascribes it to the fermentation which the 
blood undergoes, when the youth is becoming a man. Sydenham (who has given 
so perfect a description of small-pox, that it can never be surpassed) had no idea 
that it was a specific contagion. He thought that scarlatina was most prevalent in 
the autumn; and ascribed it to a moderate effervescence of the blood, arising from 
the heat of summer. He entertained much the same opinion of measles and small- 
pox. I mentioned'' that Gadbury, the astrologer, wrote (without fear of being 
laughed at) that plague was not more infectious than the small-pox. Then another 
worthy man (Etmuller) who is much quoted by German writers, says that no 
doubt small-pox and measles take place from the child drinking morbid nourish- 
ment in the uterus; and from sucking it in the milk after birth. He says, — " It is 
not probable that those who assert that measles and small-pox arise from copulation 
after conception has taken place, are correct; and therefore I suppose that the found- 
ation of measles and small-pox lies in the milk, which the child takes first when 
in utero, and then afterwards when born." 

Influence of the Atmosphere. — Small-pox was distinctly declared to be conta- 
gious by Bo rhaave; who mentioned contagion as the only cause of it. But 
though nobody now doubts that it is contagious, yet its spread is greatly influ- 
enced by certain states of the atmosphere. Violent cold will check an epidemic 
small-pox. The wind called " harmattan"" stops small-pox, just as it does the 
plague; and it is said to prevent the effects of inoculation; so that if we inoculate 
when that wind is blowing, it is a fruidess task. I mentioned'* this particular 
circumstance, when speaking of contagion in general, in order to show what 
influences are exerted on it. Sir John Pringle says, that the small-pox was 
carried by some troops, on one occasion, to the camp; but. in consequence of some 
peculiar state of the atmosphere, it w'ould not spread. Van Swieten mentions 
a similar fact. Dr. Odier, a physician at Geneva, mentions that when this disease 
was not epidemic, it would not spread by contagion. When children had the dis- 
ease by moculation, if they were carried about the streets, and brought into con- 
tact with otiier children, during the eruption, there was not a single instance of a 
child catching the disease. Sir James M'Grigor says, that when the disease was 
prevading extensively at Bombay, in the neighbourhood of liis barracks, although 
there was the freest communication between the inmates of the barracks and the 
surrounding population, yet no person about the barracks caught the disease. 
When we are considering whether a disease is contagious or not, we must set no 
value upon the circumstance of certain states of the atmosphere putting a stop to it. 
Contagious diseases, in this respect, are in the same predicament as those wliich 
depend altogether upon atmospherical influence. That it is a contagious disease 
cannot be doubted, when we reflect that it will habitually occur to children, when 
their parents will not allow them to have the cow-pock. 

Inoculation. — Small-pox is communicated artificially by inoculation; because the 

^ See Page 387. ^ See Page 307. « See Page 255. ^ See Page 309. 



432 PUSTULE. 

disease which then arises, is much more mild than that which occurs naturally. 
The effect of inoculation is to lessen the number of pustules; and thus to lessen 
the general violence of the disease. The effect of vaccination upon the disease, if 
it do not prevent it altogether, is rather that of lessening its duration. Inoculation 
produces the disease with a far smaller number of pustules, and less general irrita- 
tion; whereas, if a person have small-pox after vaccination, the disease goes on in 
the usual way for a certain time; and then, all at once, the feverishness ceases, and 
there is rapidly an end to it. It will terminate, in fact, on the sixth day, instead of 
the eleventh. 

It appears sooner after Inoculation. — It is found, also, that the disease appears 
much more quickly when it is communicated by inoculation, than when it is com- 
municated naturally. The afl'ection usually appears on the seventh, or at the latest 
upon the eighth day, when it is communicated by inoculation; whereas, when it 
occurs by infection, it is generally from the twelfth to the fourteenth day before it 
appears; — and consequently we may, by inoculation, anticipate infection. If a 
person has been exposed to the infection of small-pox, and has great chance of 
having a severe disease, it is right (if we do not vaccinate him) to inoculate him 
immediately; because we then produce the disease more quickly than it would 
otherwise occur. The artificial form gets the start of the natural; and the patient 
has the former, instead of the latter. 

The Quantity of Matter Influences its Severity, — Dr. Fordyce also mentions, 
that the quantity of matter applied, greatly influences the severity of the disease. 
He says, that if we introduce only a small quantity of matter, a less severe dis- 
ease is produced, than if a considerable quantity be employed. On this account, 
the quantity of matter should be as sparing as possible. It should only be just 
sufficient to produce the disease. In cow-pock, however, a different rule must be 
observed; because the object, in that case, is to have the affection as complete as 
possible; and therefore s considerable quantity of matter must be introduced. We 
must not be contented with making one insertion; but must make several. 

History of Inoculation. — The fact of inoculation rendering the disease milder, 
appears to have been communicated to the Royal Society of Edinburgh in the 
eighteenth century; and the knowledge of it to have been brought to England 
from Constantinople. The knowledge of this fact is said to have existed in China, 
and Hindostan, for a great number of years. The Chinese were in the habit of 
placing the crusts taken from small-pox patients in the nose; — having frequently 
kept them in jars for some years previously. Sometimes they reduced the crusts 
to powder, and made the children snuff them up; — this was called "sowing the 
small-pox." The Brahmins are in the habit of scratching the surface of the skin, 
and then binding upon the scratch a piece of cotton moistened with the pus. It is 
said that a particular caste has the charge of this practice. They, however, pre- 
pare the patients for this process by some months' abstinence; — even from milk 
and butter; and this would be pretty low diet; for they have \\t animal meat at any 
time. This mode of inoculation appears to have been long practised in Persia, 
Armenia, Georgia, and Greece; but its origin is unknown. Some imagine that it 
arose in the deserts of Arabia; where there were no physicians or priests; — 
nothing but old women; and that the knowledge of the fact was acquired by the 
vulgar. However, the practice appears to have been very long known, among the 
peasants, in the provinces of Italy, in France, Germany, Sweden, Denmark, and 
even in Great Britain. In the north of Scotland, the people were in the habit of 
giving the children the disease, by putting them to bed with others labouring under 
the affection; or tying threads soaked with pus upon their wrists. But although it 
was known in this way, among the lower orders, before the enlightened part of the 
public were aware of it, — ^just as we shall see was the case with regard to cow- 
pock preventing small-pox, — the practice ostensibly came to us from Constanti- 
nople. Dr. Timoni wrote to Dr. Woodward on the subject, from Constantinople; 
and the letter was published in the "Philosophical Transactions" the year after. 
Pylarini, a physician, also wrote on the Turkish practice; and sent his communi- 



L 



PUSTULiE. 433 

cation home in 1715; nnd this was likewise 'given to the public in tlie "Philo- 
sophical Tmnsactions." Lady Mary Wortley Montague was at Constaniinoi)le 
with her husband, who had been appointed amba^rsador to the Ottoman court; >and 
she there learned the practice; and, being a courageous woman, tried it (with suc- 
cess) on her own son. On her return to England, she had her daughter inocu- 
lated. Caroline, Princess of Wales, wished to have her children inoculated; but 
was desirous that the experiment should first be made on six felons in Newgate. 
She obtained the consent of George the First; and the operation was performed. 
Five of the felons did well; but the sixth did not take the disease; — havings in 
fact, had it previously. On account of being inoculated, they were all saved 
from hanging. Inoculation was now thought favourably of in England; and it 
appears that, in the first eight years, eight hundred and forty-five persons were 
inoculated; of whom only seventeen died. At Boston, only one out of forty-five 
died. 

As this was a new practice, it excited opposition. AVhether the practice was 
good or bad, its novelty was sufficient to account for this; and many clergymen 
and dissenting ministers raved against it from the pulpit, and called inoculation 
" the offspring of atheism." Those who performed it, were called " sorcerers;" 
and the whole thing was said to be " a diabolical invention of Satan." Others, 
however, were of a different opinion; and Bishop Maddox and Dr. Doddridge de- 
fended it; and, in doing so, employed Scriptural quotations. The devil can quote 
Scripture, to suit his own purposes; and therefore it was very fair for good men 
to quote Scripture too. However, the reasonable side of the question at last pre- 
vailed. 

After a time, the practice was nearly relinquished throughout Europe; — ^just as 
we saw* was the case with regard to the use of Peruvian bark. After the practice 
of exhibiting bark had been approved, the good opinion formed of it was entirely 
lost; so that it became " a Jn^-o-" in the market; and inoculation was almost dis- 
used in England, from 1730 to 1740; and in France it was absolutely forbidden. 
The truth was, however, that inoculation caused a great loss of life. It saved the 
lives of a great part of those who were inoculated; but it kept up the pestilence to 
such an extent, that far more caught it than otherwise would have done so; and it 
increased the general amount of the disease. 

Success of Inoculation. — With regard to the success of the practice, I may re- 
mark, that those w^ho were not medical men, were frequently the most successful. 
Some Carmelitish friars inoculated the Indians of South America, very success- 
fully; and the most successful inocnlators, in every part, were non- medical men. 
A planter, at St. Kitts, is said to have inoculated three hundred of his slaves him- 
self; without having lost one. Medical men made a great preparation for inocula- 
tion, by purgatives, emetics, and various drugs; and employed all these things also 
in the course of the disease. They likewise confined their patients to bed, and kept 
them in a hot room, with a view to encourage perspiration. This practice ao-gra- 
vated the feverishness, and increased the mortality from the disease. Great fury 
prevailed against it; when, in 1754, the London College of Physicians published 
a declaration in its favour. Inoculation, however, met with but slender success, till 
the time of a person named Sutton. This quack used purgatives, and common- 
sense treatment, and succeeded wonderfully; so that he spread inoculation, more 
than the College of Physicans and all the doctors together. Sydenham practised 
free ventilation and refrigerants; but Sutton omitted the opiates which Sydenham 
was in the habit of giving, and gave calomel and tartar-emetic. Sutton also re- 
stored the Turkish practice of making only a slight scratch with a lancet. 'I'he 
practice, indeed, fell very much into the hands of quacks. Medical men ceased to 
have recourse to it; but quacks took it up, and endeavoured to " turn a penny" by it. 

Such is the curious history of inoculation. Its efficacy was first doubted; the 
practice was afterwards approved; then violent disunion and party feeling were- 

«At Page 272. 
VOL. I.— 28 



434 PUSTULE. 

excited; the most virulent abuse was poured forth; and the plan was dropped alto- 
gether. Then it was taken up by quacks; and quacks were frequently much more 
saccessful than the doctors; because they did not employ a number of medicines, 
Avhich did harm. When inoculation was first practised, it is said that only one 
patient out of fifty died; but now, not above one in two hundred dies; and some 
have calculated it at not more than one in five hundred; whereas the mortahty from 
natural small-pox was as much as one in six, even where medical aid was rendered; 
and where there was no medical assistance, the mortality was frightfully great. In 
fact, at one time, nearly all died where medical aid was not resorted to. Tlie 
annual deaths from small-pox in England, during thirty years of the last century, 
were from thirty-four to thirty-six thousand. Before vaccination was practised, and 
after inoculation was established, one child in seven throughout Russia, is said to 
liave died from small-pox; whereas Spain, which did not trouble herself about ino- 
culation, suffered far less than any other country; — the disease having been kept 
up in others by inoculation. 

Diagnosis of Small-Pox. — [Before the appearance of the eruption, the diagno- 
sis of small-pox is always liable to uncertainty, even with every attention to the 
character of the prevailing epidemic; for the precursory symptoms are common to 
other diseases. The grounds on which we attempt, at this early period, to deter- 
mine the nature of the approaching disorder are: — 1. The suddenness of the attack. 
2. The absence of previous ailment. 3. The exposure to variolous contagion. 
4. The having previously undergone one or more of the exanthemata. The dis- 
eases with which, after the occurrence of febrile eruption, small-pox may be con- 
founded, are measles, febrile lichen, varicella, and secondary syphilis. 

1. The papulae of true small-pox are firmer than those of measles. They feel 
granular, like hard bodies, under the fino'er. In measles, too, there is accompany- 
ing cough, and watering of the eyes. Further: forty-eight hours elapse, in small- 
pox, from rigor to eruption; seventy-two hours in measles. 2. Febrile lichen is 
the disease from which small-pox, at the onset of eruption, is with most difficulty 
distinguished. The aspect of eruption is in both cases neatly alike. The surest 
and safest grounds of diagnosis are based on the interval which has elapsed from 
rigor to eruption, and the seat and extent of eruption. In febrile lichen, twenty-four 
liours elapse from sickening to eruption; in small-pox, as we have said, forty-eight. 
Small-pox almost always appears first on the face; the eruption of lichen is equally 
developed, from the first, on the trunk and head. The diagnosis of small-pox and 
chicken-pox will be pointed out by and bye.* 4. There is a form of secondary 
syphilis, in which an eruption appears on the face and trunk, very similar to dis- 
tinct small-pox. This eruption passes through the several grades of papula, vesi- 
cle, and pustule. It is preceded by a febrile attack of variable duration. This 
circumstance has, in many instances, given rise to the notion of small-pox occur- 
ring twice. A case of this kind fell under our own observation'' very recently. 
The diagnosis is to be effected by accurate inquiry into the prior history of the 
case, and the further progress of the eruption. The pustular syphilitic eruption 
runs a tedious course, exceeding ten days; and the pustules are developed, not 
simultaneously, (as in small-pox,) but in successive crops. 

Prognosis.- — The danger, in small-pox, is dependent on a variety of circum- 
stances; but chiefly on the following: — 1. The quantity of the eruption. 2. The 
condition of the mucous membranes. 3. The state of the fluids. 4. The state 
of the nervous system. 5. The age of the patient. 6. His habit of body. 7. 
The circumstances in which he is placed, and the treatment adopted. 

1. Distinct small-pox is a disease of litde or no danger. Confluence is always 
unfavourable, especially on the face; nor is the nature of the danger always under- 
stood. A confluent case sometimes appears to progress favourably; when, unex- 
pectedly, a convulsive fit occurs, and the patient is destroyed. The drain which 
confluence necessarily occasions in the system is sometimes the obvious cause of 

• See Page 445. »» That of Dr. George Gregory. 



PUSTULiE. 435 

danger. Nevertheless, if the pustules on the extremities acuminate well, and are 
surrounded by a crimson areola, a good ground of hope exists. If the vesicles on 
the trunk and extremities, on t le other hand, be flat, with a clarely areola, while 
the eruption on the face is white and pasty, no reasonable hope of recovery can be 
entertained. 

2. The condition of the mucous membranes, especially that of the larynx, is 
equally important with reference to prognosis. Hoarseness at an early period of 
the disease, is always unfavourable. A natural tone of voice, again, is a good omen; 
even though the eruption be full and confluent, with a disposition to cellular in- 
flammation. The appearance of the mouth and throat will also serve as a useful 
guide to the probable stale of the larynx and trachea. 

3. The condition of the fluids is a circumstance by which the physician will, in a 
great degree, be guided in his prognosis. Every thing which indicates malignancy 
and putrescency is highly unfavourable. Petechiee, menorrhagia, mucous haemor- 
rhages, and vesicles filled with a bloody ichor, are therefore among the worst signs 
that can occur. Recovery from the petechial small-pox has been recorded; but it 
is among the rarest events which the history of this disease presents. 

4. A tranquil state of the brain and nervous system is particularly Awourable; 
and is the circumstance to which the recovery of all severe confluent cases is mainly 
attributable. Quiet nights, composure of manner, a contented disposition, and 
confident hope of recovery, are good signs; restlessness (on the other hand), a 
continual moaning, despondency of mind, and a succession of sleepless nights, 
aff"ord but little hope of recovery. Children who grind their teeth seldom do well. 

5. Age is a point of great moment, in estimating the comparative dpgree of 
danger in confluent and semiconfluent cases: the extremes of life are those on 
which small-pox always falls the heaviest. Persons above forty years of age, 
seldom recover, even from semiconfluent small-pox; infants are in danger, even 
from a moderate quantity of eruption; in both, the process of cicatrization is attend- 
ed with great exhaustion of nervous power; the result of which is, that some 
internal organ necessary to life (the larynx, brain, or lungs) takes on acute and 
rapidly destructive inflammation. The arteries here act without the due control of 
the nerves. The most favourable age for taking small-pox, is from the seventh to 
the fourteenth year; when the powers of life are in full vigour, without the risk of 
plethora. 

6. The habit of body is, of course, also to be taken into account. Small-pox is 
always aggravated by its concurrence with a plethoric habit. Great constitutional 
debility is equally to be dreaded. In the strumous habit, the sequelee of small- 
pox are peculiarly severe, and often bring life into danger after the crisis has been 
passed. 

7. The probability of recovery must depend, lastly, upon the circumstances in 
which the patient is placed; on the possibility of applying remedial measures eff*ect- 
ively; on the treatment which has been pursued in the early stages, and other 
contingencies which scarcely admit of enumeration. In hospitals, the danger of 
contracting fever and erysipelas, during the later stages, is never to be lost sight of. 
In private life, small rooms, superabundant bed-clothes, and ill-iimed cordials, may 
aggravate or bring on local congestions and inflammations, from which the hospital 
patient is exempted. In certain seasons and states of the air, small-pox is more to 
be dreaded than at other times. 

These principles of prognosis will lead naturally to the consideration of the 
average mortality in small-pox, the usual sources of death, and the morbid appear- 
ances. 

Mortality. — The average mortality by small-pox is usuallv stated as one in four 
of those attacked, or twenty-five per cent. At the Small-Pox Hospital, the ex- 
tremes have been fifteen percent, and forty-two percent. The average of twenty- 
five years prior to the introduction of vaccination, gave thirty-two per cent. Thu 
proportion which the mortality by small-pox bears to the "total mortality in any 
town or district, has been a favourite subject of inquiry with all writers on medical 



436 



PUSTULE. 



Statistics. Prior to 1800, — that is, before the period when vaccination influenced 
the results, — tiie deaths by small-pox were to the total deaths, both in town and 
country, as sixteen to one hundred. It has been observed, by all writers, that in 
the unprotected the greatest morlality takes place in the early periods of human 
life. Dr. Haygarih computed that at Chester, in the latter part of the last century, 
one half of the deaths in children below ten years of age, was due to small-pox. 
The mortality is heaviest from the second to the fifth year. From the " First 
Report of the Registrar General of England," it appears that in 1837, there were 
only five diseases more fatal in England than small-pox; and that the deaths 
throughout England and Wales, by that disorder, amount now annuallv to about 
12,000. 

Small-pox may prove fatal at any period from the first invasion of fever to the 
fortieth day. Death may even take place prior to the development of eruption; 
but such cases are rare. In all countries it has been observed, that the eighth is the 
day of greatest danger, and the second week that which exhibits the greatest 
amount of mortality. The following table, extracted from the records of the 
Small-pox Hospital for 1828-9, showing the period of eruption at which 16S 
patients died, and the days on which the disease proved fatal, illustrates this; while 
it points out how lilde importance can be attached to the doctrine of critical days 
in small-pox. 

Of 168 fatal cases of small-pox there died on the 

Cases. 

- 3 

- I 

- 3 

- 1 

- 1 

- 1 

- 1 

- 1 

- 1 

- 1 

- 2 

16 

The mortality varies, of course, with the character of the eruption. The sub- 
joined table shows the proportion in which each variety of small-pox proved fatal 
at the Small-pox Hospital, during the epidemic of 1838.^ 

a Table exhibiting the Comparative Morlality in the several Varieties of Normal and 
Abnormal Small-pox at the Small-pox Hospital, during the Epidemic of 1838. 



fDay. 


Cases. 




fDay. 


Cases. 


J fDay. 


Cases. 


fDav 


1 3d - 


- - 1 


^ 


8th - 


- - 27 


13 15th - 


■ - 7 . 


22d 


j 4th - 


- - 5 


u 


9th - 


- - 15 


1 16ih - 


- - 5 ^ 


23d 


] 5ih - 


- - 10 


^ 


10th - 


- - 14 


^<; 17ih - 


- - 3 ^ 


24th 


1 6th - 


- - 5 


c1 11th - 


- - 16 


.t 18th - 


• - 3 ^ 


25th 


L 7ih - 


- - 11 


g 12th - 


- - 11 


r 19Lh - 
t20ih - - 


. . 1 c 


27ih 




— 


S 13ih - 


- - 11 


-23, 


28ih 




32 


^14:h - 


- - 5 

99 




21 1 


29 Lh 
31st 
32d 
35ih 














:x. 


38lh 



Normal Small-pox. 
Confluent ------ 

Semiconfluent - - - - 

Distinct 

Total Normal - 

Abnormal Small-pox. 
Confluent Modified - - 
Semiconfluent Modified - 
Varicelloid 

Total Abnormal 

Grand Total - - 


Unprotected. 


Vaccinated. 


Admitted. 
295 
78 
19 


Died. 
149 

8 




Admitted. 
56 
42 
20 


Died. 

21 

4 




392 


157* 


118 


25 


2 

1 
1 








38 

28 

114 


4 

1 
1 


4 


180 


6 


396 


157 298 


31t 



* Of these there died of fever and superadded erysipelas, 14. 
t Of these there died of fever and superadded disease, 10. 



PUSTULJE. 



437 



The concluding table will complete this branch of the subject, by pointing out 
the comparative mortality of small-pox at ditferent ages; distinguishing the vac- 
cinated from the unvaccinated."* 

The immediate causes of death, in small-pox, are various; — as the preceding 
detail of symptoms will have shown; but it may be useful to exhibit them in a 
condensed form: — 1. Prior to the maturation of the pustules, (that is, from the in- 
vasion of fever to the seventh day of eruption,) small-pox proves fatal by that 
general derangement of the system which occurs in malignant fever. Such a 
condition of the body is well designated by the term ''acute malignancy.^^ 2. 
During the second week of eruption, the chief cause of death is to be found in affec- 
tions of the larynx and trachea, and consequent suffocation. 3. During the third 
week (that is, during the stage of secondary fever) death may happen either by 
general excitement, — leading to effusion of the brain; or by supervening pleurisy, 
pneumonia, or laryngitis; or, lastly, by extensive sloughy or gangrenous destruc- 
tion of the skin. 4. During the fourth week, and at still later periods of the disease, 
death may take place from mere exhaustion; or it maybe the result of erysipelas, or 
of some other disease excited by the small-pox, or engendered by that constitu- 
tional debility which such a disorder in any of its severe forms so frequently 
leaves.''] 

Treatment. — There is nothing peculiar in the treatment of this disease. It is 
only the treatment of any ordinary fever. The utmost cleanliness should be ob- 
served; the patient should have plenty of clean linen; and mild antiphlogistic diet 
will be proper; — at least in the first instance. There is no harm whatever in cold 
or tepid abhition; provided the body is hot. Some say that they have stopped the 
disease by affusion; but we may have recourse to tepid ablution, if there be any 
objection to cold; and, as the fcetor is very great, it would be well to wash the 
patient with a solution of the chlorides, and to use them freely around the bed. 
Now and then it may be proper to bleed. The head is sometimes so much affected 
that, in the case of adults, general bleeding may be premised; or, at any rate, the 
application of leeches to the temples. The pain in the loins, which characterizes 
the disease, generally goes off very soon; but the oppression of the head may re- 
quire local bleeding; or, in adults, general bleeding. Usually the latter is not 
necessary; but every practitioner must judge of that for himself. Purgatives are 
proper; for the bowels should be kept freely open. By cleanliness, the employ- 
ment of the chlorides, purging, bleeding (general or local), and low diet, the dis- 
ease will be got through in the most favourable manner. 

After a time, if the patient's pulse become weak, or if the pustules be not well 
filled, and there be no violent local disease; — if, in short, there be any signs of 
debility, and of the disease assuming^ a typhoid type, — then wine and stimulants 
should be given. Sydenham was in the habit of giving opium at first; and I cer- 
tainly think, in that respect, his practice was bad. In confluent small-pox, when 



* Table exhibiting the Mortality of Small-pox at different ages, and in different Circum- 
stances, as displayed at the Small-pox Hospital of London, in the Epidemic of 1838. 



AGES. 


Unvaccinated. 


Vaccinated. 


Under 5 years of age . . - 
From 5 to 9 inclusive - - - 

" 10 to 14 "... 

" 15 10 19 " 

" 20 to 24 "... 

" 25 to 30 " . . - 

" 31 to 35 "... 
Above 35 years of age 

Total . 


Admiued. 
42 
37 
30 
104 
115 
45 
12 
11 


Died. 

20 

11 

8 

32 

50 

23 

7 

6 


Admiued. 



5 

25 

90 

lOG 

55 

13 

4 


Died. 



6 
16 
8 
1 



39G 


157 


298 


31 



b "Library of Medicine;" Volume 1; page 303 to 306. 



438 PUSTULiE. 

the patient is covered with pustules, so great a number of little abscesses must be 
considered equal to one large one. There is universal suppuration of the surface; 
and the patient requires to be supported; — ^just as he would in tlie case of a common 
abscess. It is frequently necessary, also, towards tlie close of the disease, to give 
wine, ammonia, and sulphate of quinina; together with good nourishment. But 
tiiere may be, on the other hand, such sharpness of the pulse, and such general 
irritation, that measures of this nature are improper; and we must be contented 
with giving the patient, perhaps, no more than milk or whey, and keep him cool. 
There is, as I have already said,* nothing peculiar in the case; it is only the treat- 
ment of fever. 

Some have advised the letting-out of the matter from each pustule. It is an old 
practice; but it has lately been talked of again. This might be done with a needle; 
and it is said there is some utility in the practice. Any inflammation that may 
occur (whether in the head, eyes, bronchia, or intestines) requires to be attended to. 
We must constantly be on tlie look-out for these affections; but the treatment is 
certainly to be conducted altogether on general principles. We have only to re- 
member that we are treating, not merely an inflammatory^ but a specific disease; 
— a disease attended by suppuration on the surface. Fresh air, cleanliness, and the 
chlorides, are very proper; — just as in other cases. 

[Mercurial plasters are said to have the power of preventing the maturation of the 
pustules, and have been lately much recommended. I tried this practice in the Phila- 
delphia city hospital, and feel satisfied from the experiments there made," that the 
mercurial plaster exerts a decided influence upon the pustules, preventing more or 
less their perfect maturation, and diminishing the concomitant inflammation, swell- 
ing and soreness. The subsequent process of desiccation, loo, is less likely to be ac- 
companied by the formation of thick scabs, and the resulting cicatrices less marked, 
than when the eruption is left to pursue its natural course. I did not find, how- 
ever, that it prevented pitting altogether, but only that it lessened the liability to it. 
Independently, however, of its influence in this respect, the application of the 
mercurial plaster to the face, is valuable in some cases, with the view of mode- 
rating the inflammation, as the patient is thus relieved of considerable swelling and 
pain, as well as from the inconvenience arising from the formation of thick scabs. 
The strong mercurial ointment was used in some cases, whilst in others it was 
rubbed down with an equal bulk of lard. It was spread upon a piece of thick 
muslin shaped like a mask, and then carefully applied to the forehead and face. 
Its good effects are chiefly observable where the eruption has not advanced beyond 
the third or fourth day. T. S.] 



SECTION VI.— VACCINIA. 

Nature. — The next disease which I shall describe, the cow-pock, was placed, 
by Drs. Willan and Bateman, in the order "vesiculae;"" but although there are 
only vesicles at first, the contents become so turbid that, at last, there is genuine 
pus; and I think it is much more consistent altogether to put it in the same order 
with small-pox. Indeed the cow-pock (called "vaccinia," from "vacca," a cow) 
is believed, by many, to be nothing more than a modification of small-pox; — to be 
merely the small-pox, modified by passing through the cow. There can be no 
doubt that small-pox is ai affection which cows, and perhaps other brutes, may 
have. Accounts have been published, in different journals, of experiments made 
with a view of ascertaining this point. Clothes have been taken from patients 
labouring under small-pox, and laid on cows; and they have had the disease called 
*'cow-pock." If the disease be really small-pox, modified, we then see no wonder 
in the circumstance that cow-pock generally affords an immunity from small-pox. 

^ See Page 437. 

*» American Journal of Medical Sciences, January, 1843. ' Order 5. 



PUSTULE. 439 

Cow-pock, however, is a far milder disease than small-pox; and is strictly con- 
tagions. It cannot be communicated by infection, as small-pox may; it is only 
communicated by palpable matter. 

Are Variola and Vaccinia Identical? — [The answer to this interesting ques- 
tion, is to be found in the late very interesting researches of Mr. Ceeley, published 
in the last volume of the Transactions of the Provincial Medical and Surgical As- 
sociation. In the report on this subject, we are informed that Mr. Ceeley — 

"" Resolved to attempt to ascertain whether he could, by inoculation, impregnate 
the cow with human small-pox. Twice he has succeeded in accomplishing this 
important object, after many previous fruitless trials. His experiments were con- 
ducted in the presence of five medical men and one veterinary surgeon. He pro- 
duced five vesicles on the cows; from which source several hundred patients have 
bee!i vaccinated, and have exhibited all the phenomena of vaccination, in the most 
perfect form and complete degree. There was no attendant eruption; nor any 
thing that could lead him to suspect, that he had not in this manner propagated the 
genuine ' variolas vaccinae.' He kindly transmitted portions of this lymph to the 
President of the Section, who immediately committed it to the care of Mr. Coles 
and several other gentlemen; in whose hands it produced regular vesicles, which 
in every respect corresponded with those so beautifully delineated by Dr. Jenner, 
in his first publication.^ This circumstance forcibly arrested the attention of every 
one who saw the vesicles; and that too, in several instance?; though the source 
whence the lymph was derived was not known. The correctness of the vesicle 
formed by it, exhibits a marked contrast to that which we have seen produced by 
other virus now in use; and we fear that the local as w^ell as general disturbance 
occasioned by the latter, so far from being a source of protection, will be found to 
be the reverse. 

"On the first of February, 1839, he inoculated with small-pox matter (' variola 
discreta') of the seventh or eighth day, three young heifers; a fourth was, at the 
same time, vaccinated. The reporters limit their account of what happened to 
the first. 

" Mr. Ceeley made seven punctures, and introduced fourteen points near the 
left labium pudendi; and, on the same day, inserted two setons with matter from 
the same subject. On the ninth day after this process, he vaccinated the same 
animal on the right labium pudendi, with fifth, sixth, and seventh day's lymph 
from a child, in seven punctures with fourteen points; and below the pudendum, 
in four punctures with eight points. On the tenth day after the insertion of the 
variolous matter, one of the punctures, near the posterior margin of the left labium 
pudendi, had assumed the form of the natural vaccine vesicle. By gendy removing 
the central irregular crust, and carefully puncturing the cuticle, he was able, in the 
course of an hour, to charge thirty-eight points with lymph, and on the same and 
subsequent days to use part of it on children and adults. On the thirteenth day 
the small-pox vesicle was more inflamed and florid; this was the fifth day after the 
insertion of vaccine lymph, at which time all the eleven punctures were converted 
into effectual vesicles; from these he took fine clear lymph, and used it on children 
and adults. Both the variolous and vaccine vesicles subsequently ran nearly a 
parallel course; so that, on the twenty-sixth day of the former, and on the seven- 
teenth day of the latter, the scars of both appeared perfecdy similar. 

*' To obviate objections which might arise from the insertion of the vaccine 
lymph on the ninth day after the inoculation with the variolous matter, Mr. Ceeley 
re-inoculated a sturk on the fifteenth of February with small-pox matter, of the 
seventh or eighth day, on the labium pudendi. He made eight punctures; which 
were deluged with the variolous fluid from capillary tubes. On the fifth day, 

*" An Inquiry into the Causes and Effects of the Variolse VaccincF;— a Disease disco- 
vered in some of the Western Ctmnties of Ens^land, particilnrlv Gh)ucestershire; and 
known by the name of the ' Cow-pox.' By Edwnrd Jenner, M. D." See, also, his " Further 
Observations on the Vaiiolne Vaccinae;" and " Coniinuation of Facts and Observations re- 
lative lo the Variulae VaccinaB, or Cow-pox." 



440 PUSTULiE. 

the four upper punctures were enlarged and elevated; the other four were less so. 
On the sixth day all presented the appearance of the vaccine vesicle. From one 
of them he took lymph with difficulty, and scantily charged thirty-nine points. On 
the eighth day, he again took lymph from the vesicle opened on the sixth. On the 
r.inth day, the vesicles were enlarging; and he again opened carefully the first 
vesicle and charged twenty points. On the tenth day, the four lower vesicles were 
increasing; and from them he charged twenty-seven points. After this lime the 
brown crusts appeared, and the disease gradually declined. This animal was sub- 
sequently inoculated, both with variolous and vaccine matter; but no result followed. 

" The practice of inoculating the cow with vaccine virus taken from man, was 
very early attempted. It is not to be overlooked, that the difficulty of accomplish- 
ing this is almost as great as that of inoculating the animal with small-pox. It 
succeeded, however, in the hands of Dr. Waterhouse; who, in 1801, impregnated 
one of his cows; and obtained from her a ' crop of matter on the ninth day, which 
produced the disease in the human subject to perfection.' Mr. Fox, of Cerne Ab- 
bas, — who has paid great attention to this subject, and seen the disease, as well 
among the cattle as on the hands of the milkers, — has also successfully vaccinated 
the cow. 

" The same experiments have been performed at Passy, in the neighbourhood of 
Paris. The lymph found there in 1836, among the cows, has been recently again 
passed through the animal; and this is called ' retro-inoculation.' Mr. Ceeley, 
too, has often been enabled to communicate the vaccine disease from man to the 
cow. He has observed, that good human lymph, when transmitted in this man- 
ner, loses some portion of its activity. It rises late, and produces smaller vesicles; 
but ultimately, after successive inoculations on man, it resumes its activity. 

" The reporters rightly designate this a triumphant conclusion of an investiga- 
tion of more than fifty years' duration; and the best monument to the sagacity of 
Jenner. They deduce from what has been done the following aphorisms; to which 
they entreat the attention not only of the profession, but of the public: — 

" 1. Cattle, in many ages and diflferent countries, have been afflicted with small- 
pox. 

" 2. This disease among the inferior animals has simultaneously existed with 
the small-pox in man, and pursued its victims through every quarter of the globe; 
and it exists at this time in Asia, in a fatal and pestilential form. 

" 3. It appeared among the catde in England in the year 1745, and again in 
1770, and continued its ravages up to the year 1780; and the local remains of this 
epizootic still occasionally show themselves, with considerable severity. 

" 4. The casual transmission of this disease to the milkers in the dairies of 
Gloucestershire, and their subsequent immunity from human small-pox, first led 
Dr. Jenner to the investigation of this singular afTection, and ultimately to establish 
it as a substitute for the more pestilential and fatal form of the disease. 

"5. When the disease appears among the inferior animals in a malignant form, 
it produces, by inoculation, a disease of similar severity in man. 

*' 6. As man has received this affection from the cow, so likewise has the cow 
received it from man. 

"7. The direct inoculation of the cow with human small-pox, has produced a 
mild and 'mitigated disease; and such disease, reproduced by inoculation on man, 
accords entirely in its character, in its progress, and in its protecting influence, 
with the ' variolae vaccinae,' as described by Dr. Jenner;'' — thus irresistibly proving 
his fundamental proposition, that cow-pox and small-pox are not bona fide dis- 
similar, but identical; and that the vaccine disease is not the preventive of small- 
pox, but the small-pox itself; — the virulent and contagious disease being a malig- 
nant variety.'"'] 

^ See Pao^e 439. 

b " Medico-Chirurgical Review;" October, 1840; Page 399. This extract has come to us 
through ihe medium of Braiihevvaiie's '■ Retrospect of Practical Medicine and Surgery, for 
the year 1841." (Pages 259 to 2G2.) As a work of reference and record, this is a very 



PUSTULE. 441 

Phenomena. — The disease, given artificially, begins a few days after the poison- 
ous matter has been inserted into the body. By a slight scratch, or by a wound of 
any description, a small transparent pearl-coloured vesicle is formed, with a circular 
or somewhat oval base. The upper surface is more elevated at the margin than at 
the centre, till the end of the eighth day; — the margin itself being red, turgid, 
shining, and roundish; so that it often extends a little over the line of the base. 
The vesicle contains clear lymph, in little cells that communicate with each other. 
About the eighth or ninth day, it is surrounded by an areola, varying in diameter 
(in different cases) from a quarter of an inch to two inches; and is usually attended 
with considerable swelling, and hardness of the adjoining cellular membrane. The 
areola declines from the twelfth day. The surface of the vesicle then becomes 
brown in the centre; and the fluid concretes into a hard round scab. The colour 
afterwards becomes black; and so it may remain for two or three weeks. It is 
important to remember, that there is left a permanent cicatrix, about four or five 
lines in diameter; the surface of which is marked by pits, denoting the number of 
cells of which the vesicle has been composed. 

The vesicle is formed about the sixth day after the insertion of the virus. About 
the seventh or eighth day, there is an inflamed areola; — a swelling and hardness; 
and it is on the eleventh day that all the symptoms decline. The vesicle then 
becomes muddy, and darker. If there be any pyrexia of the system, it occurs 
about the eighth or ninth day. Now and then (and I have seen such a case 
myself) the disease has not appeared for two or three weeks after vaccination; and 
then suddenly the disease has begun, inflammation has taken place, and the affec- 
tion has gone through its regular process. 

Indications of Perfect Vaccination. — If there be a violent degree of inflamma- 
tion, or if the disease vanishes too rapidly, or if there be any variation from its 
proper course, we must not imagine that any security from the small-pox is afforded. 
If, on the one hand, there be too little inflammation, — so that the affection soon sub- 
sides, and no genuine vesicle is formed; or if, on the other hand, there is too violent 
an inflammation; then, in either case, we may doubt whether the disease will be of 
any use. Nay, more: if the cicatrix, after the disease has appeared to go through 
its stages properly, is not of the description which I have now mentioned; — if there 
be not a permanent cicatrix, about five lines in diameter (a little depression, with 
very minute indentations,) we may then suspect that the disease has not been per- 
fect. In the case of all contagious diseases, we may have a disease of the greatest 
mildness, or the greatest severity. A contagious disease will not only vary as to 
the time at which it appears after the virus has been applied, but it will vary as to 
the time at which it goes through its course;^ and it will vary as to its degree; — so 
that I am satisfied that the plague will sometimes occur with only a slight indis- 
position; and we continually see gonorrhoea so mild, as to last only twenty-four 
hours; whereas, in other cases, it will be so severe as to last some weeks. Now 
this general fact is strikingly shown in cow-pock. It continually dies away, from 
the disease not being fully formed; and, on the other hand, it sometimes is so very 
violent, that the whole course of the affection is disturbed. Nothing should occur for 
twenty-four, or perhaps forty-eight hours; and then there should be a little irritation. 
A vesicle ought to be gradually formed; on the seventh or eighth day there should 
be an areola, and all the symptoms should decline on the eleventh day. When it 
is all over, a dark and hard scab ought to be seen, for two or perhaps three weeks; 
and then a permanent cicatrix should be left; with little indentations, arising from 
the cells of which the pustule has been composed. 

Small-pox Modified by Vaccination.— This disease, in the greater number of 
cases, gives immunity from the small-pox; and where it fails (which it frequently 
does) the small-pox is, in the greater number of instances, milder than it otherwise 
would have been. In general, when that disease occurs after cow-pock, it suddenly 

useful publication; since it gathers into a small compass the most valuable medical commu- 
nications, scauered through the different periodicals, in the course of the year. 
^ See Page 311. 



442 PUSTULE. 

• 

stops; it is ushered in by great pyrexia; and then, about the sixth day, it suddenly 
declines. 

I mentioned^ that the effect of inoculation for small-pox, is not of this descrip- 
tion; — that it causes the disease to be produced with a smaller number of pustules: 
whereas vaccination does not lessen the number of pustules, but shortens the course 
of the disease; so that, about the sixth day, all the violence generally ceases. This, 
however, is not a universal occurrence; because some patients die of the small-pox, 
after they have had the cow-pock. At first, it was imagined that cow-pock was a 
certain preventive of the small-pox. That, however, was a hasty conclusion. 
Because it prevented the disease for a certain time, and in the majority of cases, 
that afforded no solid basis from which to infer, that it would prevent it in all cases, 
and for the rest of life. Further experience was necessary, before such a conclu- 
sion coidd with propriety be drawn. But we may now safely assert, that a great 
number of persons who are vaccinated escape the small-pox; and where persons do 
not escape, the greater number of them have the disease very mildly. I believe 
the whole of the matter comes to that. 

Circumstances Influencing the Protective Power of Cow-Pox. — [Among the 
circumstances that materially influence the protecting power of cow-pox, is time; 
In the early periods of vaccination (ISOO to 1805,) the practice of inoculating after 
cow-pox, — so as to test its prophylactic power, — was carried to a great extent; and 
many thousands were exposed to the variolous effluvium, with impunity. Since 
the year 1808, these experimental testings have almost entirely ceased; and, con- 
sequently, we know very little concerning the effect of inoculation at long intervals 
from the date of vaccination. But it is a matter of general notoriety, that small-pox 
taken casually after vaccination is very rare under the age of eight years. The 
protective power may be considered as nearly complete for that period. About tbei 
ninth or tenth year of life, small-pox after vaccination begins to be met with. It 
increases in frequency ct the period of puberty, and is still more common between 
the ages of 18 and 25. With these facts before us, it is impossible to conceal the 
apparent conclusion, that time lessens the power of resistance to the variolous germ. 

The influence exerted by an atmospheric constitution over the power of variolous 
resistance, opens a wide but hitherto neglected field of inquiry. Having now wit- 
nessed in London two severe epidemic visitations of small-pox, we** have no hesitf!« 
tion in stating, that such influence is undoubted. The fact does not, from its very 
nature, admit of direct proof; but the number of persons attacked during epidemic 
seasons, after having successfully resisted small-pox contagion communibus anniSf 
offers an argument in favour of the position, which to our minds is irresistible. 

We"" come now to apply these views of vaccine pathology to the examination of 
the two practical measures suggested, of late years, to remedy the acknowledged 
defects of vaccine influence. The first of these is recurrence to the cow, for sup- 
plies of primary lymph. The second is revaccination, at distant intervals from the 
date of the primary process. 

1. Recurrence to the C020 for Primary Lymph. — The impression that vaccine 
virus decays in power in proportion to the number of times that it makes the circuit 
of the human body, has long prevailed, and is steadily gaining ground. In all parts 
of the Continent, and in England, it has led to frequent trials of lymph recenUy 
obtained from the cow. 

Persons vaccinated by Dr. Jenner himself, in the very infancy of the practice, 
before such deterioration could possibly have taken place, have undergone small- 
pox in after-life. Such occurrences are now more common than formerly; but 
much may be attributed to the extension of the practice of vaccination. The Royal 
Jennerian Institution of London employs, now, the same lymph which has been in 
use since the year 1806, when the Institution was founded. According to this 
authority, lymph recently obtained from the cow, does not generate a vesicle in 

» See Page 432. ^ Dr. George Gregory. 



PUSTULE. 443 

any way superior to that produced by the old lymph. ("Report of the Royal 
Jennerian Institution," for 1836.) The same result was obtained in Italy, in 1829; 
when the alarm of epidi^mic small-pox induced the Piedmontese physicians to try 
a variety of new stocks of lymph. We are informed by Dr. Griva ("Epidemia 
Vainolosa del Torino," 1829), Chief of the Vaccine Establishment at Turin, that 
*'no perceptible difference was to be traced between the aspect and progress of the 
old and the new, the primitive and the long humanized, virus." In Germany, the 
plan of recurrence to the cow has been largely tried of late years. In Wirtemberg 
alone, between 18.SI and 1838, forty varieties of primitive lymph were successfully 
employed. The notion of superior efficacy attaching to the new lymph was, how- 
ever, not generally entertained. (Heim's "Historische Kritische Darstellung der 
Pockenseuchen.") On the other hand, we are bound to acknowledge, that the 
Small-pox Hospital of London, changed its old stock of lymph for more recent 
matter in 1837; and that a marked improvement was perceived in the resulting 
vesicles. The local inflammation was more severe; the constitutional symptoms 
were more violent; the virus was more energetic; the most minute incision took 
effect; and the lymph given out on the ninth and tenth day was still in an active 
state. The National Vaccine Establishment has also, on several occasions, varied 
its stock of lymph with advantage. In France, a new variety of vaccine lymph, 
obtained from the dairies of Passy, near Paris, and called ^^ Passy lymph," was 
brought into use in 1836: and is considered by many as superior to the old stock. 
In 1838, Mr. Estlin, of Bristol, opened a new source of lymph from a dairy in that 
neighbourhood. It has been found very energetic; and is now employed in many 
parts of England, in preference to the lymph of the National Vaccine Establishment. 

2. Revaccination. — By many of the physicians of Germany, this measure is 
extolled as scarcely less important in its effects, nor less widely applicable, than 
vaccination itself; The authorities in Paris, on the other hand, have reported to 
the French government against the necessity of revaccination; and there is really 
some difficulty in deciding on the actual merits of the plan. The Germans aver that 
few, if any, of the recently revaccinated have fallen under the influence of small-pox; 
but the time which has elapsed since the general adoption of the measure, detracts 
from the value of such a statement. The practice may be recommended for its 
safety, even if it be much less serviceable than the Germans contend for. We have 
sufficient facts before us to state, with confidence, that it need never be recommended 
prior to the tenth year of life; and that the year best fitted for it is from the period 
of puberty to that of confirmed manhood.*] 

Mode of Operating. — This disease produces only a single vesicle or pustule. 
It does not produce a number all over the body; as small-pox, and other pustular 
diseases, do. As it is very desirable that the disease should be fully formed, and 
the constitution thoroughly affected by it, it is the practice to make several inser- 
tions of the matter; perhaps two in each arm. The arm is as convenient a place as 
can be chosen; and it is usual to make two wounds in it. The lancet should be 
held so that the matter may gravitate into the wound. There is no treatment 
required in this affection, unless we think it advisable to give the child a mild 
aperient. 

History of Vaccination. — As to our knowledge of the effect of this disease, in 
preventing the common form of small-pox, I may mention, in a few words, that we 
are indebted for the publication of the fact to Dr. Jenner. In 1768, when he was 
an apprentice, he learned by report that the cow-pock, on the hands of milkers, pre- 
vented them from having the small-pox; and he very frequently, at his master's, 
had to dress the hands of such persons. From his inquiries, he satisfied himself 
that the ulcers he dressed, were derived from the teats of cows. He learned, too, 
that it was very well known among the peasants, in that part of the country, that 
persons who had these sores upon their hands, could never be made to take small- 
pox by inoculation. In the further prosecution of his studies, he came up to 

* " Library of Medicine;" Volume 1; Pages 325 and 326. 



444 PUSTULJE. 

London; and having returned to the country, and settled there as a surgeon, he 
commenced a series of inquiries into this matter. He found a very considerable 
number of persons insusceptible of the small-pox; and, in all these cases, he was 
assured that the persons had had the cow-pock. The oldest farmers, however, 
said that the idea was not known in their younger days. Notwithstanding this 
insusceptibility which he found among so many persons, he met with exceptions; 
and he found some who had had those sores, and yet afterwards had the small-pox. 
Some medical men, of whom he made inquiries, believed the fact; and others dis- 
believed it. He found the difficulty cleared up, in a great measure, by ascertaining 
that there were several sorts of sores, arising from cows' teats, which were com- 
municated to those who milked them; but that there was only one which was the 
genuine cow-pock. He likewise had to encounter another obstacle. From the 
influence of external circumstances, the pock among the cows ceased; and he was 
unable to make any experiments on the subject. 1 mentioned,^ when speaking of 
contagious diseases in general, that affections, respecting the contagion of which 
there can be no doubt, will sometimes cease, and sometimes cannot be made to 
spread; — merely (as it would appear) from certain external circumstances. Now 
cow-pock — which is only contagious^ not infectious — is said to have ceased for a 
time; so that it was impossible for Dr. Jenner to get matter with which to make 
experiments.* However, in 1796, the cow-pock broke out in a dairy-maid, whose 
finger had been scratched. From this finger he vaccinated a boy; and regular 
cow-pock was produced. He repeated the experiment on another; — taking the 
virus from the human subject; and he then likewise produced the disease. He 
mentioned the facts to several of his medical friends; and prepared a document to 
lay before the Royal Society; but he was advised, in kindness and true friendship, 
not to expose himself by communicating any such nonsense, merely because it was 
new. However, he persevered. He did communicate his knowledge to others; 
and just the same fury was excited among medical men, that had been excited 
formerly, when inoculation was first made known to them.'' It was said that it 
was taking the power out of God's hand, that God gave us the small-pox; and that 
it was impious to interrupt it by the cow-pock. When I was a boy, I heard people 
say that it was an irreligious practice; for it was taking the power out of God's 
hand; — forgetting that it is merely using that power which God has given to us. 
Sefmons were preached for it, and against it; and hand-bills were stuck about the 
streets. I recollect seeing it stated, in a hand-bill, that a person who was inoculated 
for the cow-pock, had horns growing in consequence of it. Many were said to have 
died of mortification, produced by this practice. One of the surgeons at St. Thomas's 
Hospital," — there being no clinical lectures then, — used to give gratuitous lectures 
against the cow-pock; in which he advised the students not to resort to such a 
practice. He was interred in London; and, by his direction, a tablet was erected 
to his memory; on which was inscribed the fact, that he was all his life strongly 
opposed to cow-pocking. His rancour did not cease even with his death. It 
appears that a great want of candour and of principle was manifested; and that an 
account was forged, setting forth a number of deaths as having arisen from the 
disease. After a time, however, all this ceased; and now, I need not say, it is a 
regularly established practice; although it certainly does not deserve such encomiums 
as Dr. Jenner supposed it did. It is not an absolute preventive of the disease; but 
it does prevent it in a large number of cases; and where it does not, it generally 
makes it much milder. I will not take up more time with its details; because Mr. 
Moore's *' History and Practice of Vaccination*^" (which is almost as amusing as a 
novel) contains every thing that can be said respecting it. 

> See Page 309. ^ See Page 433. 

« Mr. pirch. ^ See Note (b) to Page 426. 



PUSTULE. 445 



SECTION VII.— VARICELLA. 

There is another disease, very much allied to all these; and called " the little 
small-pox," " varicella," (the diminutive of " z;«no/«,") or (in common lang-uage) 
*' the cA«cA;e>2-pock," or " swi^ie-pock." In general, it requires no treatment; 
any more than coz^-pock. It is only important to know that there is such a dis- 
ease; because people frequently think that their children are going to have the 
small-pox, when they are not.* 

Diagnosis. — The affection begins as a vesicular disease; but there are generally 
some pustules. There, are, however, fewer pustules than in small-pox; and, for 
the most part, they did not amount to more than two hundred. They go through 
their course, too, witli far greater rapidity than small-pox; and there is very little 
irritation of the system; frequently none at all. It is sometimes a difficult matter 
to distinguish between it and small-pox; but when we consider that the disease has 
far fewer pustules, that it generally runs through its course with great rapidity, 
and with scarcely any disturbance of the system, there is no great difficulty in 
making the diagnosis; more especially if we know that the child has had the small- 
pox before.'' It is said that, in chicken-pock, there is always cough; that a case 
never occurred, without being attended by some degree of cough, 

Si/mptoms. — It is a contagious affection; and there is a little feverishness before 
the (iisease takes place; but in about six days the whole is over. I believe there is 
never any internal affection, of any consequence, when this disease exists. In very 
rare cases, there are violent pyrexia, headache, delirium, and even convulsions; but 
they are all transient. There is no severe affection of the larynx, of the bronchia, 
or of the intestines; as there is in many other cutaneous diseases. 

Identity ivith Small-Pox. — Some have imagined that this disease is only a 
modification of small-pox; — that it is only a milder form of the disease called 
'•'modified small-pox;" but I will not give any opinion on the subject; because I 
do not think that we have sufficient observations, on these various diseases, to ena- 
ble us to speak with any degree of certainty. After this disease, just as after 
small-pox," I have frequently seen ecthyma and rupia take place; and sometimes, 
as in small-pox,'' there have been scars. I had the small- pox myself, and was not 
pitted at all; but the chicken-pock came afterwards, and left several pits; — so that 
the disease occasionally produces pitting, here and there; — the same as small-pox. 

fDr. Thomson maintains, that varicella is nothing more than modified small- 
pox; and supports this opinion by the following arguments: — 1. Persons placed 
in contact with patients affected with chicken-pox, have contracted variola; and 
the contagion of the latter affection has given rise to varicella. 2. Wherever small- 
pox is epidemic, varicella is also observed. 3. Chicken-pox is never developed, 
except in persons whose constitutions have undergone some modification from 
vaccination, or a previous attack of small-pox. This opinion of Dr. Thomson, 
however, is far from being generally adopted, even by those who coincide with 
him entirely respecting the varioloid nature of the vesicular eruptions observed in 
small-pox epidemics. The following are the arguments they use: — 1. The true 
vesicular varicella cannot be transmitted by inoculation; and never, in any circum- 
stances, generates small-pox. 2. Those persons who regard varicella as conta- 
gious, have confounded it with the modified small-pox. 3. Chicken-pox may 

a The best description of this disease, is contained in Dr. Heberden's " Commentaries," 
Chapter 96; and is well worth reading. The appellation he gives it, is " varioloe pusillae;" 
and he stales his belief, that the '' chicken-'pox'' and " swine-^ox'' differ only in name. 

•^ " [n the true chicken-pox, the vesicles have not that regular organization, which we 
have described as belonging to, and actually essential to the existence of variola, even in 
its mildest aspect. (See^ page 427.) The vesicles of chicken-pox have neither a hard papu- 
liform base, nor cells, nor central depression. They are mere elevations of cuiicie, of irre- 
gular and undetermined shape." (" Cyclopeedia of Practical Medicine;" Volume 4; Page 
434.") This eruption is well represented in Willan's work on Vaccine [noculaiion. 
c See Page 429. d See Pa^e 427. 



446 PUSTULE. 

occur in persons who may have not been vaccinated, and who have never had 
small-pox; in whom, therefore, it cannot be regarded as the modified disease. 4. 
Vaccination practised shortly after the subsidence of varicella, observes its regular 
course; which is never the case after variola. 5. The course of varicella is always 
the same, whether it shows itself after vaccination or after small-pox. 6. Both 
these affections may prevail as epidemics, independently of each other. We have 
known it prevail epidemically, to a remarkable degree, in localities where not a 
single case of small-pox was observed. 

Varieties. — There are two varieties of varicella. In the first the vesicles are 
small, but slightly elevated, and contain a colourless fluid. It is to this form that 
the name " chicken-pox" is more properly applicable. In the other, the vesicles 
are large, globular, soft, and broader in the circumference than at the base. The 
contained fluid is limpid at first; but afterwards has a milky appearance (" swine- 
pox"). 

Chicken-pox. — In the varicella with small vesicles (" varicella lenficularis^^ of 
Willan; " c/iicA'm- pox"), small, pointed, transparent, red vesicles appear suddenly 
on the first day, and increase in size for two or three following days. On the 
second or third day, the fluid has a milky appearance, and the vesicles become 
shrivelled; an the fourth day they are surrounded by red areolae. Desiccation 
begins on the fifth day; and on the sixth the vesicles are changed into small brown- 
ish scales. These desiccate from the circumference towards the centre, and fall 
off about the ninth or tenth day. As the vesicles appear in succession for two or 
three days, the different stages of the eruption may be seen at once in the same 
individual; so that the duration of the complaint may be prolonged into the eleventh 
or twelfth day. 

Sioine-pox. — Varicella with globular vesicles (the " varicella globata,^^ or 
" stn^^e-pox") is preceded by the same symptoms, and developed in a similar 
manner. The red points are quickly replaced by large round vesicles, containing 
a transparent fluid, which becomes opaque on the second day of the eruption. 
The vesicles have then reached their greatest size; they are soft and flabby; their 
colour is of a pearly white; and their circumference is larger than their base, which 
is surrounded by an inflammatory areola. 

About the second day, the vesicles become faded and wrinkled; their fluid is 
thickened, and converted into a yellow colour. As the itching is generally very 
considerable, it often happens that the vesicles are torn, especially in children; by 
which the inflammation is increased, and yellow pus (of more or less thickness) 
formed. This accident most frequently occurs on* the face; where the succeeding 
scabs may remain a considerable time, and produce permanent scars or pitting. 
This occurrence may also take place in the preceding variety. 

The vesicular are succeeded, about the fourth day, by lamellated scales of a 
brown colour. These also desiccate from the circumference towards the centre, 
and fall off about four or five days after; — leaving little red marks, which gradually 
disappear.*] 

c. Tubercular Eruptions. 

SECTION VIIL— ACNE. 

Those eruptions of which I next proceed to speak, are not placed by Bateman 
with pustular, but with tubercular affections; because there is a considerable hard- 
ness of the skin. The fact is, however, that suppuration generally takes place in 
these affections, if they last long; and I therefore prefer arranging them, with 
Rayer, as pustular diseases. There is only this difference in them; — that there 
are chronic pustules, instead of acute ones, — they are blind, as people commonly 
say. 

• " Library of Medicine;" Volume 1; Pages 389 and 390. 



PUSTULiE. 447 

Nature. — The first of these to which I will allude, is called (by Willan and 
Baleman) " acne;'"' and (by Rayer) " couperose." It is exceedingly common, 
and not at all contagious; nor is there the least harm in it. It occurs particularly 
in young men and women, — especially the former; and prevents them from being 
very handsome, about the period when they wish to " look their best." Some- 
times the face will continue to be affected with this disease for four or five years. 

Acne Indurata and Simplex. — In the ordinary form it is called " acne simplex;^'' 
and is described, by Bateman, as an eruption of small pimples, not very numerous, 
and without much inflammation; — the surface between the pimples being perfectly 
healthy; with the exception of a little roughness of the face. Sometimes there is 
a very great hardness; and it is thence called " acne indurata.''^ 

Acne Punctata. — Now and then it causes the sebaceous follicles to be large and 
distinct, and marked with a black speck on the top; and then it is called " acne 
punctata.'" By squeezing them, we force out what is called a " maggot;^^ but it 
is only the contents of the sebaceous follicles; and by repeated squeezing, we may 
force out this secretion, as long as the follicles will supply it. It will take place 
in the neck; but the face is its usual seat. Many people have a little of this affec- 
tion; but some have it very severely. There is no occasion to remember the par- 
ticular names. Sometimes there are black specks; and sometimes there is a good 
deal of redness around them. 

Acne Rosacea. — Now and then, it occurs with considerable surrounding redness 
and prominence of the skin; so that we may discover each particular vessel; and 
from its redness it is then called " acne rosacea.''^ We see this in middle-aged 
and elderly persons; and in this form the " maggots" lie in a bed of roses. This 
is a very permanent complaint. I do not know that it is often got rid of; but, 
luckily, it does not occur till late in life; and it is taken for granted to be an indica- 
tion of being devoted to the bottle. Every person, who has such a nose as is 
represented in Willan's sixty-fourth plate, is set down for a tippler. 

Suppurating Stage. — Each of these hard inflamed pimples of the skin, may 
suppurate. Some will subside after a time, but a great many suppurate^ and if 
they do not, it is an instance of termination by resolution; and we ought not the 
less to call it " a pustular disease;" because, if it pursue its course, — if it be not 
arrested by some cause or other, it goes on to that end. If it is not resolved, sup- 
puration is the termination of it. 

Treatment. — There can be no doubt that, when these pimples are small, it is 
much the best practice to squeeze them, and empty the contents. If this be done, 
the tubercle will for the most part subside; and of course, if they suppurate, the 
sooner the matter is let out the better. I am not aware that internal medicine has 
any effect on the disease; but I have seen great benefit arise from the application 
of stimulants; and one of the best is the ointment of the nitrate of quicksilver," 
rubbed well upon the part. This stimulates the disease; which seems to be one 
of inaction. Of course, if it stimulate too much, cold applications should be em- 
ployed, and the irritation diminished. Sometimes this ointment is too strong; and 
then it is necessary to dilute it with simple spermaceti-ointment, or with zinc- 
ointment. 

Some people give sarsaparilla, and nitric acid, in these complaints; but I do not 
know that they do any good; nor do I know that "Plummer's piU"° is service- 
able; but I think I have seen benefit from tar-water. The best local applications, 
are the stimulating substances that I have now mentioned. I have seen the face 
swollen all over, when they have been employed; and of course, if any very great 
inflammation come on, that must be treated in the ordinary way. 

* From aKy.ai, pimples on the face. 

^ "Unguenium Hydrargyri Nitratis." 

« "Pilulee Hydrargyri Chloridi Compositse," 



448 PUSTULiE. 



SECTION IX.— SYCOSIS. 

This is another disease which occurs in the face; but chiefly upon those parts 
which are covered with hair. It takes place, particularly, in the beard of men; 
and, from its appearance when ulcerated, it is called sycosis.^ When it occurs on 
the chin, it is called " sycosis ■menti.^''^ If it occur about the margin of the hairy 
scalp, it is called " sycosis capiUitii.'''"' There is, however, no occasion to make 
a variety, because it occurs in these different situations. We might as well make 
varieties of rheumatism, according as it attacks the shoulders, or the knees. 

Characters. — The tubercles, in this disease, are not so hard as in acne. They 
continue for a length of time, and are more inclined to suppurate. It makes shav- 
ing an unpleasant operation; notwithstanding that we have a good razor, a good 
strop, good soap, and warm water. These affections are merely slow chronic 
pustules; and the complaint is exceedingly obstinate. 

Treatment. — I have not seen the disease much relieved by bleeding, either 
general or local; or by the exhibition of mercury; but, of course, there are cases 
where antiphlogistic measures are proper. I have seen it subside from the adminis- 
tration of iron; but, for the most part, applications of all kinds fail. Stimulants 
may be applied; but, after a time, they do no good. Or we may employ cold 
soothing applications; but, after a time they also lose their effect. 

It is absurd to call these " tubercles;^^ for there is simply inflammation. There 
is no tubercle; — no organic change in the skin. The gentleman represented in 
Plate 65 (of Willan), must have regretted having a beard. Acne is a disease of 
the follicles: and is frequently attended by extreme hardness; whereas sycosis is 
not so hard. I really do not know what to recommend in the disease. Every one 
must be left to his own judgment. I have been tired out and out by the treatment. 
Of course, as this is a disease which occurs in the beard, women are exempt from 
it; unless their ovaries begin to dry up, and they acquire the character of men; but 
it does not occur where there is no hair. Both these diseases are confined to the 
head; — acne to the face at large; and sycosis to those situations where there is hair. 
Rayer gives a drawing of both these affections. 

d. Boils. 

Classification. — The other pustular diseases which I shall describe, are not 
treated of by Willan and Bateman; but they are all, or nearly all, spoken of 
by Rayer. One, however, — to which I will now direct attention, — is not 
spoken of even by him. Rayer makes a distinct class of those diseases which 
are disposed to gangrene. Now and then plague is attended by pustules on the 
skin {large ones, indeed; — such as are commonly called " boils"); and there is a 
great tendency to gangrene. The same occurrence takes place in the disease 
called " pustule maligne," — " malignant pustule;" which is generally communi- 
cated from brutes. He makes a separate class of these; but they are merely sup- 
purations; and therefore, I think, they ought to be classed with pustular diseases. 
However, if the suppuration be very considerable (forming not merely pustules^ 
but a very extensive suppuration), it may only lead to confusion to speak of them 
in that way; and it is to be remembered that they are not merely pustules; but that 
the cellular membrane is chiefly implicated, and the skin only secondarily. Still, 
however, as the disease occurs on the surface of the body, it is well to consider it 
as an affection of the skin. 

Sties, Boils, and Carbuncles. — The most simple affection of this description, 
is a sty of the eye. A more severe one is a boil in which there is a disposition 
to gangrene; and another is a carbuncle, in which there is a strong disposition to 

a From o-yjtov, a fig. b From " mentum," the chin. 

« From " capiilitium," the scalp. 



PUSTULE. 449 

gangrene. These three diseases (not one of which is mentioned by Willan and 
Baleman) Rayer puts together; and calls them " 6oi7y diseases;" — diseases cha- 
racterized by boils. A carbuncle is only a large boil; but it is of such an extent, 
that surgical aid is necessary to let tlie matter out. He makes another kind, 
differing only in having a tendency to gangrene. Of this kind are " malignant 
pustules" (which he includes among the " inflammations gangreneuses"), and the 
plague. To these may be added another; — " the glanders" of horses; — a disease 
which may be communicated to the human subject. 

Malignant Pustule, Plague, and Glanders. — With respect to sties, boils, and 
carbuncles, I shall say nothing; because they are spoken of in treatises on surgery. 
Those of which I shall speak are "malignant pustules," *'the plague," and 
*' glanders." The plague, indeed, is not confined to the surface; but neither are 
many other aff'ections called "skin-diseases" (small-pox, for example). It is a 
general affection of the system; and involves the skin among other parts. The 
characteristic of these suppurations, is a disposition to gangrene. In respect to 
all these diseases, whether small ones (such as sties and boils), or great ones (such 
as malignant pustules and the plague), they bear the same relation to porrigo and 
bullae, that the latter do to the small vesicles of herpes. I said,^ that I thought it 
wrong to separate them; and so, with respect to these, I think it a pity to make 
different classes merely on account of their size. Because small-pox and porrigo 
have small suppurations, and plague or carbuncle is characterized by a suppura- 
tion o^ greater extent, it is no ground for constituting a different class of diseases. 
They are merely pustular diseases, with suppurations on a large scale. 



SECTION X.— THE PLAGUE. 

The plague is very similar to typhus and continued fever; but it so affects the 
surface of the body, that I have thought it well to speak of it among diseases of the 
skin, as Rayer has done. 

Symptoms. — Like many other diseases of the skin, it is an acute fever; attended 
by headache, delirium, and a burning sensation at the epigastrium. Perhaps there 
may be great strength of body at first; — the person may be of a full phlogistic dia- 
thesis; but great debility soon comes on; and very often there is debility from the 
first. Glandular swellings speedily appear in the arm-pits and groins; — so that the 
disease is characterized by buboes;*" but the glands of the groins are more frequently 
affected than those of the arm-pits. Sometimes these glandular swellings, or buboes, 
come on at the first; and sometimes not till towards the end of the complaint. Be- 
sides them, however, there appear upon the surface vesicles of various sizes; the 
contents of which are frequently dark. There are, upon the surface, boils, car- 
buncles, and vesicles; and between them, and even where they do not exist, there 
are often vibices, petechiae, and ecchymoses. These petechias, it is said, will some- 
times rise into carbuncles; — where at first there was merely a little effusion or con- 
gestion of blood, there will sometimes, at last, be carbuncles. Occasionally, there 
is not sufficient power of the constitution, — not sufficient strength of inflammation, 
for carbuncles and buboes to arise. Just as in the case of the violent application 
of malaria, or the violent application of the poison of typhus-fever, and also as in 
cholera, persons will sometimes die immediately, without any reaction taking 
place. "^ 

Duration. — The plague usually destroys life in from two to five days; but if a 

»■ See Pa^e 415. 

»> From (SovBoDv, ike f^roin. 

c Dr. Shapler (" Library of Medicine," Volume 1, Page 188) has described three varieiies 
of plague:— i. Simple ox glandular ^\ag\XQ; which is rarely fatal in its termination, and bur 
seldom characterized by any very urgent symptoms. 2. Ervptive plague; which is attended 
by a period of reaction, and occurs more frequently than either of the other varieties. 3. 
Malignant plague; in which the period of reaction is either entirely absent, or but very 
imperfectly developed; and death ensues with great rapidity. 
VOL. I. — 29 



450 PUSTULE. 

person survive the fifth day, recovery is generally expected. Most people who are 
seized with this disease die; even though they enjoy every advantage of treatment 
and comfort. It is said that the disease may be had more than once. 

History. — Some consider it a very ancient disease. The symptoms are men- 
tioned by Hippocrates; and Dr. Bancroft contends that the disease is mentioned ia 
the Bible; and that this was the affection under which the Philistines laboured, 
when they are said to have been smitten in the private parts, after taking away 
the ark. He says that the disease spread as they carried about the ark; — that 
it was a contagions disease; and the more they carried about the ark, the more the 
disease was communicated; till, at last, it spread from Ashdod to Ekron.* He 
considers that the Philistines probably received the disease from Egypt. Some 
consider that, as the Philistines were smitten " in the hinder parts," they were 
afflicted with piles; but Dr. Bancroft contends that piles would not have killed 
them, in the way in which they perished." However, I think there is this objec- 
tion to Dr. Bancroft's argument; that, in the book of Psalms, it is said, they were 
not only smitten "in the hinder parts," but were put to a/jerpe/im/shame."" This 
intimates that a chronic disease was left; but the plague would not have left a chronic 
disease of that description. It is stated that from fifty to seventy thousand persons 
were smitten by the disease. But whether Dr. Bancroft be right or wrong, the 
symptoms were distinctly mentioned by Hippocrates. It is a disease that almost 
always prevails in the Mediterranean, at Constantinople, at Venice, and all the 
various ports of that sea. It has likewise prevailed at Marseilles, Moscow, and 
London. 

It is Contagious, not Infectious. — There can be no doubt whatever of its being 
a contagious disease; but it is rarely communicated without contact. It is, for the 
most part, believed to be a contagious diseases, in the strict sense of the word; — 
not infectious. One of the latest writers upon this subject (Mr. Madden, a sur- 
geon) says, that if there be a deficiency of ventilation and cleanliness, so that the 
emanations from the patient are very much concentrated, it may be communicated 
by infection; but if there be any ventilation at all, then it can only be communi- 
cated by contact with the individual, or with something that he has touched. 
Some have denied, of course, that this disease is contagious; but there are proofs 
without end that it is. The case of Dr. Whyte, who inoculated himself and died, 
has been already quoted.*^ Dr. Duncan, in his " Medical Commentaries," men- 
tions similar instances.^ 

When the French army were in Egypt, about eighty medical ofl[icers died of it 
in one year. The next year, they employed Turkish barbers to dress the patients, 
and bleed them; and then only twelve medical officers died; but one half the bar- 

* " They carried the ark of the God of Israel about. And it was so that, after they had 
carried it about, the hand of the Lord was against the ciiy, with a very great destruction. 
And He smote the men of the city, both small and great; and they had emerods in their 
secret parts." — "First Book of Samuel;" Chapter 5; VersesS and 0. 

^ " There was a deadly destruction throughout all the city. The hand of God was very 
heavy there." (" First Book of Samuel;" Chapter 5; Verse 11.) The disease which proved 
fatal, however, would appear to have been something distinct from the emerods; for we are 
lold, in the sixth verse, that "He destroyed them, and smote them with emerods;" and, in 
the twelfth, that " the men that died not were smitten with the emerods." 

= " He smote hi^ enemies in the hinder pari; he put them to a perpetual reproach." — 
Pmlm 78; Vp.r&e 66. 

^ See Page 304. 

e Very ditierent results have followed this operation. In some instances the symptoms of 
plague have appeared, whale in others the only effect was slight local irritation; — as might 
be anticipated from inserting a poisonous fluid matter into the cellular membrane. But 
even had plague occurred in all these cases, no satisfactory conclusion could be deduced; — 
owing to the fact of their having been performed in situations where the disease was 
prevalent at the lime. In order fairly to test the question, it would be necessary to institute 
a most unjustifiable series of experiments; namely, to inoculate with plague products per- 
sons living at a distance from the localities where this disease occurs, and who could have 
no communication (either direct or intermediate) with plague-cases, except through the 
matter with which the experiment is made.— "Z/i/5ir«ry of Medicine;''' Volume 1; Pa^t? 209. 



PUSTULE. 451 

bers (lied. It is said, that at Moscow, in 1771, all the assistant surgeons (amounlino* 
to fifteen) were seized with it, and of these three died; but the physicians, who did 
iiothint^ but walk through the wards with a pen in their hands, generally escaped. 
The assistant-surgeons were here reduced to the same state as the barbers. 

At Marseilles there had been no plague for fifty years, till 1720; when an in- 
fected vessel arrived. The disease, at that time, was distinctly traced to the arrival 
of an individual from an infected spot; and half the inhabitants died, in a short 
period after the arrival of the infected vessel. It is said that the plague had not been 
known at Moscow, for one hundred and fifty years, till they had war with the 
Turks; when two soldiers from an infected place arrived, and died; after which, 
eighty thousand perished from the disease in the city, and twenty thousand in the 
neighbouring villages. It is said, that the plaorue had not been known in Malta, for 
one hundred and thirty-seven years previously to 1813; and then the disease was 
brought from Alexandria. 

Howard says that the plague of London, which occurred in 1665, was conveyed 
to a village in the Peak of Derbyshire, by means of some old clothes. He was 
so astonished at the absurdity of many medical men, in denying that it was con- 
tagious, that he writes as follows: — " Have not some of our professors sullied their 
names with the dangerous doctrine of the non-contagion of the plague? From no 
other cause than the error of the physicians, who constandy maintained that the 
disease then epidemic was not contagious, happened that terrible visitation which, 
in 1743, ravaged the city of Messina and its vicinity, with the loss of above forty- 
three thousand individuals, in the short space of three months." Most writers 
show, that persons who attended others labouring under the disease suffered; while 
those who ran away escaped it. Tlie Turks are so satisfied of its being conta- 
gious, that when the disease prevails, they shut themselves up; and the Pacha 
holds communication with no person whatever. I think there can be no doubt of 
the plague being contagious, — in the strict sense of that word.* 

Influence of Heat and Cold on its Progress. — It is remarkable that great heat 
and great cold will stop the plague. It is a disease that will not bear great heat; — 
so that it has never been known to occur in tropical climates; and when the heat 
rises to a certain point, it stops. This takes place in Egypt about the twenty- 
fourth of June; and as that is the nativity of John the Baptist, he has the credit of 
putting a stop to the plague. The Catholics ascribe it all to him. From the in- 
tense heats, it is said never to appear in Upper Egypt; and it ceases altogether as 
the hot weather comes in. The winter also causes a cessation of it; and frequenUy 
renders exposure to a person labouring under it, perfecUy harmless. 

Cause of its Cessation in London. — From its being so contagious a disease, 
Dr. Wells considered that it was owing to quarantine laws, that we are not now 
troubled with this pestilence. He uses the following arguments: — 1. Many per- 
sons ascribe our exemption from the disease to the fire of London; but the plague 
has not been known in London, since 1665; whereas the fire did not take place 
till 1666. The fire of London consumed only one-fifih of the town; — leaving un- 
touched the Borough, Wapping, Whitechapel, Clerkenwell, St. Giles's, and the 
purlieus of Smithfield; which were among the dirtiest places. 2. Bristol has 
escaped for the same length of time as London, and yet there has been no fire in 
that city; and the improvements there began much later than in London. The 
Dutch are as cleanly as we are; and yet the plague continued there forty years 
longer than in England. 3. The town of Cracow is a very dirty place; and yet 
there has been no plague there for a century. 4. Ague alarmingly increased, and 
returned eleven years after the fire; and dysentery continued till the end of the 

» For very full details, and reasonings at great length on this subject, the reader is re- 
ferred to the following work: — "Results of an Investigation respecting Epidemic and Pes- 
tilential Diseases; including Researches in the Levant concerning the Plague. By Charles 
Maclean, M. D.; Lecturer on the Diseases of Hot Climates to the Honourable East India 
Company." The second volume contains an account of the author's experience in a plague- 
hospital; where he himself took the disease, but recovered. 



452 PUSTULE. 

century, notwithstanding the improvements; and therefore he 2irg\]es, a fortiori, 
that as the improvements could not prevent dysentery, tliey could not prevent 
the plague. 5. The plague is not known in India, China, and North America; 
where, in many places, they are filthy in the extreme. 6. The plaffue began first 
among the poor, who associated with the sailors of infected vessels. Dr. Wells 
contends that, from the time the quarantine laws were established, the plague has 
been unknown in England; and that, from the considerations I have now stated, 
the circumstance could not arise from the increased cleanliness, and general im- 
provement of London; but from a strict adherence to quarantine laws.* 

Objections by the Non-Contagionists. — [The objections made to these views, 
by those who maintain that the disease is solely caused by epidemic influences, 
are the following: — I. A miasm emanating directly from a plague-patient, or the 
transmission of the disease intermediately by fomites, are facts by no means con- 
clusively proved; in truth, the whole statements in favour of contagion are imper- 
fect and unsatisfactory. 2. Certain places, when the immediate neighbourhood 
was under the influence of plague, have not been kept healthy by means of quaran- 
tine regulations. It has often been shown, that in such situations some few cases 
have occurred, but that the disease has not spread; which immunity has been 
attributed to the ventilation and internal discipline rendering those within the 
cordon less susceptible of the epidemic influence. 3. Many of those in the most 
constant communication with the sick, do not take the disease; the attendants, who 
perform all the necessary offices, as well as the medical men, escape; and many 
who have advocated the doctrines of anti-contagion have ventured with impunity 
upon the more rash and hazardous experiments of tasting the secretions, wearing 
the clothes, and sleeping in the beds of those aflTected. Those engaged in burying 
the dead, are not more subject to plague than other persons; and even sexual in- 
tercourse has been known to take place, without communicating the disease. 4. 
The evidence of plague being communicated by inoculation, is any thing but satis- 
factory. It has already been remarked, that to make the experiment conclusive, 
the person to be inoculated with plague-matter should be living in some district far 
from the local or general influences of the disease. On the contrary, those cases 
previously referred to, where this method produced no results, go far to negative 
the communicability of the disease through the medium of pus, or other plague- 
products introduced into the system by inoculation. 5. The occurrence of sporadic 
cases is conclusive against the notion, that contagion is the sole origin of plague; 
and the existence.of those cases, without spreading the disease, is a fact which 
militates gready against its being contagious at all. It is evident that the occur- 
rence of isolated cases in large cities, which is not nnfrequent, is a fact totally irre- 
concileable with the doctrines of contagion, as sanctioned by its advocates. 6. 
When the disease becomes prevalent in a district, it is found to occur in situations 
and among individuals where there is the least possible communication with the 
infected; and it frequently breaks out in remote and separate parts of a town, with- 
out any traceable intercourse or communication, 7. In maritime towns, where it 
is said to have been imported, it frequently happens that those who are the first 
affected, live in parts which are distant from the shore, and therefore not in the 
nearest and most likely places to receive the infection. 8. It is found to arrive in 
many localities at the same time; and this applies both to the country and to towns. 
In the East, it is frequently observed to arise within a few days in places which 
are not only very distant, but in circumstances which prevented communication; 
and to occur, in like manner, simultaneously in different parts of the same town; 

• We believe that, were they perfect and pracLically well carried out, which they cer- 
tainly are not, they would yet be, comparatively speaking, useless. But they are, as now 
worked, nut only useless, but most severe and vexatious incumbrances upon^he liberty of 
the person; while the lazarettos— from the situations in which they are placed, from the 
nature of the buildings themselves, and from the ignorance of the rnedicai men which are 
appointed to them— tend unnecessarily to harass and annoy the individuals condemned to 
confinement in them, as also to constitute them places where disease may be rather origin- 
ated than prevented. ^^ Library of Medicine;' Volume I; Page 212. 



PUSTUL.^. 453 

— facts wliich evidently show a more diffused influence, than is probable on the 
supposition of human contagion. 9. Notwithstanding all the very curious and in- 
genious modes in which the propagation of plague has been said to have taken 
place, the possibility of which it requires a very large share of oriental credulity to 
believe, the disease is really very difficult to propagate by any means which as yet 
have been devised by man. Many instances of adventurous experiment, made 
without success, sufficiently prove this. 10. Numerous instances may be quoted, 
of large masses of persons moving from an infected district without carrying the 
disease with them. The contagionists state, that immense multitudes of hadjis, or 
pilgrims, — who go every year from Turkey to Arabia, through both Syria and 
Egypt, — are the instruments by which the plague is spread in the countries thus 
visited by them. So far, however, is this t^rom being the case, that the marches of 
these people, in different years, take place at different seasons, while plague is a 
disease more especially of one season; and that, excepting when these marches of 
the Mussulmen coincide with the plague-season, their progress is not characterized 
by its occurrence; and, moreover, that many of the districts through which they 
pass, during their pilgrimage, are never known to suffer. In 1824, when the 
plague raged so fiercely in European Turkey, many thousand Turkish pilgrims 
passed through Alexandria, on their way to the Holy City; but in Alexandria there 
was only one case of plague; though no precautions were taken, and no quarantine 
regulations then existed to interrupt their progress. 11. Plague is a disease of 
endemic origin; and, therefore, all those cases which are said to have been caused 
by contagion, are really owing to endemic influences. 12. The spontaneous and 
sudden decline of plague at a particular season, disproves the operation of a conta- 
gious principle; — this being evidence, that plague is influenced by climatorial 
changes; a condition which the advocates of contagion do not suppose consonant 
with its laws. On the other hand, it proves plague to be owing to some endemic 
influence which has now ceased to exist. On this periodic cessation taking place, 
in the countries which are the most frequent seats of the disease, the inhabitants 
lose all dread; and from experience know, that without any evil consequences 
they may meet each other, visit the sick, and wear the clothes of those who have 
died. 13. Besides the above more general arguments against contagion, an infer- 
ence to the same effect may be drawn from the fact, that before plague sets in, es- 
pecially in such countries where it is of more rare occurrence, diseases of a putrid 
character and fatal tendency are prevalent; and that epizootic affections take place, 
and frequently cause great mortality among animals.*] 

Period of incubation. — When the poison has been applied, the disease generally 
appears in from three to five days. 

Not communicated by the Dead. — It is said that the disease is rarely caught 
from a dead body. When speaking of the innocuous agency of putrefied animal 
matter, I mentioned the statement of Howard; — that persons did not suffer from 
the stench of the putrefying dead bodies of those who had fallen victims to the 
plague.'' I believe persons may touch the dead bodies, without fear of catching 
the disease; but touching their clothes is another thinsf. It is said by Dr. Ban- 
croft, that all the Turks employed by the French to bury the dead escaped, with 
the exception of one individual. Howard says, that in Turkey people are not 
afraid to handle the dead bodies. 

Treatment. — As to the treatment of the disease, I believe that one-half of those 
who have it perish; and therefore we must (jonclude that the treatment is not very 
successful. But we are told, that the treatment must be conducted on the same 
principles as in common fever. If there be a phlogistic diathesis, active bleeding, 
cold affusion, and calomel, are recommended; but, on the other hand, when there 
is debility, we must exhibit wine, quinina, ammonia, and (if Dr. Stevens be cor- 
rect) the neutral salts, in great abundance. Of course those who follow one ex- 

» " Library of Medicine;" Volume 1; Pages 210 and 211. 
" See Page '31 4. 



454 PUSTULE. ^ 

elusive rule of practice, will kill a great many. Those who always bleed will 
destroy a great number; and those who always give brandy, will do the same. But 
Mr. Madden has compared the two modes of treatment. He says that, where 
bleeding has been had recourse to, the mortality has generally been very great; 
but where he gave strong brandy and water, and induced a copious perspiration, 
liis success was very great. He also gave enemas of the same ingredients; — that 
is to say, hot brandy and water; he sponged the body with vinegar and water; 
soaked the head with vinegar; had hot poultices put on the buboes, till they gave 
pain; and cut into the carbuncles to arrest the mortification; and by this local and 
general treatment he was so far successful, as to save seventy-five patients out of a 
hundred. I should suppose that the period for a lowering plan, in this disease, is 
very short; and that stimulating treatment is preferable. The best antiphlogistic 
treatment would be, not to evacuate blood, but to apply cold water, and purge. 
From the accounts I have seen, 1 should think that active depletion would be very 
dangerous. The moment softness of the pulse is perceived, I should imagine that 
the treatment mentioned by Mr. Madden would be very proper. 

Nature of Plague. — [The phenomena attending the development of plague 
during life, and the lesions observed after death, do not enable us satisfactorily to 
decide upon its proximate cause, or nature. Those writers who have entertained 
theories upon fevers generallly, apply them most complacently to plague; and — 
without much effort, but with some little ambiguity, — reconcile all that takes place 
to their favourite views. We shall not, however, dwell upon the " considerable 
spasm and loss of tone in the extreme vessels" of Cullen; nor upon the " gastro- 
enteritis" of Broussais; — the frequent absence of which (even to the period of 
death) he explains, by saying it has not had time to develope itself; nor to the 
equally puerile views of another pathologist, who states plague to be an inflamma- 
tion of the bronchial tubes; (comparatively speaking, a very rare seat of lesion in 
this disease;) nor upon several others which might be named; but shall content 
ourselves by giving a short abstract of the opinions entertained by Craigie and 
Bulard. The former of these writers applies the general view which he advocates; 
namely, that it is owing to derangement of the capillary system. In reference to 
the disease now under consideration, he says, that *' the remote material agent 
which causes it, whatever that may be, acts upon the capillary vessels, immedi- 
ately or secondarily through their contents, in every tissue and every organ of the 
human body. The result of which is, that the fluids are no longer freely trans- 
mitted through them; — so that there is produced a sudden and almost immediate 
retardation of the motion of the blood through the capillaries of the whole system." 
He infers this to be the case from the four following circumstances: — " 1. The 
arteries of the brain and the investments of the stomach, of the intestinal tube, 
and of the secreting glands, are distended with dark-coloured semi-fluid blood. 2. 
The vessels (of all the organs) are much loaded with dark-coloured fluid blood; 
which escapes immediately on the smallest incision. 3. In several of the organs — 
for instance, the brain, the lungs, the liver, the kidneys, and other solid organs, nay 
even in the muscles, — dark-coloured half-coagulated blood is found fixed in clusters 
of vessels; — so as to form dark or carbonaceous patches and masses. 4. Dark 
grumous blood is found, not only in the right chambers of the heart, but in the 
left auricle and ventricle; in which they are not usually found in ordinary death." 
(" Practice of Physic") 

Bulard is not less ingenious. He states plague to be the contagious product of 
lymphatic absorption. This view is grounded upon the statement, that the only 
symptom which has been remarked as alone and distinct from any other at the 
commencement of the disease, is pain in the lymphatic glands. This is at first but 
a slight throbbing, becoming more violent and continued, and ultimately succeeded 
by swelling and buboes. This change in the lymphatic glands is the only lesion 
which is to be found totally isolated from all others, and it is consequent upon 
changes in the lymph; and therefore each, during the local affection, is to be con- 
sidered only as consecutive to this disorder in the lymphatic system; in which 



PUSTULE. 455 

consists the simple orig-jnal affection, — tlie essence of the dispnse, and without 
which no general disturbance could have occurred. This view Bulard supports, 
on the grounds that the vi^hole system of lymphatic vessels, whether going from or 
to the gland, is not diseased, but only the glands themselves; therefore he argues 
that, as the glands are always diseased and the vessels never, it is evident that the 
malady is not conveyed by continuity of tissue, but that the diseased principle is 
introduced into the lymphatic circulation; and therefore the alteration of the lymph 
is cause and reason sufficient for the phenomena of diseased absorption, the patho- 
logical effects of which are displayed on the glands. The disease, therefore, arises 
from a change in the lymph. This constitutes the primary affection; the second- 
ary effect of which is, that as this degeneration in the lymphatic fluids becomes 
more or less advanced, the blood itself becomes decomposed by the morbid lymph 
entering into its composition by the venous circulation. It thus loses its normal 
qualities, and then causes a general disturbance, — a deep disorganization in all its 
functions; in short, all the derangements of a true poisoning. From this moment 
it loses its physiological character, and assumes one entirely peculiar to itself: and 
hence are to be explained the lesions met with throughout the system — the livid 
colour of the stomach, the swollen slate of its mucous membrane, the softened 
state of the spleen, gorged as it is with black grumous blood, the enlarged and 
softened condition of the heart, &c.; in fact, every lesion which has been men- 
tioned. Hecker, in his account of " the black death," reverses the theory of 
Bulard; — stating that* the blood is first attacked through the atmospheric poison 
acting on the organs of respiration; and that the inflammation in the lymphatic 
glands and other organs, is only consequent upon the change thus effected in the 
vital fluid.*] 



SECTION XL— MALIGNANT PUSTULE. 

The two inflammatory and pustular diseases of which T have next to speak, 
are both derived from brutes. The first is what is called by some writers " the 
malignant pustule;" by the French it is called " pustule maligne;" and I rather 
think it is this disease (though I am not certain) that is called by the Germans 
*' milz-brand." In this affection there is produced a carbuncle, very similar to 
the carbuncle of plague. I do not imagine that the disease is by any means well 
understood; but its existence is an undoubted fact. 

Causes. — When animals have died of a particular disease, in which there are 
pustules tending to gangrene, it has occasionally happened, that the individuals who 
have skinned them have had carbuncular pustules (of a dark colour) take place on 
the surface, and have perished from them. It is said occasionally to have arisen 
from persons having merely touched the blood of an animal, which was killed 
while labouring under this disease. Indeed, one instance is recorded of a butcher 
being seized with a gangrenous inflammation in the face, and speedily dying, after 
having put between his lips a knife, with which he had killed a bullock labouring 
under this disease. Some suppose that disease of this description (a carbuncle 
tending to gangrene, and bearing a resemblance to the carbuncle of plague) is never 
produced but by the contact of the blood, or the secretions, or the body of a brute 
which has died of this disease; or of something which the body has touched; but 
Il:iyer, who gives an account of this disease, considers that, now and then, it occurs 
simultaneously and sporadically. However, I should hardly think him correct. 
It is possible that the person may have touched somethiuif, which had been in 
contact with the animal previously to its having its skin taken off. The animal 
may have been sent to market, and contact is possible (just like the infection of 
scarlet-fever and small-pox) without our being able to trace it. 

History. — It has been described by Morand (a French surgeon) in the history 

» " Library of Medicine;" Volume Ij Pages 207 and 208. 



456 PUSTULiE. 

of the French Royal Academy, for 1766. He there gives - cases of butchers and 
others, who have been affected with gangrenous erysipelas, and carbuncles. He 
thinks it can arise, even vi^ithout an abrasion of the surface, if the blood of the 
aninnal be applied. Enaux and Chaussier described the "pustule maligne," in 
their work on the Treatment of Bites, pdblished in 1755; — that subject being 
followed by a short account of malignant pustules. Two instances are mentioned 
in Hufeland's Journal, for 1822, of diseases of this description, which proved fatal 
to two men. They had been wetted, in the performance of venesection, with the 
blood of a cow labouring under the disease. In each case, the chief inflammation 
found after death was peritoneal; and also they had buboes. The pustules, or 
carbuncles, of this disease, have generally been observed among veterinary sur- 
geons, shepherds, tanners, blacksmiths, butchers, and labourers; — in fact, among 
all those persons who were most likely to come in contact with brutes labouring 
under the affection. It is said usually to display itself on those parts of the body 
which are uncovered; such as the face, neck, hands, shoulders, or arms; — all those 
parts being uncovered, in many descriptions of work. 

Contagious, not Infectious. — I never saw an instance of this disease. I believe 
that, in general, it is not infectious^ but merely contagious. There is an account 
of many people being seized with a disease in 1818, at Ostiano, in Italy. Thirty- 
five persons visited an ill-ventilated stable, which contained three cows and ten 
horses; one of which had laboured under an offensive discharge from the nostrils 
for twelve months. Eleven of them were seized with the disease; and all but one 
(lied. Violent pyrexia, pains, spasms, boils, and at last a large carbuncle, charac- 
terized the first stage; gangrenous vesicles, and a typhoid fever, were the chief 
features of the second. Whether this was the same disease I do not know; but if 
so, it would appear that where there is a want of ventilation, and many animals are 
crowded together, it may be infectious. 

Treatment. — It is at present rather an object of curiosity than of practice; for I 
believe that no treatment does good. Some persons, however, recommend the 
application of the cautery to the carbuncles, as soon as they appear. It is supposed, 
by Rayer, to bear a very great resemblance to the plague in human beings; but it is 
very likely, notwithstanding, to be a different disease. 



SECTION Xn.— EQUINIA. 

Diseases of Brutes communicable to Man. — That the diseases of man are com- 
municable to brutes, is a well established fact. The measles (according to good 
authority) have been imparted to sheep; and, in like manner, have trichoma and 
plague been each communicated to brutes. On the other hand, several diseases 
may be communicated from brutes to men; — as the cow-pox by vaccination, the 
mange from dogs,* and hydrophobia; — the probability being that, in each case, the 
disease may be given back from man to brutes. The cow-pox certainly may;'' and 
Magendie has himself reproduced hydrophobia in a dog, by inoculation from tlie 
froth of a rabid man. To these instances may now be added " glanders;" — a dis- 
ease well known from its destructive ravages among horses, but which has only 
recently been observed to occur in the human subject. 

History. — The fact of iis occurrence in man was first established, or (at least) 
rendered highly probable, in this country, by Mr. Coleman; and by three cases 
which came under the notice of Mr. Travers, and were reported in his work on 
"Constitutional Irritation,"'^ as being very like cases of glanders; but were described 
by him (as if glanders in man were not possible) as instances of a diseased stale of 
the constitution. Mr. Coleman had taken some of the glanderous matter from one 
of these cases, and inoculated an ass with it. Glanders and farcy were the result, 

a In which case the disease in man assumes the appearance of itch, 
b See Page 440. «= See Page 350. 



PUSTULE. 457 

and death ensued in twelve days. Further proof, moreover, was obtained; yet the 
facts were alluded to at the time by Mr. Travers as a matter for wonder, ihat dis- 
ease could be communicated from man to a brute, and yet the disease in the brute 
not be the same as that which existed in the man. 

Case 1. — Of the possibility of this disease occurring in the human subject I 
was perfectly ignorant, when a young man was admitted into St. Thomas's Hos- 
pital, under the care of Dr. Roots, on the nineteenth of March, 1829. 

The upper half of the face— including the eyelids and nose, with a portion of the 
cheek on each side (especially on the right) — was greatly tumefied; — so that the 
eyes were closed. The eyelids and swollen portions of the cheeks, were red and 
hot, dry and shining; but the nose was dark-coloured; and its right half black, cold, 
and senseless. From around the gangrened portion of the nose, and some other 
points, a little pus was oozing, as well as a thin dark-coloured fluid; and /row the 
nostrils a thick discharge {of a deep yellow colour^ here and there a little bloody) 
iims taking place. It was very copious from the right nostril. Several hard 
phlyzacious pustules existed on and immediately around the nose, — still principally 
on the right side; and in various parts of the trunk and extremities. Tumefactions 
werp observed in both fore-arms, and on the back of the right hand. Some of 
these were hard; others softening into suppuration. The temperature was high; 
the pulse 136, and sharp; the tongue white, and rather dry. The respiratory mur- 
mur was indistinct at the lower part of the chest, and the respiration quick and 
difficult. The gums were slightly turgid. It was stated that, twelve days pre- 
viously, he had been attacked by pain in the right hypochondrium, extending up 
the chest, attended by dyspncea, and rigors; that he took ten grains of Pilulse Hy- 
drargyri; and the next day felt quite well. The pain and dyspnoea, however, 
returned on the day following; but subsided at the end of the week; under the use 
of leeches and purgatives. On the Sunday, five days before his admission, a pim- 
ple was said to have appeared on the right side of his nose. While this increased 
and suppurated, the surrounding parts swelled and grew red; and the state of things 
became such as I have already described. 

Fourteen ounces of blood were taken from the arm, and became both buffed and 
cupped. Some of the tumefactions were cut into, and large quantities of pus dis- 
charged. Lint soaked in a solution of the chloride of soda, and covered with a 
poultice of stale beer-grounds, was applied over the nose, and was renewed every 
hour; and a common poultice was applied to the abscesses which had been opened. 
An ounce of castor-oil was given; and the diet restricted to slops, milk, and arrow- 
root. 

Late in the evening, two greenish and very offensive stools were passed involun- 
tarily; and a litde delirium was observed. Tumefactions had begun upon both legs, 
one upon the left hand, and one upon the right elbow. The next morning, more 
tumefactions were seen upon the extremities. They were red, — as all the others 
had been; but the latter had now acquired a purple tint; and the wounds looked 
dark. The forehead was swollen and red; and more pustules had formed upon the 
face. There was constant agitation, frequent delirium, and profuse diarrhoea; and 
there had been no sleep. Mistura Gretas was ordered; sixteen leeches were ap- 
plied to the temples; and strong beef-tea was added to the diet. In the evening, 
the diarrhoea was checked; but the upper lip had grown very dark. Sordes en- 
crusted the teeth; the surface, still hot, was covered by a profuse sweat; and many 
new, hard pustules, were seen upon the trunk and extremities. The pulse had 
become soft, and was small and rapid. Twenty-five minims of Tinctura Opii were 
given in the first dose of the Mistura Cretae; and one grain of the Quinae Disulphas 
every four hours was prescribed. The Oleum Terebinthinae was substituted for 
the solution of the chloride of soda. 

He was calm after taking the opium; but, about four o'clock in the morning, was 
observed to breathe with more difficulty, to be unable to swallow, and to be con- 
stantly delirious. From that time he sunk gradually; and expired at six. 

I was not present at the inspection; but understood that there were proofs of a 



458 PUSTULE. 

violent pleuro-peripneumonia in the lower part of the right side; and that two ounces 
of heaUhy pus were found between the adherent lung and diaphragm. A dark red 
patch existed in the stomach, and several at irregular distances throughout the 
intestines. The mucous membrane of the stomach was very lacerable at that spot. 
The other viscera, and all the contents of the head, as well as the veins of the ex- 
tremities, were reported healthy; but the mucous membrane of the nostrils was not 
examined. The abscess which had been opened in the back of the right hand, 
communicated with the joint of the metacarpal bone of the middle finger; but those 
on the arm did not communicate with the elbow. 

The appearances suggested to me the idea that some deleterious matter had been 
introduced into the system. I inquired if he had probably been in the way of 
catching such a complaint, if he knew of any one similarly affected, and if he had 
taken any other food than was good and habitual to him, or was used by the rest 
of the family. But all these questions were answered in the negative; and there- 
fore, when asked by the pupils my opinion, 1 declared myself perfectly at a loss. 

Case 2. — On the following June, I lound a young man lying in one of my beds, 
in precisely the same state. The nose and surrounding parts were exceedingly 
swollen; so that the left eye was closed completely, and the right nearly. The 
tumefied parts were hot, and of a bright red, with the exception of an inch of the 
left half of the nose; which was of a mulberry-colour; — precisely the same state 
of things, that occurred in the other young man.'' A profusion of deep-yellow 
tenacious mucus, with a few streaks of blood, exuded from each nostril; but par- 
ticularly from the left. Several hard phlyzacious pustules existed on the nose and 
adjacent parts; as well as on the arms, thighs, and legs; and each was surrounded, 
in the latter situation, by a blush of red. A patch of the same colour was observed 
on the left elbow. His pulse did not justify bleeding; it was rather an undulation 
than a pulsation. I ordered him beef-tea, wine, and sulphate of quinina; but he 
was dead in a few hours,'' 

As in the former case,'' the father was present at the inspection; and he would 
not allow the head to be examined, or any incisions that would disfigure to be 
made. Many j^iarts of the lungs were gorged with blood and frothy fluid, and the 
corresponding bronchial branches were very dark; numerous papillae, with pointed 
black summits, were seen at the end of the ilium; and clusters of minute grayish 
black points throughout the small intestines, and most abundantly at the com- 
mencement of the duodenum. The walls of the left ventricle of the heart were 
very thick. Nothing, however, was detected, either peculiar or important, or cal- 
culated to throw the faintest light upon the disease; — a disease which to me (I 
confess) was truly awful; — from its suddenness, rapidity, gangrenous source, and 
seemingly uncontrollable power. 

While I was standing at the bed-side, considering in silence the case before me, 
its identity in nature with that which I had seen in March,* appeared certain; and 
the disease appeared, as certainly, to be a specific eruptive fever. I therefore 
stated to the pupils, that while at the occurrence of the former case,* I had only 
the idea of some deleterious agent (without being able to imagine of what kind), I 
now felt satisfied that this agent in the two cases was a morbid poison; — a poison 
furnished by a living system under the same disease. I put the same questions to 
this patient and his friends, as in the former instance;* and received the same nega- 
tive answers. 

The morbid poison could not have been generated in the system of the patients 
themselves: because their clean appearance, and the good circumstances and 
respectability of the friends with whom they lived, were such as to preclude the 
generation of any morbid poison. Although acting but seldom upon human beings 
in this country, still its residence among us was certain, if it really existed; for 

a See Case 1, Page 457. 

^ A drawing was made of each patient ; that of Dr. Roots's was executed by Mr. Solly; 
and the other (which contains two representations, — the one before^ and the other after 
death) by Mr. Alcock. 



PUSTULE. 459 

neither of the patients had been near persons from abroad. Yet no other person in 
the vicinity of either patient, or anywhere that either had been, was known to have 
had such a disease. The morbid poison, and its residence among us (of which I 
entertained no doubt), together with the circumstance of its rarely affecting human 
beings, now seemed fully explained by the supposition, that the disease was one 
common to some of our brutes; and the profuse discharge from the nostrils, and the 
tumours and tubercular pustules on the surface, agreed with the supposition that 
this disease was the glanders. 

Case 3. — Soon after this, a "Fatal Case of Acute Glanders in the Human Sub- 
ject" was reported, in the "London Medical Gazette,"* by Mr. Brown, — a sur- 
geon in the second regiment of dragoons; which, on examination, I found to agree 
precisely with the cases above described. The man was seized, on the night of 
the sixteenth of April, with rigors, headache, and slight irritability of the stomach; 
— all the symptoms which usher in an eruptive fever. However, he had great 
pains and stiffness of all the large joints; and these increased to an alarming 
degree. The left shoulder was rather swollen, though not inflamed; but the tume- 
faction became considerable, and of a livid hue. Similar swellings, but smaller, 
took place on the arms, legs, thighs, and sacrum; — exacdy as in these cases in the 
hospital. The tumours were insensible and hard; but, in the cases in the hospital, 
the tumours were soft. They were of a chocolate-colour; but acquired a deep 
vermilion hue, and soon became of a dark brown, One appeared upon the left 
temple; and the eye-lids became tumefied. The right nostril was gummed up 
with an inspissated discharge. The posterior fauces were much inflamed, and 
nearly of a purple hue. Several watery pustules (which I have termed " phlyza- 
cious") rose above the skin, in various situations around each of the tumefactions. 
On examination after death, a cluster of tubercles was found in the cellular mem- 
brane exterior to the pericranium'' of the left superciliary ridge, and in the right 
frontal sinus; — exacdy resembling (according to Mr. Brown) those observed in 
the frontal and other sinuses of the hoise, af^ter acute glanders. On dividing the 
various livid tumours down to the bone, the muscles appeared perfectly decom- 
posed, and of a dark livid colour; and under each was a cluster of gray circular 
tubercles. The existence of these tubercles is so common in the glanders of 
horses, that one French writer takes this for a tubercular disease; and it is de- 
scribed under that name in a French Veterinary Dictionary. The army-surgeon 
adds: — " It appeared that the patient had had, for some time, the sole charge of a 
glandered horse, which had been destroyed on the very evening of his attack; and 
that he had skinned him; and exerted himself a good deal, in cutting up and bury- 
ing the carcase. But these circumstances did not at first create the least suspicion: 
and his complaint was considered a very severe case of acute rheumatism; and was 
treated as such." 

Case 4. — About a fortnight or a month afterwards, a general practitioner at 
Clapham, to whom I mentioned these cases, told me of a case which he thought 
was of the same description. A young man (a pupil of the Veterinary College, 
and the son of a veterinary surgeon at Clapham) had been seized with a very- 
severe acute affection of the knee-joint (apparently rheumatic;) and with severe 
pains; — just like the other cases. He proposed that I should see the patient; but 
the father put it off till the next day, and in the interim the son died. Before 
death there was a copious sero-mucous discharge, occasionally a little bloody, from 
the eyes and nose; the Schneiderian membrane was excessively red and nearly 
excoriated; and the eyes were closed. A pretty abundant eruption, very similar 
to small-pox, but larger and hard, appeared in different parts; but particularly the 
neck. There was scarcely any sleep; but occasionally delirium, and at length con- 
vulsions; and the patient died. Unhealthy pus was found in the absorbents of the 
arm; and the bursa of the knee contained a large quantity of pus, with flakes of 

« Volume 4; Page 134. (No. 83; July 4, 1829.) 
*• From TTjpj, about; and x^avtov, the cranium. 



460 PUSTITL^. 

coagulable lymph. He appeared to have had under his care, at Clapham, a horse 
affected wiih " farcy-ghinders.'"* The ring-finger of the rjfrht hand, and the 
absorbents and axillary glands, became all at once inflamed and painful; but whe- 
ther after any wound or abrasion, could not be satisfactorily ascertained. The 
finger suppurated and was opened; and, a few days afterwards, he was seized with 
headache and pains in his limbs; which pains wera considered rheumatic. 
There were afterwards pimples on the face; and a profuse discharge from the 
Schneiderian membrane. 

Commimicated to Man hy Brutes. — The perfect correspondence in the symp- 
toms and progress of those cases that had fallen under my observation, with those 
of Mr. Brown's case,^ convinced me that an active investigation would trace the 
origin to horses, from which they had received the contagion. I had a great deal 
of trouble in endeavouring to ascertain this fact, and indeed I could not prove it at 
last; but I found that these men (although in an occupation that one would sup- 
pose would never lead them near horses,) had actually been in the neighbourhood 
of glandered horses. Further than that I could not ascertain; but it is a very sin- 
gular circumstance, that this was satisfactorily proved. I found, with respect to 
my own patient, that he was a whitesmith, at Lambeth. I went there, and inquired 
whether he had had any thing to do with horses; taking it for granted, that, as a 
smith, he had. They told me that he had never been near horses; — that he was 
a ivhite'Sm\\\\. However, I went to the workshop, and found it situated in a 
mews. I then asked if there had been a glandered horse in the mews; to which 
the father replied — " No;" but one of the men immediately said — " Why, don't 
you recollect there was a glandered horse in the stable, for six weeks, just next the 
corner where Tom used to work?" He then showed me that the boards which 
separated the stable from the whitesmith's shop were so defective, that the dis- 
charge from the animal's nostrils had come through; and occasioned so great a 
stench, that the young man frequently said he should not be able to work, unless 
the horse were taken away. T learned, that when this horse was being led to the 
knacker's, about a month before the commencement of this disease, it fell down 
exhausted at the door of the forge; and that he went and patted it about the head 
as it lay; and took hold of the head while the rest endeavoured to make the animal 
rise, i also found that he had a number of pimples on his face, which were raw; 
and his faner said he recollected that his son had got a habit of wiping his nose 
with the back of his hand. So far I went; and, though this is not proof, yet these 
are singular facts. 

With respect to the man that came first to St. Thomas's,'' he was a tailor; and, 
tailors not being famous for horsemanship, 1 almost despaired of being able to trace 
any connection between him and a horse. But at last I found, that the next-door 
neighbour of the man to whom this lad was apprenticed, had kept a worn-out 
pony in a filthy wretched shed, opposite the two houses. I ascertained that the 
animal had glanders, and was afterwards killed on this account; that this youth 
was in the habit of harnessing it, and getting into a little cart which it dragged, to 
have a ride. Nothing is more likely, than that he had brought some of the matter 
from this horse in contact with him. 

An examination of the history and progress of these, and other cases which had 
occurred in Germany,*^ led me to conclude that the cases in question were those of 
true glanders, and that man is susceptible of its contagion, on comings in contact 
with animals labouring under it. My reasons for this opinion are the following: — 
1. There is a perfect similarity and uniformity of the symptoms and course of all 
the acute cases of the affection; and they are quite distinct from those of any other 
disease. There is a perfect correspondence between the post-mortem appearances 
in cases that have been properly examined, and those that present themselves in 
the horse. 3. Each of these persons had been in communication with a glandered 

^ See Page 461. ^ See Page 459. <= See Page 457. 

d See Rusi's " Masrazin fur die Gesammte Heilkunde:" Volumes 11 and 17. 



TJJSTULM. 461 

horse; though the occnpations of some of them had rendered this extremely im- 
probable. 4. Glanders were produced in asses, by inoculaiion with matter taken 
from some of these cases. 

a. appearance and Varieties in the lower Animals. 

Varieties'. — Although it would be foreign to the character of this work to enter 
into a minute description of glanders as it occurs in the lower animals, still, as the 
disease may (and, as we have seen, does occasionally) occur in man, some notice 
of it is rendered necessary. Glanders may appear in two forms; — first, as ulcera- 
tion of the nostrils; and, secondly, as tumours arising in various parts of the body, 
combined with corded or elevated lines in the neighbourhood of the tumours, 
formed of what are thought to be the absorbents. "When the disease is limited to 
the former symptom, it is called " glanders;" when to the latter, " farcy." The 
two, however, are the same disease, though distinct in name; and, from "glanders," 
the affeciion will at length become " farcy."* 

Acute Glanders in the Horse. — The pituitary^ membrane is very red, and very 
much inflamed; and presents little erosions, which take place rapidly, and become 
chancres (if we must, in compliance with custom, so call them); with edges thicker 
and moie exuberant than those of the milder form of the disease. Sometimes the 
lips and the end uf the nose swell; and afterwards the ulcerations commit more 
extensive ravages, and give rise to a discharge of a purulent appearance, and occa- 
sionally of a disagreeable smell. A fetid, purple, and perhaps bloody sanies, is 
mixed with it from time to time (at least in some instances); and, at length, the 
nasal membrane looks gangrenous. The discharge continues, and becomes more 
abundant; even blood issues from the nose. The sublingual glands, which are 
much swollen in all the forms of the disease, are more painful than in the mild 
acute glanders. The conjunctiva and nasal eyelid (" membrana nictitans") are at 
first inflamed, and injected with blood; and afterwards acquire a violet hue. The 
eyelids swell, and the eyes discharge. The local phlegmasia soon extends to the 
surrounding parts; respiration becomes laborious; the superficial vessels are suc- 
cessively congested; and the animal dies, in spite of all we can do; — frequently in 
a few days, at other times after a longer or shorter interval. If the disease is pro- 
tracted, the symptoms occasionally, though rarely, relax; and the inflammation 
declines. The animal then appears partially to regain its powers, and may be to 
a certain degree useful; but the state of the pituitary membrane, and of the auge^ 
and the permanence and character of the nasal discharge, show that the acute stage 
has degenerated into the chronic. It is in this form, especially, that attacks of 
glanders may be considered epizootic. That violently acute glanders is always 
speedily fatal, and never becomes chronic, is disproved by the following fact: — In 
a stable of eighteen horses and three asses, all of which were affected, ten died 
within the first days of the attack; four, after the violence of the disease had abated, 
remained stationary for two months, and then were cut off by a return of the 
inflammatory symptoms; — a relapse into the acute stage. The seven which sur- 
vived presented all the symptoms of chronic glanders, and worked in the country 
nearly a year, when it was thought proper to kill them." 

Chronic Glanders in the Horse. — The symptoms of chronic glanders in the 

» Mr. Vines (in his work on glanders) says, that when the skin only is affected, — as with 
buds, ulcers, or (Edematous sweHings, — the symptoms are called "farcy;" but when the mu- 
cous membrane of the nostrils and lungs partakes of the disease, and becomes ulcerated, — 
with a discharge of unhealthy matter from the nostrils, and swelling and induration of the 
submaxillary lymphatic glands, — it then takes the name of "glanders;" but wiihout any 
real ditference being necessary in their treatment, although one set of symptoms may exist 
independently of ihe other. 

*" From " piluita," _pAZeo'm. 

c Dictionnaire de Medfcineet de Chirurgie Veterinaires." Article, " La Morve;" Pages 
458 and 459. (Third Edition.) 



462 PUSTULiE. 

horse, are thus detailed by Mr. Blaine:'*— "An increased and diseased secretion 
from the membranes of one or both nostrils, continually flows in small or large 
quantities. This discharge is seldom at first perfectly purulent; but is more glairy, 
thick, and not unlike the white of egg, and it sometimes continues thus for a long 
time; at others, it soon becomes purulent; but even then there is always a degree 
of viscidity and gluiness in it, that sticks the nostrils together (as it were) from its 
tenacity; differing from other pus, and which very circumstance strongly charac- 
terizes the complaint. The general colour of the Schneiderian membrane becomes 
changed, first to a violet colour, and afterwards to a leaden hue. As ulceration 
takes place, the discharge becomes bloody, and sometimes sanious and offensive; 
— which is always the case where the bones prove diseased. From an absorption 
of the morbid matter from the nose, by the lymphatics of the part, the lymphatic 
maxillary glands under the jaws (through which these vessels pass) become swollen 
and tender; and, as one side of the head only is sometimes affected with ihe glan- 
dered running, in such case one lymphatic gland only is tumefied; and, of course, 
the one of the affected side." — "The disease sometimes remains long without pro- 
ducing ulceration; at other times, on the contrary, an ulcerating process quickly 
appears. The ulcers have a very peculiar character. They are not unlike the 
venereal chancre; but usually commence by small limpid bladders; which soon 
ulcerate into a sore of a particular kind; and where there are several of them, they 
are always placed high in the course of the lymphatics." — "As the disease ad- 
vances, much of the Schneiderian membrane becomes ulcerated; till, at length, the 
bones prove carious. At an uncertain period of the disease, the lungs become 
affected; when hectic symptoms soon follow, with tubercles which ulcerate; fre- 
quent vomicae also form and burst; there then appear cough, emaciation, and weak- 
ness in the loins; the hair feels dry, and falls off on being handled; the matter 
from the nose increases in quantity, becomes sanious, fetid, or bloody; and is 
coughed up by the mouth also; and, in this state, the animal dies." 

Farcy in the Horse. — [The farcy generally appears in the form of small tumours 
(called by farriers "buds"), or small ulcers, about the legs; sometimes on the lips, 
face, neck, or other parts of the body. These tumours are, in some cases, so small, 
so few in number, and create so little inconvenience to the animal, that for a time 
they escape observation; at other times they are larger, more numerous, painful to 
the touch, and spread more rapidly; and, in these instances, a general swelling of 
the limb often takes place, particularly when the hind legs are attacked; and some 
degree of lameness ensues. The tumours (or "buds") are at first hard; but soon 
become soft, and burst; — degenerating into foul ulcers, of a peculiar appearance. 
The edges of the skin surrounding the ulcer, terminate abruptly; and the surface 
of the sore has a pale glossy appearance. The lines of communication between 
the "buds" or ulcers, are generally very observable; particularly when they occur 
on the inside of the limbs, where the superficial veins are large: — as in the thigh. 
They consist of what the farriers call " corded veins;" but, in reality, are inflamed 
and enlarged lymphatic or absorbent vessels."**] 

h. Appearance and Varieties in Man. 

Varieties, — I propose to call this disease "equinia" when it appears in the 
human subject, — as indicating its communication from the horse; for the same 
reason that "cow-pock" has been called "vaccinia," It may occur as true glanders, 
characterized primarily by ulceration of the nostrils; in which case I would call it 
"equinia catarrhalis;" or as farcy characterized by tumours in various parts, — 
"equinia apostematosa." Equinia may be either acute or chronic; but it has been 
observed more frequently, I believe, in the chronic form. The three cases, re- 

* In his "Outlines of Veterinary Art." 

b «'A Treatise on Veterinary Medicine. By James White." Pages 7 and 8. 



PTTSTULJE. 463 

ported by Mr. Travers,* are examples of chronic eqninia; though not reported as 
such by him. The other cases which I have detailed,^ may be considered as in- 
stances of acute farcy and glanders. 

Symptoms of Equinia Catarrhalis. — [The disease ordinarily presents the fol- 
lowing phenomena in its progress, when it occurs in the acute form. Articular or 
muscular pains, in some cases simulating rheumatism, followed by subcutaneous, 
circumscribed, painful swellinffs (the probable result of angeio-leucitis); which 
either undergo superficial mortification, or are converted into abscesses, containing 
either laudable or sanious pus; — a yellowish, viscous, nasal discharge, of limited 
quantity; issuing, in the great majority of cases, from both nares; and first ob- 
served from the {"ourth to the sixteenth day; accompanied, in some instances, by a 
similar excretion from the mouth or eyelids; — occasional tumefaction of the nose 
and adjoining parts followed by gangrene in one-eighth of the cases; — in very rare 
examples, swelling of the submaxillary lymphatic glands, or depositions of pus 
therein; and, pretty frequently, inflammation of the throat and tonsils; — a peculiar 
pustular eruption, differing from all varieties hitherto observed; namely, gangrenous 
bullae, appearing (towards the twelfth day of infection) on the face, arms, thighs, 
and anterior surface of the trunk; and sometimes preceded or accompanied by pro- 
fuse fetid sweats; a rapid and full pulse at the outset; subsequendy weak, de- 
pressible, and sometimes intermittent; and, as death approaches, extremely small 
and frequent; — diarrhoea, with watery stools, of a cadaverous smell, and occasion- 
ally containing dark coloured blood; — dental sordes; — dry, brown tongue; — tympa- 
nitic abdomen, with hardly any abdominal tenderness;- — thirst, in a few cases; — 
difficult deglutition; — occasional vomiting, especially towards the close; — no typhoid 
maculae on the surface; — violent cerebral symptoms, terminating in delirium, coma, 
and death."] 

M. Rayer distinguishes three varieties of the acute form of this affection; — the 
pustular, the gangrenous, and the pustulo-gangrenous. — "In some cases, the most 
striking phenomena consist of a pustular cutaneous eruption, a thick and glutinous 
nasal discharge, and a typhoid aspect. In others, the symptoms of nasal lesion 
are obscure; while the external characteristics (the pustular eruption and gangrenous 
affection of the skin) predominate. Again: pains in the limbs, purulent deposition 
in various parts of the body, and inflammation of the lymphatic vessels and glands, 
form, in the outset, the most striking features of another set of cases, still more 
strictly analogous in character to the acute farcy-glanders of the horse. Lastly: 
there are others more violent and promptly fatal; in which all these morbid changes 
and symptoms appear rapidly and at once, a few days after vague initiatory pheno- 
mena."* 

Symptoms of Chronic Equinia Catarrhalis. — The following case of chronic 
glanders, will best illustrate the symptoms in this form of the affection: — Thomas 
Gue, aged 50, was admitted on the thirtieth of April, 1835, under my care. He 
had been a sailor during the greater part of his life; but has lately followed the 
occupation of a groom. About two months since, his master having a glandered 
horse, he administered medicine to the animal, and washed his mouth; he also 
cleaned the nose with a sponge and warm water. He does not recollect that any 
portion of his hands were abraded of cuticle: but he had an open sore on his lips; 
— the consequence of a blow from a hammer. The horse occasionally sneezed in 
his face, which he wiped with the same cloth that he had used for the horse's 
mouth and face. About three weeks prior to admission, he was seized with the 
following symptoms: — a dull aching pain across the brows and in the eye-balls; 
his nose felt stuffed; and there was a considerable discharge of thick, yellow, offen- 
sive pus from one of the nostrils; no ulcers were discernible on the pituitary mem- 
brane; but, from the patient's statement, they probably existed in the more remote 

^ See Pa.o^e 456. d See Pages 457 to 4G0. 

<: Analvsis of " Raver on Glanders and Farcv in Man," in the "British and Foreign 
Medical Review/' for July, 1838. (Volume 6; Pa^e US.)' 
d Rayer on Glanders and Farcy in Man; Page 642. 



464 " PUSTULJE. 

parts of the nose. The throat, on pressure, was rather painful, and the lymphatic 
glands were enlaro^ed. He had also cough, and expectorated matter of a similar 
character to that discharged from the nose. His health had not been disturbed 
until about two days previously to admission; when he lost his appetite, and was 
seized with a pain in the epigastric region. This man recovered under the use of 
kreosote as an injection. " At a later period, sometimes after several months, 
tumours begin to appear in difTerent parts; and their evolution is accompanied by 
rigors, nausea, delirium, general febrile disturbances, and frequent slimy evacua- 
tions. From this state the patient seldom recovers, but in general sinks gradually.'"^ 

Chronic Equinia Jipostemaiosa. — [In this form of the disease, the nasal mem- 
brane at first remains sound; and small tumours gradually appear about the face, 
trunk, and limbs. These break; — producing an unhealthy discharge; and are 
attended or followed by purulent collections in the joints, or various parts of the 
body. The disease may terminate fatally in this manner; but the nasal afiection 
often comes on at a later period.*] 

Causes, — Among the various diseases of the lower animals to which man is sus- 
ceptible, equinia is the most readily communicable of them all. According to the 
testimony of the best veterinarians, it is contagious (in the restricted sense), not 
infectious;* it is therefore only communicated by contact with the diseased secretion 
from t!ie mucous membrane of the nostrils in glandered horses, or the pus pro- 
duced in tumours on other parts. To render its contagion efTective, abrasion of 
the surface is necessary; as it is believed, by most veterinary surgeons, that glan- 
derous matter never excites the disease in the horse, even if applied to the pituitary 
membrane, while the surface is entire.'' 

Period of Incubation. — [There occurs in this, as in other contagious diseases, 
a variable though limited period of incubation. Thus, after the inoculation of 
glanderous matter, a period of from two to eight days, or more, elapses before the 
occurrence of any notable symptoms. At the end of this time, the evidences of 
local irritation appear at the injured part; its extension follows; — as is proved by 
the condition of the neighbouring lymphatic glands and vessels, and by general 
febrile phenomena. In some instances these local symptoms were slight, and 
easily relieved; the patients even appeared on the brink of recovery, when the 
essential and specific symptoms of glanders supervened. When the disease is con- 
tracted by infection, the invasion is marked by fever; attended by gastric symptoms, 
diarrhoea, or pains of the lim.bs.*^] 

Duration, — [The duration of acute and chronic equinia, is very various. In 
the former, death may occur in a few days; but, in the greater number, life has 
been prolonged beyond the twelfth day, and in some cases to the thirtieth. The 
chronic variety may last a month only; a few tumours and pustules slowly form, 
and disappear under curative measures; sometimes ten months have elapsed before 
the fatal termination occurred.^] 

Treatment. — All attempts to cure the acute form of this disease have hitherto 

* " Library of Medicine;" Volume 1; Page 406. »> See Page 300. 

e The opinion here expressed by Dr. Elliotson, is no longer general. Dr. Eck, of Berlin, 
in a recent and valuable paper, thus expresses himself: — "Though ihe glanderous nasal 
discharge is recognised as the chief vehicle of infeciion, and (on this account) the use of 
harness, mangers, drinking-vessels, &c., which have been in contact with glandered horses, 
and are liable to be brought in contact with the pituitary membrane of sound animals, is 
especially to be feared; yet it can hardly be doubted, that the contagion may exist in the 
other excretions; nay, that occasionally, as in damp stalls, infection may take place without 
any observable contact;— probably through the medium of respired air." ("British and 
Foreign Medical Review;" Volume 6; Page 116.) This opinion is also adopted by Rayer; 
who has divided his collection of cases into those, — " where no local results of inoculation 
are observed; the first symptoms being those of a general infection of the system;" and those, 
— " where the earliest phenomena are angeioleucitis, local phlebitis, or diffuse cellular in- 
flammation in some region of the body, usually the arm; while the lesions and symptoms of 
glanders do not appear until subsequently." (Rayer on Glanders; Page 643.) 

d Analysis of Rayer, on Gl mders; inihe "British and Foreign Medical Review;" Volume 
6; Page 117. (No. 11; July, 1838.) 

e " Library of Medicine;" Volume 1; Page 406. 



PUSTULE. 465 

failed. Rayer is decidedly hostile to bleeding, either topically or generally; — as 
tending to accelerate prostration, stupor, and local gangrene. On the other hand, 
bark and other tonic antiseptics have proved equally fruitless. Rayer recommends 
the immediate excision of the swollen glands, in the early stages of the disease; 
and if the local inflammation following this operation, or resulting from the inocu- 
lation alone, were intense, " debridement" and mercurial frictions might (he pre- 
sumes) be employed with advantage. He also recommends the employment of 
repeated purgings, and the exhibition of large doses of acetate of ammonia; — a 
favourite remedy with veterinary surgeons. As to topical treatment, he advises 
the free incision, and subsequent cauterization of the pustules and abscesses; while 
the patient's strength is supported by tonic drinks, and generous wine diluted with 
gaseous water. Solutions of the chlorides, — used as gargles, taken internally, or 
injected into the nostrils, — have been recommended; — on account of their powerful 
antiseptic properties. Turpentine — either in the form of warm embrocations ap- 
plied externally, or administered internally in small and frequently repeated doses 
— has also been recommended.* The patient's excessive thirst should be assuaged 
by the use of soda-water, or^slightly acidulous drinks. 

In two cases of chronic glanders which have come under my notice, the em- 
ployment of kreosote has been attended with complete success. In one case, that 
of Thomas Gue already mentioned," the injection of a solution (consisting of one 
minim of kreosote to an ounce of water) into the nostrils, effected a cure in about 
three weeks. In the other case, this man's master, I administered it internally, in 
addition to the injection, with the like result. From one to three minims may be 
administered daily. 

A ^ew words as to the sanatory applications of the facts which are now so pro- 
minently before us. The subject is one of the highest public importance; and 
demands the serious consideration of those on whom the care of the public health 
devolves. The facts peremptorily behove all persons who have any thing to do 
with glandered horses, instantly to destroy them; and in all cases to do so, unless 
a cure be discovered for the disease, or some new mode of treatment be proposed. 
I am told by Mr. Youatt and other veterinary gendemen, that at least forty-nine 
out of every fifty glandered horses ultimately perish of the disease. Then why 
suffer animals so frightfully dangerous, to linger out the remainder of an existence 
which they pass so wretchedly, and run the chance of giving the disease to other 
animals and to men? With such evidence before us, every glandered horse in the 
kingdom ought to be kdled forthwith; — unless it is thought fit to institute some 
new investigation into the treatment of the disease. Nothing can be more wrong 
than to keep glandered horses alive for the little work which may, in spite of the 
debilitating effects of the disease, be forced from them. Let their owners but 
reflect for a moment on the multiplied opportunities which occur for contagion 
between these animals; the innumerable occasions for smearing, with a poisonous 
matter, the various parts of the stable; the risk of depositing it on the grass when 
turned out; and, above all, of giving it to man; who must assuredly perish by it in 
the most dreadful manner; — for no remedy is known for it. The effect is awful to 
me beyond any thing that I ever witnessed in disease. Here we may have young 
men in all but perfect health one week, — after acute suffering, offensive discharges, 
and sores and putrefaction, corpses the next. I thought when I had seen the fatal 
cholera, that I had witnessed the acme of sudden suffering and death; but the man 
who is glandered presents a scene quite as heart-rending to our view, as the cholera- 
patient. 

* Dr. Pedduck, in a letter to Dr. Elliotson, published in the " Lancet" for February 19, 
1831, (No. 390; 1830-1, Volume 1, Page 689,) has related a case of glanders in the horse, 
which was successfully treated with oil of turpentine. The analogy between oil of turpen- 
tine and kreosote, in many respects, explains this success. 

b See Page 463. 
VOL. I.— 30 



466 PURPURA. 



CHAPTER VI. 

PURPURA. 



I SHALL now describe an affection, which consists in extreme congestion of the 
skin, without any injlammation; and is characterized by the presence of peiechise, 
vibices, and ecchymoses on the skin; which occur throughout the body, on the 
conjunctiva, and even within the mouth, and in the interior of the body; — so that 
the blood will actually be poured forth on the various viscera. This disease is 
called at present, in this country, " purpura."* It was formerly called " petechias 
sine febre," or " haemorrhagia petechialis." Rayer has, very properly, separated 
it from inflammatory diseases; and has placed it in the order " congesta." 

Pathology. — It is a very singular disease, and sometimes occurs in the most 
opposite circumstances; — occasionally with great debility, weakness of pulse, and 
exhaustion; sometimes with the most inflammatory state of the system.** Although 
the skin is not actually in a state of inflammation, yet the syster^ is in an inflam- 
matory condition; as is proved by the buffy and cupped state of the blood. 

Analogous to Scurvy. — It bears a great affinity to scurvy, and some fancy it is 
the same disease; but I cannot subscribe to that opinion. ° It is a disease that fre- 
quently happens without any constitutional affection. I have seen persons going 
about with it, and yet quite well in other respects; and in other cases, persons have 
died with it. There is no affection of the limbs, and no sponginess of the gums, 
as in scurvy. The disease, too, has often arisen without any evident cause; 
whereas scurvy (I believe) never takes place, except from a deficiency of proper 
food. 

Symptoms and Varieties. — If the disease occur merely on the surface of the 
body, forming patches, it is called "purpura simplex.''^ But frequently there is 
extensive bleeding from the mucous surfaces of the mouth, stomach, and intestines. 
I once had a patient, who died from bleeding within the head (" apoplexy"); and 
a clot of blood, which had oozed from the vessels of the pia mater, was found 
under the arachnoid membrane. Sometimes the spots are large; and sometimes 
there is ecchymosis. There is no inflammation or tenderness of the particular 
;parts. It appears to be a mere congestion of blood. In severe cases, the patient 
is pale; he looks as if he were in a state of anaemia; and I dare say the blood is 
deficient in quantity. On the other hand, I have seen children with many hundreds 
of these spots upon them; and yet running about perfectly well. Sometimes there 
would appear to be a little inflammation connected with this congestion; attended 
with great tingling, and even little wheals; and then it is called " purpura urticans.''^ 
Frequently there is such tenderness of the vessels in old people, that if they rest 
upon their arm, or knock their hand against a door, — so as to produce the slightest 
bruise, — ecchymosis will take place; and that has been called " purpura senilisf^ 
although, indeed, it is not this disease at all. It conveys the idea that it is the same 
disease; but it is merely such a tenderness of the vessels, that the slightest contu- 
sion produces ecchymosis. Persons may have the disease for many years, at the 
latter part of their life; and yet be perfeefly well. We are often consulted by 
patients on this occurrence; and it is right to know that it is ecchymosis, and 
should not be called "•purpura.''^ It is merely a bruise; and may be produced on 
old persons with the greatest facility. 

Causes.— Petechiae may take place in many circumstances; — frequently in typhus- 
fever; frequently in small-pox, between the pustules; and sometimes in scarlet- 
fever. It is very common to meet with them in dropsy, where there is great 

* From 7rog<}>v^a, a shell of a purple colour. 

b See Page 364. See Page 233. 



DISCOLORATIONS OF THE SKIX. 467 

debility; they very often occur where there is extreme dyspnoea; and sometimes 
in phthisis, where there is extreme difficuhy of breathing. 13ut there may be such 
debility of the vessels, that they allow the blood to ooze forth. Or there may be 
an impediment to the return of the blood; and the blood may he forced out. Fre- 
quently, however, no reason can be assigned for the disease. The person may be 
living as usual; when, all at once, the disease makes its appearance. 

Treatment. — I do not think there is, at present, any satisfactory or universal 
mode of treatment; but we must treat it according to the particular circumstances 
IQ each case. In mild cases, moderate bleeding, or mere purging, answers very 
well; and I think I have satisfied myself that purging with colclncian, answers 
better than other things. I have made observations upon this medicine, in other 
cases. I have purged with colchicum, and with other things; and the difference 
has been very greatly in favour of colchicum. I am sure we shall get rid of this 
disease sooner, by purging with colchicum, than by any other means. Where 
there is strength of pulse, it is necessary to bleed, and bleed freely. I have seen 
patients lose two or three pints of blood, in a few days, with great relief; and they 
have got well. A great number of cases are of this inflammatory nature; but by 
no means all. 

Others are of a different description; and wine, bark, and good nourishment, 
must be given. I recollect a case (which occurred in a child) where there was 
merely moderate debility; and the child was out every day. The disease was not 
intense, but these petechise existed; and under good nourishment and tonics the 
patient got well. But in extreme cases, it is necessary to do more than this. It is 
necessary to give wine and opium; and to treat the patient as we should if he 
were sinking under typhus-fever, or confluent small-pox with typhoid symptoms. 

Turpentine. — Where there is hsemorrliage, I have no doubt it would be best 
treated by oil of turpentine. As the latter restrains haemorrhage from, the alimentary 
canal, better than any other medicine, I have no doubt it would restrain it under 
this peculiar affection. One of the most severe, and most successfully treated cases 
that I ever saw, was at St. Thomas's Hospital, under the care of Dr. Roots, 
There were petechia?, vibices, and ecchyraoses, in every part of the body; together 
•with great congestion of the liver; — so that the right hypochondrium was distended. 
Blood was also poured forth from different cavities. The patient was bled, and 
took oil of turpentine; and he got well rapidly. Every one who saw him, must 
have supposed that he was near death. I was much disappointed in a case of ray 
own, which I treated in the same way. Apoplectic symptoms came on; and, on 
opening the patient, a clot of blood was found on the brain. 



CHAPTER VII. 
DISCOLORATIONS OF THE SKIN. 

Before proceeding to those affections which are of a structural nature, I may 
perhaps make a few remarks on those diseases which consist in a discoloration of 
the skin. Some of these are really not affections of the skin itself. For instance: 
in jaundice the skin is yellow; in chlorosis the skin is exceedingly pale; and like- 
wise in anaemia. On other occasions, however, the skin is itself discolored; and 
among these affections are mentioned "sun-spots;" and that blackness or blueness 
of the surface, which is induced by the continued exhibition of nitrate of silver. 

Lentigo. — ["Lentigo,"'' or "freckle," is the name given to the multifarious 
small, rounded, brownish-yellow or fawn-coloured stains that appear upon the face, 

* From " lens, lentis," a lentil;— from its resemblance to leniil-seeds. 



468 DISCOLORATIONS OF THE SKIN". 

bosom, hands, and necli; — more especially in individuals of fair complexion and 
delicate skin. Sometimes these spots cover the whole surface of the body. They 
are generally most abundant in childhood and youth; and are much less seen in 
dark complexions, in manhood, and in old age. They are evidently induced by 
exposure to light and heat; although they do not seem to result from the direct 
action of the sun's rays. The parts upon which they appear, never evince the 
slightest symptom of derangement. The best mode of preventing their appear- 
ing or increasing, — which they generally do in spring, — is to avoid carefully a 
too vivid glare of light, and to protect the skin by some slight covering. They 
require no treatment. 

Ephelis. — "Ephelis"* is characterized by one or several irregular-shaped broad 
patches, of a light or dark yellowish-brown; occurring most frequently on the front 
of the neck, chest, abdomen, groins, and inner part of the thighs; generally accom- 
panied with itching, and sometimes with slight desquamation of cuticle. 

The patches of ephelis generally appear slowly; and remain several weeks, or 
even months. They often occur in individuals enjoying the most perfect health, 
but sometimes appear to depend on a particular state of the system; — such as that 
which occurs on the approach of the menstrual period, and during pregnancy. 
Violent excess may sometimes occasion their appearance; but they have often a 
connection with disease of the digestive organs. They occasionally occur upon 
the face of pregnant women; — covering it with a kind of mask. 

The patches of ephelis, at first small, increase slowly; and attain a size varying 
from that of a sixpence, or less, to that of the palm of the hand. These patches, 
being separated by intervals of healthy integuments, give the skin a very peculiar 
appearance. But at a later period they coalesce, and cover extensive continuous 
surfaces with a single coloured patch; in the breadth of which, here and there, 
some spots of healthy skin are seen; and at first sight appear like so many morbid 
stains. These patches are usually attended with itching; which is increased by 
exposure to heat, by slight moral impressions, by indulgence in spirituous liquors, 
and by scratching. Sometimes, though rarely, slight cuticular desquamation takes 
place. 

The two latter symptoms distinguish the patches of ephelis from " pityriasis 
versicolor;"^ in which there is no pruritus, and much desquamation. The red 
copper-colour of syphilitic blotches, will always prevent their being mistaken for 
epiielis; and if, in some rare cases, the yellowish cast of a patch of nsevi should 
cause any doubt, the duration of the latter, and the knowledge of its being con- 
genital, will soon clear up the mystery. 

Treatment. — The patches of ephelis readily disappear on the use of the sul- 
phurous water-bath, with or without the internal use of the same remedy. The 
waters must first be taken mixed with two-thirds of barley-water or milk; and their 
quantity increased by degrees. When the itching is very troublesome, a lotion con- 
taining one ounce of sulphuret of potash dissolved in two pounds of water, may be 
frequently applied. Gentle aperients may, at the same time, be administered; and 
all stimuli should be strictly forbidden. 

Naevi. — Under the common title of "nsevi," two very different forms of con- 
genital alTection of the skin are included. The one — termed also "spili,""" "naevi 
pigmenlares,"'' or "mole," — is met on all parts of the body, is of various sizes, and 
cannot be considered as a disease of the skin. The other — "naevi vasculares" 
("mother mark") — is owing to an original morbid condition of the vascular^ sys- 
tem of the part affected. Of these, some are quite superficial, often met with on 
the face, and are of the colour of claret or port-wine. They remain indolent; and 
appear to be formed by a simple dilatation of the arterial and venous vessels, dis- 
tributed to the part of the skin affected. Others are somewhat elevated, and of the 
same deep-red colour; these are of a far more dangerous nature, and are formed of 

* From £7n; and ?iXio?, ike sun 

b See Page 403. ' From a-7Ti.\o(:, a spot. ^ From "pingo," ^o j!?azw^. 

e From " vasculum, ' the diminutive of " vas," a vessel. 



ORGANIC DISEASES OF THE SKIN. 469 

erectile vascular tissue. Their size is very various: sometimes a small speck not 
bigger than a pin's head, aad of a bright-red colour, rajiidly acquires such dimen- 
sions as to render it necessary to have recourse to a surgical operation. The treat- 
ment of the vascular erectile tumours is, indeed, altogether surgical. 

Vitiligo. — ''Vitiligo"* is a partial colourless state of the skin, either congenital 
or accidental, occurring in irregular white patches of various extent. It occurs fre- 
quently among negroes, and occasionally among whites. The "vitiligo hydropi- 
corum, gravidorumque'"" — a name given by Frank to the small white lines which 
are seen upon the abdomen of females after delivery, or those which succeed to 
ascites — does not really consist of patches of vitiligo; but of small lacerations of 
the corpus mucosum, induced by the distension of the parts. The patches of 
vitiligo are white; and when they occur on parts naturally covered with hair, the 
latter is also white. It is not uncommon to observe vitiligo upon the scrotum." Iti 
aged persons, these patches acquire sometimes considerable extent: they never 
cause pain, heat, or itching; and require no treatment.''] 



CHAPTER VIII. 

ORGANIC DISEASES OF THE SKIN. 

The organic affections of the skin are, for the most part, of a tubercular nature. 
The most important of these are lupus ("'noli me tangere"), cancer,® elephantiasis, 
and ichthyosis. 

SECTION I.— LUPUS. 

Lupus^ is a disease more frequently treated by the surgeon, than by the physi- 
cian; and is an aifec ion that is particularly seen upon the face, around the nose, 
and upon the upper lip. 

Characters. — Lupus is characterized by tubera; which are rather oval, and fre- 
quently flat; and of a brownish-red or livid colour. They increase and terminate 
in ulceration; and an ichorous discharge is then poured out, and concretes into 
crusts. It appears on the nose and cheeks, and sometimes upon the ears and chin; 
but it is calculated that, eight times out of ten, it attacks the nose. The parts 
around become harder and harder; suppuration goes on to ulceration; till, at last, a 
great degree of destruction is produced. It is exceedingly intractable. 

Varieties.— Owe variety occurs in scrofulous children; and frequendy gives way, 
sometimes to one application, and sometimes to another; — occasionally, perhaps, 
spontaneously. But there is another des<'.ripiion, which produces deep ulceration 
and extreme pain; and frequently appears to be somewhat allied to cancer. This 
is called "noli me tangere;" from its generally becoming worse, if interfered with 
by medical men. 

Diagnosis. — [It has been compared to, and probably sometimes confounded 
with, scirrhous ulcerations of these parts; but the features by which it may readily 
be distinguished from such affections, are the following: — 1. Cancerous disease of 

» From " vitulus," a calf. 

*• "Viiiligo of the dropsical and the pregnant." « From "scrotum," a skin. 

d " Library of Medicine;" Volume 1; Pages 424 and 425. 

e Wiih respect to cancer of ihe skin, I need say nothiiisj; because I have already spoken 
of it, when treating of structural diseases at large. (See Page 195.) The particular treat- 
ment of cancer, falls within the province of the surgeon. 

f So called from its re.semblance to a icolf {Xw^m^) in the ravages which it makes. 



^7© ORGANIC DISEASES OP THE SKIN. 

these parts usually occurs first on the lower lip. 2. The uneasiness belong^ing to 
it is, in no case, described to be worse than are comprehended under the general 
designations of "heat," " itching," "tingling," or "smarting;" while scirrhous 
ulceration is accompanied by severe darting pains, 3. Diseased enlargement of 
the contiguous glands, does not often make its appearance in its train, even though 
the disease has existed for years; which is not the case with cancer. 4. The sur- 
face of the sore is never occupied by fungous granulations, or has thickened and 
hardened or everted edges; but retains its peculiar character to the last.*] 

Treatment. — Some cases have been cured, it is said, by the application of caus- 
tics, and particularly arsenic; but there is no rule for the treatment; and I believe, 
in a great number of cases, the disease resists all means. 



SECTION II.— ELEPHANTIASIS. 

The next disease which I shall briefly notice, is one of very rare occurrence in 
this country; — so that I have seen only two or three instances of it. I refer to 
"elephantiasis." It receives its name from the skin becoming as rough and hard 
as the back of an elephant. It has been termed " the elephantiasis of the Greeks;^'' 
—to distinguish it from another form, which is local.'' 

Characters. — In this disease the features become extremely altered. The lips 
are very thick; and the whole of the face, and great part of the body, are beset 
with hard tubercles; — so that a person could not be recognized, by those who 
knew him previously to the appearance of the disease. The face is particularly 
rough. It is considered by Rayer to be a chronic inflammation; but we may either 
regard it as such, or as an organic disease of the skin. It is characterized by nume- 
rous independent tubercles of a livid colour; particularly developed on the face and 
ears, the upper and lower extremities, and likewise on the arch of the palate. The 
tubercles terminate, either by resolution, or by small ulcerations; which seldom 
extend in depth or breadth. They are covered by adherent crusts, under which a 
cicatrix is formed. It may occur in any part of the body; but, like lupus, it attacks 
the face much more than other parts. It has been said, by a great many writers, 
that the sexual desire becomes insatiable in this aflection. Others, however, deny 
this; and not only so, but they go to the other extreme, and say it is extinguished. 

[A kind of dry gangrene pervades the fingers and toes, which are generally 
eaten away, and drop off at the first phalanges; these sores then generally cica- 
trize, without any rete mucosum; and the next joint becomes invaded, by a 
renewal of the ulcerative process. It is singular to observe that, notwithstanding 
these extensive sores, the patients can wear hard shoes, which are saturated with 
the sanious ichor that exudes from these ulcerated surfaces. The disease progres- 
sively advances; — eating throuj^h the ankles and wrists; and performing slow, but 
certain and successive dismemberment; — every revolving year bearing some trophy 
of this tardy, but gradual march of death; till, at last, the vitals become affected. 
During all this time, a sleepy inertness overpowers the mind, and " seems to be- 
numb and almost annihilate every faculty, as well of the soul as of the body; 
leaving only sufficient sense and activity to crawl through the routine of existence." 

In the last stages of this complaint, the flesh gapes with long sores; the mouth, 
nose, and brain become exposed to its ravages; and death, at length, terminates 
this loathsome existence. The patient is usually cut off by the supervention of 
diarrhoea. It is astonishing, however, to witness how long the victim lingers; — 
from twelve to twenty years being no uncommon duration. During the greater 
part of this period, he has a good, and even voracious appetite; and moves about 
from village to village. ""] 

Causes. — [It is not contagious, but appears to be hereditary; though not neces- 

« Plumbe, on Diseases of the Skin; Fourth Edition; Page 119. 

•» " Barbadoes-leg," or " elephantiasis of the Arabs.'" See Page 471. 

« Brett's " Practical Essay on the Surgical Diseases of India;" Page i64. 



ORGANIC DISEASES OF THE SKIN. 471 

sarily so. M. Biett lately attended a lady, from the West Indies, afTected with 
tuberculous leprosy in a very severe degree; and who had been delivered of seve- 
ral children since the disease first appeared. These children, who are now of a 
certain age, all enjoy excellent health; and do not show the least symptoms of 
Greek elephantiasis. This disease attacks both sexes equally; and appears at all 
periods of life, but less frequently in elderly persons.- The cases seen in Europe 
generally come from the West Indies and other colonies. We have seen it in a 
young Portuguese; who, according to his statement, had never left Portugal before 
the appearance of the disease. In the colonies, damp dwellings, malaria, and un- 
wholesome food, especially pork, often appear to be exciting causes. To these 
may be added, over-working, the too free use of spirits, and especially depressing 
moral aifections. 

Diagnosis. — In the commencement, the erythematous patches may be consi- 
dered as symptoms of a disease far less fearful than lepra tuberculosa; and often, 
for a time, mislead. The impaired or total loss of sensibility in these points of the 
integuments, their dusky red hue, soft feel, and the circumstance of the patient 
having previously inhabited a tropical climate, may assist the diagnosis; the mis- 
take would, however, be only that of not foreseeing the disease that is about to 
occur. At a more advanced stage, we conceive an error to be almost impossible; — 
if we compare the symptoms of the occasional tubercle of lupus, or those con- 
nected with a syphilitic origin, of mollusca, and of framboesia, with those of ele- 
phantiasis.*] 

Treatment,'— The only case which I have seen, occurred in a person who came 
from Madeira; but it is also found at St. Domingo, and in the Isle of France. It 
has been cured, I believe, by the exhibition of arsenic. Many cases have been 
improved by this medicine; and slight cases have been absolutely cured by it; but, 
for the most part, the treatment is very unsatisfactory. 

[The vapour-douche, friction with volatile liniments, or (what is still more effi- 
cacious) the repeated application of blisters to the diseased surfaces, may be tried. 
When the disease is limited in extent (to the ears or face, for example), the oint- 
ment of hydriodate of potash (one scruple to an ounce of axunge) is often very 
beneficial; — the vapour-douche being frequently applied at the same time. When 
it is more extensive, and the tubercles have not ulcerated, warm water, alkaline, or 
sulphurous baths are to be employed; and, if the state of the bowels admit of them, 
arsenical preparations, or the tincture of cantharides, are to be administered, with 
the precautions stated in the treatment of psoriasis. In the advanced stages, M. 
Biett has employed the actual cautery with success. It should be kept in view, 
however, that from the frequent complication of irritation or inflammation of the 
gastric mucous membrane with elephantiasis, it is impossible to exhibit remedies 
of an active or irritating character, more especially preparations of arsenic or can- 
tharides. In such circumstances, a soothing course of internal treatment, com- 
prising measures calculated to allay the intestinal affection, is to be adopted; while 
we endeavour to ameliorate the condition of the skin, by the external treatment 
already noticed.''] 

Barbadoes-leg. — There is another disease which is called "elephantiasis;" but 
it is local, and does not spread throughout the body, or form tubercles. As it com- 
mences in a thickening of the' parts below the skin, it is mentioned bv Rayer as a 
disease, not of the skin itself, but as one of those diseases which extends from other 
parts to the skin. 

Symptoms.- — This affection is what is called *' Barbadoes-leg," and is also 
called '"the elephantiasis of the Arabs." It is a local disease, occurring in the 
scrotum, and at the lower part of the leg.'' The skin becomes diseased, but the 

a " Library of Medicine;" Volume 1; Pages 419 and 420. 

'' "Library of Medicine;" Volume 1; Page 420. 

e No part of the body, however, is exempt; the face, neck, breast, abdomen, nates, labia, 
and margin of the anus, have at different times been observed to be its seal. — '^Library of 
Medicine;''' Volume 1; Page 429. 



472 ORGANIC DISEASES OP THE SKIN. 

cellular membrane beneath it is the chief seat of the affection. It becomes exces- 
sively thickened and indurated; and at Barbadoes, it sometimes affects only one 
leg. 

[Although the progress of the disease is slow, there is more or less general dis- 
turbance at the beginning; such as fever, frequent vomiting, pain and erythematous 
redness over the course of the lymphatic vessels, with swelling of the limb or 
part. This never subsides entirely, and increases with each returning attack of 
constitutional disturbance; which intermits and returns at irregular intervals, 'i'he 
limb gradually increases to an enormous size; and becomes so hard as lo resist the 
firmest pressure. In a few months, the general symptoms and local pain disap- 
pear; but the distended and enormously swollen part — whether the leg or the scro- 
tum — not only remains in that state, but increases. The scrotum has been known 
to weigh nearly sixty pounds; and one of the lower extremities to attain a weight 
equivalent to tliat of the rest of the body. The skin — at first pale, smooth, and 
shining — becomes rough, hard, thickened, and covered with scaly incrustations of 
various thickness; it afterwards cracks in all directions, and deep and painful fis- 
sures ensue. The lymphatic glands, which were from the first hard and swollen, 
sometimes inflame and suppurate, and even mortify. Deep abscesses form, and 
discharge a large quantity of fetid pus; and death occurs with the ordinary symp- 
toms of adynamic fever. 

Treatment. — In the first stages of the disease, local and general bleeding may 
be necessary, with rest and the horizontal posture of the limb. At a later period, 
gentle and frequent friction, compression carefully applied, daily shampooing, and 
the vapour-douche, may be employed. Frictions with the different preparations 
of iodine, are of great service; but should inflammation come on, their use must 
be immediately suspended/] 

A friend of mine says it is produced by a kind of flea; which is not satisfied with 
being on the surface, but forms a bag beneath, in which it lays its eggs; from the 
continued irritation of which, he says, the disease is produced. How that may 
be, I do not know. The blacks, in the West Indies, suffer under the affection; 
and they are very dexterous in dragging out the bag, by means of a needle; — so 
that no harm ensues. But if any portion be left, an egg usually remains; and the 
disease proves very troublesome. The name given to the insect is *' chigoe." 



SECTION III.— ICHTHYOSIS. 

Nature. — The next disease which 1 shall notice, is classed by Rayer among 
organic diseases of the skin, and is one which we occasionally see. It is termed 
" ichthyosis.'"' It is not so rare a disease but that every one, in the course of his 
life, may perhaps see a fev/ cases. It is classed, by Willan, with scaly diseases;*^ 
but as the scaly diseases I have mentioned*^ have been classed, with a number of 
others, in the list of inflammatory affections, this could not come in with them. 
Moreover, although a scaly disease, it is necessarily separated, in the arrangement 
of Rayer, from pityriasis, lepra, and psoriasis; because all those scaly diseases are 
of an inflammatory nature. 

Characters. — In this disease, there is no inflammation whatever. The skin is 
neither red, hot, nor tender; but it is covered by a large number of scales. These 
scales have been supposed to resemble the scales of a fish; but they are not im- 
bricated. Indeed, in many parts, the skin looks more like the feet of fowls, than 
any thing else. This will give us the best idea of it. At a little distance from a 
j)erson labouring under the disease, we might suppose that the skin was dirty; — 
the scales which lie upon it being of a bluish colour. It exists in various degrees 

a " Library of Medicine;" Volume 1; Pages 429 and 430. 

^ From ipc.Sua, the scale of o.Jish. 

«= Order 2 (" Sqnamgc"); Genus 4. See, also, Plates 18 and J9. 

d Pityriasis (Page403)j Lepra (Page 404)j and Psoriasis (Page 406). 



ORGANIC DISEASES OP THE SKIN. 473 

of intensity, and of extent. The constitution is not in the least degree disturbed; — 
the health is not at all affected, There is nothing to be seen, but this organic 
affection of the skin; — the cuticle being formed with this diseased character. 

The affection will sometimes cover the whole body. It is said, in books, that 
it is not seen exactly over the furrow of the spine; but in the cases which I had 
in the hospital" (or, at least, in one of them), that part was covered with scales, 
exactly like the rest. The face, in those cases, was very little affected; but the 
back of the neck suffered pretty severely. 

Causes. — The cause of this affection is not known; but it sometimes occurs 
from original constitution. I had two brothers under my care for this complaint; 
in each of whom it made its appearance without any obvious cause. They were 
born at Sheerness, and lived at Woolwich.'' It seemed to be constitutional; and 
occurred in the progress of their age. It has sometimes been known to be here- 
ditary. The skin feels dry and rough, and there seems to be no perspiration; — 
in general, the skin ceases to secrete a watery fluid. If the affection be more in- 
tense, it exhibits exactly the appearance that Alibert has represented in Plate 37, 
as occurring on the knee; and which he calls " ichthyose nacree." 

Treatment. — The disease is generally thought, I believe, to be incurable; — at 
least, that internal medicine has little power over it. Pitch, however, is said to do 
good. Dr. Willan says he cured a lady, by giving her pitch. The pitch was 
made into pills; and she took as many as she could swallow in a day; — altogether 
one or two ounces. I certainly did not give these patients as large a quantity as 
they could have taken; but each boy swallowed forty to fifty pills, three times a 
day. One of them put them into his hand, and swallowed them as children do 
sugar-plumps: he must have taken, every day, a quantity of pitch, nearer two 
ounces than one. At the same time that 1 employed this treatment, I had one of 
the boys rubbed over with olive-oil. He was sent to the warm-bath; and when he 
came out, he was regularly oiled; and in this way he got well. Of course, I was 
quite in uncertainty, as to whether it was the internal or the external medicine 
that did him good; — whether it was the pitch within, or the oil without; and being 
told that he had a brotlier in a similar state, I requested that he also mi^ht come 
and be cured. I gave him pitch only; and in larger quantity than Dr. Willan had 
done; but he was no better for it. I then left it off, and had him oiled; — not all 
over, but over one extremity only; and that extremity recovered its natural texture, 
while llie other parts remained as they were. It was singular, that if a part which 
had been oiled touched, by chance, one that had not; — that is to say, if one leg 
touched the other, this last immediately improved, though not to the same degree. 
In this way the boy was perfectly cured. These two brothers went out of the 
liospital, with their skins as smooth and as soft as any girl's; and, for the time, 
they were certainly cured; but whether the disease will return, I do not know. 
The free application of oil, in these cases, answered perfectly. With regard to 
the latter boy, I made careful experiments with the pitch, the warm-bath, and the 
oil; and such intervals elapsed between the various modes of treatment, that I was 
perfectly satisfied it was the oil which effected the cure. The disease was quite of 
the intensity represented in Aliberl's thirty-seventh plate. At one period, I used 
Unseed'oW; but that did no good; for it dried directly. The o/it;e-oil, however, 
retained its moisture for some time; and answered completely. 

Varieties. — The ordinary form of the disease is called, by Willan, '* ichthyosis 
simplex;''^ but now and then it occurs in much severer form; and then it is called 
" ichthyosis cornea.'*''^ The latter of these species is a rare disease; and is of an 
hereditary nature. Several instances have occurred, in the children of parents 

» St. Thomas's. 

b See the " Medical Gazette;" Volume 7; Pa^e G36. (No. 167; February 12, 1831.) 
c" Descripuon and Treatment of Cutaneous Diseases;" Order ''2; Genus 4; Species I. 
d From " cornu," a horn. See Willan's " Description and Treatment of Cutaneous Dis- 
eases;" Order 2; Genus 4; Species 3. 



474 ORGANIC DISEASES OF THE SKIN. 

who had laboured under the disease; — not perhaps appearing' at their birth; but 
occiirrinjr, like " ichthyosis simplex,''^ at a certain time afterwards. 

The Porcupine FamlUj. — There is, in Suffolk, a family in whom it has ap- 
peared for several generations; — three or four; and (what is singular) always in 
the male line. No female has been known to have it. Every part of the body is 
covered with the disease; except the face, the palms of the hands, the soles of the 
feet, and the orlans penis, I saw one of these men; — the grandson of the person 
who is described in the " Philosophical Transactions." It was a famous family;—, 
called, from the roughness of the skin, "the joorcMjoine-family." This man told 
me, that the scales were shed every year; and, when I saw him again, they were 
in the act of falling off. The scales, in this form of the affection, all stand side 
by side; — they do not overlap each other; and when the limb is put in a certain 
position, there is a pretty smooth surface, on which you may make a noise, just as 
in striking horn; but if the part be stretched, so as to separate the scales a little, 
the divisions may be seen between them. 

There was a man, labouring under this affection, who described himself as the 
descendant of an American savage; — I suppose he wished to make himself appear 
very wonderful. He came to London, every now and then, to show himself for 
what he could get. There is also an instance of the hereditary form of this dis- 
ease, published in the ninth volume of the " Medico-Chirurgical Transactions,"* 
by a gentleman residing in Sussex: it occurred in a female. With regard to 
treatment, I conceive nothing can be done. 



SECTION IV.— FRAMBGESIA. 

Its Nature. — [Framboesia'' is a disease indigenous in Africa; whence it has been 
conveyed to the West Indies and America; it is rarely, if ever, seen in Britain. It 
is characterized by the evolution of small, red tuberculous tumours; generally dis- 
tinct from each other at their summit, but connected by their base; and very similar 
(in their form, colour, and size,) to a raspberry or mulberry. They appear on 
surfaces of various extent, and occur on all parts of the surface of the skin; but 
rnore frequently on the scalp, the face, the axillae, in the groins, around the anus, 
^nd on the organs of generation. 

Causes. — Persons of all ages. may be attacked; but it is more common in chil- 
dren and young people. It is contagious; and is propagated by the contagion of 
the matter discharged from the eruption. It sometimes appears spontaneously; 
filth, misery, unwholesome food, and living in damp dwellings, are its more evi- 
dent exciting causes. Negroes are more frequendy attacked than whites. Accord- 
ing to Bateman, framboesia is propagated solely by the application of the matter 
discharged from the eruption to wounded surfaces of persons who have not pre- 
viously passed through the disease. It does not appear to be propagated by efflu- 
via; and, like the febrile eruptions, affects the same individual only once during 
life. In Africa, it is generally undergone during childhood. 

Symptoms. — The disease begins by solid elevations of a papular nature; and 
•their eruption is sometimes accompanied by general symptoms. The affected 
surface is sometimes of limited extent; but, in a case which came under our'' ob- 
servation, it occupied the whole of the front and inferior district of the thigh; — the 
size of the tubercle varying from that of a pea to that of a hazel-nut. The vege- 
tations appeared seated in the substance of the dermis, which was in a state of 
hypertrophy; and, instead of cuticle, they were covered with dry, adherent, thin 
scales. In warm climates, the tumours frequendy ulcerate, and discharge a fetid 
ichor; which sometimes forms thick crusts. One of the tuberoulations generally 
acquires much larger dimensions than the others; and afterwards forms a foul and 

* Page 52. ^ From " framboise, (French,) a rasfherry. - 

<= That of Dr. H. E. Schedel. 



DISEASES OP THE APPENDAGES OP THE SKIN. 475 

sloughy ulcer, which the negroes call the "mama plan" or " mama yaw." The 
disease is usually of long duration, and leaves well-marked cicatrices; but is not 
attended by much pain. 

Diagnosis. — The only disease for which frambcesia may be mistaken, is some 
form of syphilitic tuberculous eruption. Affections of the latter description often 
return; their colour is peculiar and characteristic; and they never form fungoid 
tubercles united by their bases, covering surfaces of various extent. 

Treatment, — According to Dr. Winterbottom, the natives in Africa " never 
attempt to cure this disease until it has reached its height; when the fungi have 
acquired their full size, and no more pustules appear." (" Account of the Native 
Africans of Sierra Leone.") It would appear, from the experience of those who 
have seen the disease in tropical climates, that no remedy yet discovered has any 
influence over its progress. All, therefore, that is necessary in the first stage, is 
to enjoin a moderate cooling regimen. When the disease is on the decline, — indi- 
cated by the eruptions beginning to dry, and then ceasing to multiply and enlarge, 
the treatment should consist of a moderately nutritious diet, pure air, proper clothing, 
and the exhibition of sarsaparilla, bark, and the mineral acids in succession; with 
mild laxatives, and alterative doses of mercurials, according to circumstances. Dr. 
Bateman states, that the " wias^w-yaw" sometimes remains large and troublesome, 
after the rest of the eruption has altogether disappeared. It requires to be treated 
with gentle escharotics; and, under these applications, soon assumes a healing 
appearance. Stronger caustics are requisite for the cure of the " cr«i-yaw;" — 
tedious excrescences which occur on the soles of the feet. In the case we* saw 
under the care of M. Biett, the actual cautery was employed with the greatest suc- 
cess. The different preparations of iodine, and other stimulant applications, 
appear to be indicated in this disease.*"] 



CHAPTER IX. 

DISEASES OF THE APPENDAGES OF THE SKIN. 

As to diseases of the appendages to the skin (such as diseases of the nails,) I 
must leave them to the surgeon. But there is one disease of the appendages, which 
is very interesting; and, although we do not see it in this country, we have speci- 
mens of its eflects; — I mean a disease of the hair. 

Trichoma. — It appears, that the bulbs of the hair sometimes become inflamed; 
a quantity of acrid stuff is poured out; the hair becomes very much entangled; and 
sometimes grows, it is said, to a great length. This disease is called " trichoma."*^ 
Sometimes it is called "plica;"** and, having been common in Poland, it has re- 
ceived the appellation — " plica joo/onic«." From the inflammation that exists, the 
scalp becomes excessively tender. It is found that the bulbs of the hair are gummy, 
and filled with a great quantity of liquid; and the least touch of the hair induces 
very great pain. The fluid which is discharged is gelatinous, and sticks the hair 
together. Some have considered the disease contagious; but I believe that is not 
the case. 

Causes. — The causes of this aflfection are not known. Some ascribe it to the 
cessation of the perspiration; but any disease may be ascribed to that. Why it 
occurs more particularly in Poland, than in any other northern countries, is also 
inexplicable. 

Treatment. — As to the treatment, we may recommend the warm-bath, and 

* Dr. Schedel. b " Library of Medicinej" Volume 1; Pages 421 and 422. 

c From 9gj|, the hair. ^ From " plicor," to be knit together. 



476 DISEASED SECRETIONS OF THE SKIN. 

numerous remedies of different kinds. If antiphlogistic regimen be indicated (by 
the strength of the system, and the heat of the part,) we may suppose that it will 
do good. The treatment, however, is very unsatisfactory. 



CHAPTER X. 
DISEASED SECRETIONS OF THE SKIN. 

The diseases of the skin, as a secreting organ, have either been already men- 
tioned, or will be mentioned hereafter. As to excessive perspiration, that I de- 
scribed when treating of intense secretions generally;^ and as to dryness of the 
skin, that is rather a symptom of other diseases. Dryness of the skin occurs par- 
ticularly in ichthyosis, in diarrhoea, and in fevers. As to diseased secretions of 
the skin with regard to quality, it is very common (as we shall find in rheumatism) 
for the skin to secrete an exceedingly sour fluid; — so that the perspiration smells 
something like sour whey. Occasionally, excessive perspiration of parts of the 
body (either of the hands or the feet) will occur as an idiopathic disease. 

Offensive Perspiration. — Many people are troubled with sweating hands; so 
that whatever they touch they moisten. This state, however, occurs particularly 
in the feet; and is very liable to be of an exceedingly offensive character. Some 
persons are tormented with this only at certain periods of the year; but some have 
always very offensive feet, from the diseased nature of the secretions that take 
place there. Many servants, I believe, have lost their places on account of this 
misfortune; they have been discovered to have ofTensively smelHng feet. I had a 
letter, not long ago, from a medical man residing at a considerable distance from 
London;— stating that he was in this condition. He was in a state of extreme melan- 
choly, on account of the copious and offensive perspiration, which he experienced 
in the feet. He had consulted every one within his reach; but had derived no 
benefit. I advised a number of things that occurred to me, as likely to prove 
beneficial; but I had a second letter from him; — telling me that they had done no 
good. I endeavoured to alter the secretion by purging, and by applying astringents 
to the feet; and I advised a number of other things, which 1 now forget; but which 
appeared to me rational. I was not sure, however, that they would do him good; 
and, so far as I know, they did not; for the second letter which I received, betokened 
the same agony of mind, as that under which the first was written. 

This is all I think it necessary to say, respecting diseases of the skin. I have 
omitted several; some of which are trifling; while with others we are so conversant, 
that they do not require any observations; and gome of them are not common in 
this country. 

« See Page 156. 



BOOK IL 

DISEASES 01 THE NERVOUS SYSTEM, 



liXTHODUCTION. 



[In entering on the consideration of those affections to which the nervons system 
is liable, we think it will materially aid the reader in his comprehension of the sub* 
ject, if we subjoin a brief notice of the general physiology and pathology of those 
organs, which are collectively known as the nertous system. More especially 
When we consider the important additions that have been made to medical know- 
ledge, on these subjects, within the last fevv years. 

Subdivisions of the Nervous System. — All recent anatomists Iiave divided the 
nervous system into the " cerebro-spinal" and the "sympathetic." The first of 
these consists, first, of the cerebrum as a centre; secondly, of sentient nerves, 
which pursue their course to it; and, thirdly, of voluntary nerves, which proceed 
from the brain and spinal marrow, either along the base of the brain, or along the 
spinal marroxv, and then along every external part of the animal frame. The 
second comprehends the internal ganglionic, or sympathetic system of nerves. To 
these Dr. Marshall Hall has since added a third; — consisting of the true spinal 
marrow, distinguished from the sentient and voluntary nerve which run along its 
course, as an axis of excitor and motor nerves. It is the seat of a peculiar series 
of physiological phenomena, and of a peculiar class of pathological affections: in 
the former are included all the functions which relate to the immediate acts of 
i;2gestion and egestion; in the latter, all spasmodic diseases. He therefore divides 
the nervous system into — I. The cerebral; or the sentient and voluntary. II. The 
true spinal; or the exdto-motory . HI. The ganglionic; or the nutrient, secre- 
tory, &n. 

Cerebral System. — The first relates to every part of the nervous system which 
relates to sensation and volition; — the nerves of sense — the olfactory, the optic, 
the auditory, the gustatory, and the nerves of touch; and all the nerves of voluntary 
motion. Its centre is the cerebrum, including the cerebellum; its sentient nerves 
run variously from the organs of sense, and from the external surfaces, first with- 
out the cranium or spine, and then within the cranium or spine, to that centre; its 
voluntary nerves pursue a similar but retrograde course, from that centre to the 
muscles of voluntary motion. 

True Spinal System. — A peculiar set of nerves constitutes, with the true spinal 
marrow as their axis, the second subdivision of the nervous system. As tliose of 
the former subdivision were distinguished into "sentient" and " voluntary," these 
may be distinguished into the excitor and motory. The first, or the " excitor" 
nerves, pursue their course principally from internal surfaces, characterized by 
peculiar excilabilities, to the true " medulla oblongata" and " spinalis;" the second, 
or the " motor" nerves, pursue a reflex cowxse from that medulla to muscles having 
peculiar actions; — concerned, principally, in ingestion and egestion. Tlie motions 



47S DISEASES OF THE NERVOUS SYSTEM. 

connected with the former, or " cerebral" subdivision, are sometimes, nay, fre- 
quently spontaneous; those connected wfth the " true spinal" are always excited. 

Ganglionic System. — Dr. Hall regards the fifth and posterior spinal nerves as 
constituting an external ganglionic system, for the nutrition, &;c., of the external 
organs. So that the ganglionic subdivision of the nervous system would be 
divisible into, first, the internal ganglionic system, which includes that usually 
denominated the " sympathetic," and probably filaments of the pneumogastric; and, 
secondly, the external ganglionic system, which will embrace the fifth and the pos- 
terior spinal nerves. 

Pathology of the Cerebral System. — The cerebral system being the system of 
the sensations, of judgment, and of volition, it is to it that we must refer all mor- 
bid conditions of these mental acts or functions. Every derangement of the senses, 
every form of delirium or of coma, or of perverted judgment, every act of violence, 
must be referred to the condition (primary or secondary) of the cerebrum or cere- 
bellum. The facts which, in a practical point of view, are the most important, are 
those determined by M. Magendie and M. Flourens; — that it is impossible, by 
lacerations or other modes of injury of the cerebrum or cerebellum, to induce either 
pain or contraction in the muscular system. These organs are not endued with 
sensibility, or with the "vis nervosa" of Haller. They are the seat of a self-acting, 
automatic, sentient, and motive principle, — the ■^vxri, or "soul;" but they are them- 
selves incapable either of sensation, or of the production of motion. 

When the cerebrum is irritated, delirium ensues; when compressed, coma is in- 
duced; when lacerated, we have paralysis of voluntary motion. If other pheno- 
mena are seen in diseases of the encephalon, they arise from the extension of these 
to the true spinal and ganglionic systems, through irritation, ov pressure, counter- 
irritation, or counter-pressure; — points of extreme importance, to be noticed very 
particularly hereafter. In disorders of sensation, of the faculties of thinking, or of 
volition, we must attend io the course of the sentient nerves, the condition of the 
encephalon, and the course of the nerves of volition. We must examine the state 
of the circulation, and the condition of the general system. 

The olfactory, the optic, and the acoustic nerves, are (equally M'ith the cerebrum 
and cerebellum) incapable of pain, or oi exciting movements m the muscular system, 
when punctured or lacerated. They are, as has been before stated, the seat of the 
sentient principle — the soul; but they are not endowed with the excito-motory prin- 
ciple. But when the optic nerve is inflamed or irritated, there is impatience of 
light; when the membranes of the encephalon are inflamed and the cerebrum is 
irritated, there is delirium. When these several textures are compressed, there is 
amaurosis, and coma respectively; and when the cerebrum is lacerated, there is 
paralysis of voluntary motion. 

Effects of Exhaustion. — But, in treating of the pathology of the cerebral sys- 
tem, a subject of the utmost importance comes to be considered. Not only undue 
arterial action, and venous congestion, induce morbid states of the cerebral func- 
tions; but the state of exhaustion from loss of blood, the an3emious condition in 
chlorosis, &c., induce similar eflfects; and present to the physician anxious cases, 
which frequently try his skill in diagnosis. Too great action of the minute arte- 
ries, congestion in the viens, an anaemious state of the vascular system of the en- 
cephalon, alike induce morbidly exalted and impaired conditions of the mental and 
cerebral functions: — spectra, delirium, insomnia; amaurosis, stupor, coma; violent 
voluntary actions, or paralysis of the voluntary motions: these are the symptoms 
which arise out of these morbid conditions of the cerebral system and functions; 
and these only. Spasmodic actions depend upon the part of another system being 
implicated. This subject has been well illustrated by the experiments of Sir Astley 
Cooper, on the large arteries and veins in the neck of the dog and rabbit. 

The influences of position, of a whirling motion, &c., are also worthy of atten- 
tion. So also are the effects of anxiety of mind, ardent spirits, sexual excess and 
vice, &c.; — seen in the suicidal mania, in delirium tremens, and in the half mania- 
cal, half imbecile state of mind so frequently seen in such circumstances. 



DISEASES OF THE NERVOUS SYSTEM. 479 

In order, then, to obtain a clear idea of the pathology of the cerebral system, 
we must imagine the physiological phenomena assuming a pathological character. 
Now the force of these phenomena may be augmented, diminished, or annihilated. 
With regard to the cerebral functions, we have, in the sentient nerves, pain or in- 
sensibility; in the cerebrum itself, erroneous perceptions, judgments, and volitions, 
or delirium; or a total deficiency of these faculties, — coma; and in the motor nerves, 
either continual voluntary actions, or paralysis. 

Crossed Effect in Disease of the Encephalon. — It was well known to the an- 
cients, that disease in one hemisphere of the brain induces paralysis in the oppo- 
site side of the body. This fact has been confirmed by modern pathologists. It 
has been fully ascertained, that disease confined to one hemisphere of the cere- 
brum, or of the cerebellum, and to one side of the mesial plane in the "tuber an- 
nulare," constantly affects the opposite side; while disease confined to one of the 
lateral columns of the "medulla oblongata" and "medulla spinalis," affects the 
corresponding side of the muscular system. The encephalon has a crossed effect; 
the "medulla spinalis" a direct effect. 

Cause of Convulsions in Disease of the Encephalon. — It has been ascertained 
that, in experiments, lesions of the encephalon induce paralysis only; while 
lesions of the "medulla oblongata" and "spinalis" induce convulsion or paralysis, 
according to their severity. Hence it becomes important to determine the cause 
of convulsive affections, in disease of the encephalon. This cause appears to be 
either irritation or counter-pressure. The former may act through the medium of 
the nerves distributed to the membranes (as the " recurrent of the trifacial" of Ar- 
nold); — as in epilepsy induced by a spicula of bone. The latter is illustrated by a 
case, recorded by Dr. Abercrombie, in which the anterior fontanel became promi- 
nent, and pressure upon it induced convulsion. 

Attempts to Localize Affections of the Brain. — Saucerotte, in his prize memoir 
presented to the Academie Royale de Chirurgie, in 1768, and (more recently) 
MM. Foville and Pinel-Grandchamp, M. Serres, M. Lacrampe-Loustau, and M. 
Bouillaud, have attempted to show that, besides this crossed effect of the cerebrum, 
affections of the thalamus, or its posterior lobe, induce paralysis of the lower ex- 
tremities; — so that, if this opinion were true, there would be a doubly crossed effect. 
This phrase is used as a sort of mnemoiiic for those who may wish to speak of 
these opinions. M. Lallemand and M. Andral, after an examination of an exten- 
sive series of facts, have declared that the statement is without foundation. M. 
Bouillaud has further attempted to show, that disease, or lesion, of the anterior 
lobe of the cerebrum, leads to a loss of the power of articulation.. But this opinion 
is equally contested by the two authors just quoted. It is also desirable, briefly to 
notice an attempt to localize affections of the brain of a different kind, but equally 
disputed by these pathologists. MM. Delaye and Foville have stated, that the 
gray or cortical substance of the brain is principally affected in mania; MM. 
Bouchet and Cazauvieilh, while they agree with MM. Delaye and Foville in their 
view of the pathology of mania, contend that in epilepsy it is, on the contrary, the 
white or medullary portion of the brain which is diseased. The "tubercula 
qiiadrigemina" alone have a crossed effect, both of convulsion and paralysis. M. 
OUivier observes, that hasmorrhage into the " tuber annulare" only paralyzes the 
movements; M. Gruveilhier, on the contrary, asserts that such an affection destroys 
the sensations and the movements, but leaves the intellect uninjured. It need 
scarcely be added, in this place, that in those cases m which haemorrhage occupies 
an extensive space, affecting both hemispheres of the brain, — as in meningeal 
haemorrhage at the summit or base of the brain, or in extensive haemorrhage within 
the brain, extending from one hemisphere to the other, or into both ventricles, — 
general paralysis is observed; the same event takes place in cases where a clot of 
blood is farmed in the mesial line in the "tuber annulare;" — the "nodus ence- 
phali," as it has been called. 

Pathology of the True Spinal System. — The whole order of spasmodic and 
convulsive diseases belongs to this, the exciio-motory division of the nervous sys-. 



480 DISEASES OF THE NERVOUS SYSTEM 

tern; and ihey all have their source in one of three parts of it. The morbid stimu- 
lus may act upon the incident, the central, or the reflex part of the excito-molory 
arc or arcs, and produce corresponding effects, — corresponding diseases. To use 
words familiar to the physiologists of Germany, we have a class of " centripetal," 
" central," and " centrifugal" diseases; we may have centripetal or central epilepsy, 
and we may have spasmodic and other aff"ections, from an afl^ection of the reflex or 
motor nerves. In this manner, the class of " spasmodic diseases" is subdivided 
into three sw6-classes; — a division of the utmost importance in practice, and illus- 
trated by the following table: — 

Table of the Pathology of the True Spinal System. 

I. Diseases of the incident nerves. 

fl. The crowing inspiration. 
I. 1. Dental 1 Irritation | 2. Strabismus; spasm of the fingers and 

2. Gastric f i"^ ^ ^"^^» strangury; tenesmus; &c. 

3. Intestinal J infants. | 3. Convulsion. 

[^4. Paralysis, 
fl. Hysteria. 
II. 1. Gastric 1 Irritation j 2. Asthma. 

2. Intestinal [■ in <J 3. Vomiting; hiccup; &c. 

3. Uterine J . adults. | 4. Epilepsy. 

1^5. Puerperal convulsions; &c. 
III. Traumatic tetanus; hydrophobia; &;c. 

II. Diseases of the spinal marrow itself. 
I. Inflammation and other diseases. 

II. Diseases of the vertebrae and membranes. 

III. Counter-pressure,. &;c., in diseases within the cranium. 

IV. Centric epilepsy, tetanus, &c. 

V. Convulsions from loss of blood, &;c. 
III. Diseases of the reflex or motor nerves. 

I. Spasm. II. Paralysis. 

1. Spasmodic tic. 

2. Torticollis. 

3. Contracted limbs, <fec. 

What are the parts or organs physiologically connected with this system? The 
orifices, the sphincters, tlie organs of ingestion, of expulsion, and of exclusion. 
Now these are precisely the parts and organs involved in diseases of the true spinal 
system. The physiology has become pathology. The larynx is closed in the 
convulsions of children, in epilepsy, in puerperal convulsion; it is partially aflected 
in the croup-like convulsion, m hysteria (in which there is frequently loss of voice), 
&c. The pharynx is affected in some of these diseases. The respiratory muscles 
are so in all. In epilepsy we observe affections of the sphincters, and even of the 
ejaculators. 

Influence of the Passions. — The passions exert a singular influence over these 
and all the functions of the excito-motory system. Sickness, panting, convulsions, 
relaxation of the sphincters, — these, and a thousand other aflfections of this system, 
are induced through the mysterious influence of disgust, fear, &;c. Infantile con- 
vulsions and epilepsy are renewed by vexation, &c. Of all diseases, those arising 
from fright are the most formidable. 

Pathology of the Ganglionic System. — The " cerebral" system is concerned 
with psychical or mental acts merely; the " true spinal," with physical acts on the 
masses of bodies to be appropriated to or expelled from the animal economy; while 
the "ganglionic" system relates to the c/iemic«/ changes in the disposition of the 
atoms of the animal body, its solids, fluids, &c.; — its office being, to regulate the 
interstitial absorption, deposition, re-absorption, and the secretion of the atoms or 
particles of which the animal frame is composed, and of the ingesta and egesta. 



PHRENITIS. 481 

111 the case of disease or injury of the fifth (trifacial) nerve within the cranium, 
besides the loss of sensibility and of its excito-motor property, other phenomena 
are observed. The nostril loses its susceptibility to the impression of stimuli; and 
eventually the eye, not being nourished, shrinks and collapses. The power of the 
masticatory muscles is impaired; but the face is not distorted by any apparent 
paralysis. These facts, which have been confirmed by cases and experiments, 
prove that \\\e fifth, as a ganglionic nerve, regulates the nutrition of the eye, gums, 
&c.; and that defective nutrition of those parts is one of the results of injuries in- 
flicted upon it. 

The eff'ects of the division of the pneumogastric nerve on the lungs and stomach, 
as demonstrated by the experiments of Dr. Wilson Philip, and Sir Benjamin 
Brodie, prove this to be a nerve of secretion. There are probably no cases on 
record, — with the exception of a very defective one by M. Gendrin,^ — where the 
pneumogastric was distinctly affected; and in which the influence of its disorgani- 
zation upon the lungs, stomach, and other internal organs, was traced. Some dis- 
eases are obviously afl'ections of the internal ganglionic nerves; we hd^xe augmented 
action, for instance, of the liver and kidney in the cholera europaea, and enuresis;^ 
we have paralysis of the same organs in the cholera indica, in some cases of 
icterus, and in ischuria. The effect of injury or disease of the spinal marrow on 
the quantity and constituents of the urine, is also well established. 

The whole nervous system seems to have a certain influence over the action of 
the heart. According to the experiments of Legallois and Dr. Wilson Philip, to 
crush the brain or spinal marrow enfeebles or arreSts the circulation. The same 
eflfect is produced by crushing the limbs or viscera; and this is doubtless eff'ected 
through the medium of the ganglionic system. In an eel, in which the brain had 
been carefully removed, and the spinal marrow destroyed, the stomach was vio- 
lently crushed with a hammer. The heart, which previously beat vigorously sixty 
times in a minute, stopped suddenly, and remained motionless for many seconds. 
It then contracted; after a long interval it contracted again, and slowly and gradu- 
ally recovered an action of considerable frequency and vigour. No experiment can 
demonstrate, more clearly, the effect of violence inflicted upon the system generally. 
The experiment is the more remarkable, because the connection and influence of 
the brain and spinal marrow were entirely removed. The organic structures must 
have been the medium through which the effect of the violence was conveyed to 
the heart. Similar events have occurred in surgical practice; — the case of the late 
Mr. Huskisson for example. The tremendous vehicle passed over his thigh. The 
action of the heart failed; and the surgeon waited for reaction — for an opportunity 
for amputation — in vain.*"] 



CHAPTER L 

PHRENITIS. 



Having concluded my observations on diseases of the surface,** I now proceed to 
consider those affections which are situated in the interior of the head. The first 
disease of which I will speak, according to the order I have hitherto pursued, is 
inflammation within the head; which is called "phrenitis."* 

a In his Translation of Abercrombie; Second Edition; Page 109. 
b From Evoufsw, to pass urine. 

«= Abstract of Chapters 1, 2, and 3, of Dr. Marshall Hall's " Diseases and Derangements 
of the Nervous System." 

d See Pages 363 to 476. « From <;)jxv, the mind; and " itis," inflammation. 

VOL. I. — 31 



483 PHRENITIS. 



SECTION I.— SYMPTOMS. 

Ordinary Symptoms. — In the first place, we have the symptoms common to 
inflammation in every part; only that, in this case, they are situated within the 
head. There is a sense of constriction of the forehead; which answers to the sense 
of tension in other situations. Perhaps, also, we have vertigo, and violent pain 
and throbbing in the head; throbbing of the carotid arteries; throbbing at the tem- 
ples; throbbing at the back of the neck; and an acute stabbing pain in the head, or 
a dull heavy pain. Although we cannot examine the part itself which is inflamed, 
still we have evidence of morbid heat; and that heat exteiids to the external part 
which is not inflamed; so that here is another mark of inflammation; — increased 
heat. Although we cannot see the inflamed part, and therefore cannot discern the 
redness, yet this frequently extends to the eyes; so that they are very much suf- 
fused; and thus we have a third mark of inflammation. Three, then, of the marks 
of inflammation are to be observed, though not actually at the part itself. Swell- 
insr, of course, is out of the question. Besides the pain, there is what we usually 
notice in inflammation; — morbid sensibility, extreme excitability of the mind, and 
intolerance of light and noise. 

Delirium. — Another set of symptoms arises from a disturbance o^ \he function 
of the part; — so that there is delirium; and it is not of a mild or slight character, 
but violent; — *' delirium /eroa?." In the greaier number of cases, there is also 
constant watchfulness; the patient cannot sleep at all. 

Symptoms. — As to the secondary symptoms, which arise from sympathy, we 
have pyrexia, which is perhaps violent. The pulse is accelerated, generally full, 
and perhaps also hard. At any rate, in the greater number of cases, it is accele- 
rated; and it is generally full and firm, if not absolutely hard. If it should so 
happen that, instead of violent delirium, there is more or less stupor, we may then 
have a sloio pulse; but in general there is violent delirium, and ^ full pulse. The 
tongue is of course altered in appearance. It is at first white; — the usual colour 
of the tongue, in active inflammation; but as the powers sink it becomes brown. 
Not unfrequently, the stomach is aff'ected; — so that, in the greater number of cases, 
there is vomiting; and as the bowels become exceedingly torpid, there is likewise 
costiveness. The urine is generally hijjh-coloured. As the disease continues, it 
is by no means unusual to notice convulsions; and at last, perhaps, paralysis. 

Varieties in degree. — Inflammation of the brain itself and its membranes, like 
all other inflammations, may vary in degree. There may be mere headache; — 
characterized by a sense of tension, heat, and a degree of giddiness; or there may 
be simple giddiness without any pain, or watchfulness, or sleeplessness; and from 
these symptoms there may be all the intermediate grades, up to the most intense 
inflammation, and the most furious delirium. 

Varieties in Duration. — The same variations may occur, also, with regard to 
the duration of the aff'ection. Sometimes this inflammatory affection of the head, 
will destroy the patient in a few days, or even in a few hours; and sometimes 
these symptoms may last for years. Chronic inflammatory headache (which is 
neither more nor less, in many cases, than phrenilis) may last for many years. 
When the disease is of this chronic character, we may have merely some thickening 
of the membranes; but if lymph be efl*used, they are rendered still thicker. There 
may be continuous adhesions; and even the bones themselves, as well as the mem- 
branes, may become exceedingly dense and thick. 

Diagnosis of Meningitis and Cerebritis. — These symptoms may arise either 
from inflammation of the brain itself, or of its membranes; and either of these 
aff'eclions is called " phrenitis." There are no distinctive symptoms in these cases. 
It is mentioned in books that the pain is more acute, and the pulse harder, when 
the membranes are inflamed (as in the case of " arachnitis;") but that when the 
substance of the brain is inflamed, the pain is more of a dull character, and the 
pulse is not so hard. But although, now and then, we may make a very good 



PHRENITIS. 4S3 

gness, as to how it may turn out after death; yet, T helieve, in the greater number 
of cases, we shall be wronof. In the majority of instances, both parts are in- 
flamed; — the substance of ihe brain and the membranes; and frequently, when the 
membranes only are inflamed, there is not an acute, but a dull pain; and not hard- 
ness of the pulse, but merely rapidity. Besides, the distinction is of no import- 
ance. The membranes are more frequently inflamed than the substajice of the 
brain itself; and when the substance is inflamed, it is very rare indeed for the 
membranes not to be inflamed likewise. It has been said, that when the superficial 
part of the araclmoid is inflamed, there is usually delirium; but that when the 
basilary part is affected, there is rather stupor and convulsions; — at any rate, spas- 
modic movements. So that some would have a diagnosis between inflammation 
of the brain itself, and inflammation of its various membranes; while others go 
still further, and when the membranes are inflamed, (at least the arachnoid,) ihey 
would have us to infer that it is the superior part, if there be delirium; but that it 
is the basilary, if there be stupor and convulsions. This is the statement of some 
French writers. 

[We find, that in meningitis* of the convexity of ihe hemispheres, the surface 
of the brain itself is always irritated and generally inflamed; that the consequent 
disturbances of the functions of the organ are the principal, though indirect, signs 
of the meningitis; and that these disturbances are characterized, as a general 
rule, by high excitement and irritation; — evinced by smart symptomatic fever, 
headache of the acute kind, great sensibility of the eye and ear, delirium of the 
more violent kind, and convulsive movements; which, from the usually great extent 
of the cerebral inflammation, may afTect any or all parts of the muscular system, 
simultaneously or in succession, without being restricted to a particular limb or 
part. Now, in general cerebritis, no less than in meningitis, the functions of the 
brain are disturbed; but the disturbance is characterized less by excitement than 
by depression. Nor is this diflicult to understand; for when the substance of the 
organ is extensively diseased, the abolition of the function speedily overtakes, as 
it were, and supersedes any excitement existing in the early stage. Accordingly, 
though the invasion be attended with fever, quick full pulse, exalted sensibility,, 
<fec., (as is apt to be the case when general cerebritis is complicated with nienin.-; 
gitis,) yet these symptoms of vascular excitement are less violent than in' pure 
meningitis of the convexity; and they are promptly replaced by a slow irregular 
pulse, stupor advancing to coma, muscular spasms, and universal paralytic relaxa- 
tion. In some cases, we have seen universal cerebritis wholly devoid of vascular 
excitement; ?nd attended, from first to last, with a preternaturally slow, weak, and 
irregular pulse. In such instances, when post-mortem examination shows the 
membranes to have been implicated, we suspect that they had betm attacked only 
secondarily; for, in certain instances of the kind, we have noticed slight vascular 
excitement — evinced by heat of the head, with quickness of speech, manner, and 
movements of the eye — to supervene in the mid-career of marked symptoms of 
depression. It is not to be supposed, however, that convulsions — whether in the 
form of mere twitching, or of violent and general fits — are incompatible with 
symptoms of depression. We*" have repeatedly seen them in general cerebritis; 
and they may result either from the irritation of coexistent meningitis, or from 
counter-pressure on the " medulla oblongata;" — the superior extremity of the 
*' true spinal or excito-motory column." Besides convulsions, there may be tonic 
spasms;— that is, rigid contractions of limbs; and it is maintained by Rostan, 
Lallemand, Bouillaud, and others, that these are peculiar to cerebritis, and foreiga 
to meningitis; but their idea appears to extend to the cerebritis of the surface which 
accompanies meningitis, and it therefore includes the bulk of the cases which we 
denominate " meningitis." However, when the rigid contractions occur in gene- 
ral cerebritis, or in meningeo-cerebritis, it is maintained that they are not restricted 

* From "meninx, raeningis," a membrane; and "iiis"i7iJtammatio7i. 
^ Dr. James Hope. 



484 PHRENITIS. 

to a particular limb, side, or part; but affect a variety of parts on both sides at the 
same time; also, that vvlieu the rigid spasms relax, the liinb recovers its muscular 
power and sensibility/] 



SECTION II.— MILDER FORMS OF THE AFFECTION. 

Let us now consider certain milder forms of this affection, together with some 
other affections; which, though not inflammatory in their nature, present many 
points of resemblance. 

Inflammatory Headache. — When phrenitis occurs in a very mild degree, the 
patient complains, more or less, of headache; but that headache is attended by a 
throbbing sensation. There is a throbbing pain in the head, or a throbbing of the 
temples, or of some particular part; and the pain is usually most intense in the 
forehead. In the greater number of cases, the patient puts his hand up to his 
forehead. It is rendered worse by heat; — by the heat of the bed, and by the heat 
of the fire. It is rendered worse, too, by stooping; and especially on rising again 
after stooping. This will cause a sensation of great weight, or even a cutting sen- 
sation, to be experienced within the head. It is generally worse in the morning; — 
from the continued heat of the bed, and the horizontal posture. There is like- 
wise, in many cases, drowsiness; and yet the patient perhaps cannot sleep, on 
account of the intensity of the pain. There is a morbid heat of the head, and a 
morbid sensibility to light and sound. These produce, not an agony, but an un- 
easiness. The least noise frets the patient; and so does the light. The mind, 
too, in these cases, is almost always irritable. Patients are easily put out of hu- 
mour; and they are impatient. In these cases, the pain rarely extends below the 
zygoma. If it be an inflammatory affection within the head, the face does not 
suffer; nor does the pain extend, for the most part, down the back of the neck. 
The pain is usually not increased by touching the scalp. Now and then, how- 
ever, the external part may be affected, as well as the internal; and then there 
may be tenderness of the scalp; but, for the most part, there is not. 

Rheumatism of the Scalp. — In rheumatism of the scalp, on the contrary, there 
is almost always extreme tenderness. Many cases occur, where we are exceed- 
ingly anxious to ascertain whether the pain complained of is internal or external: 
and, by attending to these marks, we shall be able to say whether it is internal, or 
external. In rheumatism, there is not only, for the most part, tenderness of the 
scalp; but the pain generally extends beyond the cranium. It frequently runs 
down the face; it runs behind the ears, and down the neck; and, very frequently, 
there is rheumatism in other parts. Sometimes there is great sweating; — ^just as 
in common rheumatism. 

Rheumatism of the Membranes. — Now and then, however, the internal parts 
suffer in rheumatism; so that we may have both external and internal inflammation. 
In these instances, the nature of the case is in general easily made out, by observing 
that, although the scalp is tender, and the pain runs down the face, and the back 
of the neck; — although there is rheumatism in other parts, and the pain is worse 
in the evening; yet there is likewise giddiness, drowsiness, and a throbbing of the 
inner part of the head. When we see two sets of symptoms like these, we may 
be sure that the two parts are affected; — the external and the internal; and, in such 
a case, although the patient is labouring under rheumatism, yet we must not trust 
to such ordinary remedies as, for the most part, cause rheumatism to disappear 
sooner than it otherwise would; but we must treat the case as phrenitis. Very 
frequently this pain of the head, when it is rheumatic, is attended with a great 
sense of coldness. In these cases, too, the pain, for the most part, is worse in the 
afternoon or evening; but the latter is by far the most usual; and that without any 
cause which we can discover. The pain is not worse in the morning; and the 

a " Library of Medicine," Volume 2; Pages 38 and 39. 



PHRENITIS. 48,5 

addition of even two or three flannel nightcaps, does not make it worse; but in 
inflammatory pain of the internal part of the head, these things could not be borne; 
and (as I have before said) the pain is almost always worse in the morning; — wliich 
arises simply from the mechanical circumstance, that the horizontal posture allows 
the blood to go more easily to the head, and renders its return more difficult; and 
from the bed increasing the heat of the body. But in rheumatism (which is of a 
cold nature) this very pain is almost always worse in the evening, and is relieved 
by heat. These circumstances clearly point out the nature of the case. 

Hemicrania. — When pain of the head is of another description, — neuralgic, — 
we may frequently discover its nature, by the absence of these internal symptoms, 
and by the pain running along particular nerves. Sometimes it runs in the course 
of the supra and infra-orbital nerves; sometimes it is particularly seated in the 
branches of the fifth pair near the ears; and sometimes we may trace it along the 
mastoideus. 

At other times, however, it does not run along the course of particular nerves; 
but is situated in one spot, where there is a violent continual pain; and this is very 
common in hysteria. Sometimes the part itself is very tender; and sometimes not. 
When we see the absence of the usual symptoms of inflammation of the head, we 
may easily, in general, make out the true nature of the case. It very frequently 
attacks the brain on one side; — not in the situation of the supra-orbital nerve merely, 
but some other part of the brain; and the pain seems seated there. In this case it 
is not intermittent, nor does it run along the branches of nerves; but is situated in 
nerves terminating at one spot on the surface of the body. A pain of this descrip- 
tion is sometimes inflammatory; and is attended with these internal symptoms; 
and then we have to treat it accordingly. It may last for a few days, or for a long 
time; — coming on at a regular or irregular periods. Such a pain as this is fre- 
quently hereditary. I have known many members of the same family sufler from 
the disease; especially after they have become adults. It is a very hereditary sort 
of pain; — a pain over the brow; coming on once in three weeks, or once a month, 
or more or less frequently. It is sometimes produced immediately by mental agi- 
tation, by overloading the stomach, or by putting improper articles into it; but, in 
many persons, in spite of every thing, it will come on (without any apparent cause) 
every {q\y weeks. In many other cases, there is a local pain; — a pain not inter- 
mittent, situated in different parts of the head; and very frequently it is hysterical. 
It occurs, especially, in hysterical patients. 

Thus we have pain of the head of a decidedly inflammatory nature; attended 
with indammation of the brain itself, or its membranes. We may have pain of the 
head of a rheumatic \\?Liure\ and the rheumatism may be active, attended with heat; 
or of a cold character (which I shall hereafter speak of) relieved by warmth, and 
worse in the evening; or we may have another headache, which is neuralgic; and 
of that kind called "tic douloureux;" — running along particular nerves; but some- 
times diff"used, with morbid sensibility of a particular part; or of an intermittent 
character. 

Sick Headache. — The last kind of headache which I mentioned," where it 
occurs })articularly over the brow, has been called '•'• sick headache;" because it is 
attended frequently with sickness. The stomach is deranged in the first instance, 
or it soon becomes deranged after the headache has begun. More or less, we find 
headache connected with the afl'ection of the stomach; so that it is called " sick 
headache." I believe that most persons ascribe this to the stomach; but I am quite 
sure it is very unjust to lay it to the charge of the stomach, in every case. The 
stomach has enough to do with diseases of its own, without being accused of the 
diseases of other parts. I have experienced pain of this description, two or three 
times, from, evident local causes in the head. From having a draught blow on my 
head, when I have been overheated, I have had intense pain come on. I may 
mention, that I rarely have any thing the matter with the stomach; but, after this 

* See the last paragraph but one. 



486 PHRENITIS. 

pain has existed some time, I have had violent nausea, and then vomiting; — the 
stomach being affected only sympathetically. I have observed, too, in a great number 
of persons, that this headache has not been preceded by an affection of the stomach. 
People have declared that they digested well, and that they had a good appetite, 
not only up to the time of the occuirence of the pain, but as long as the pain was 
moderate; but when the pain arrived at a certain intensity, then the stomach fell 
into nausea and vomiting; and was disturbed as much as the head. There is no 
doubt that persons predisposed to these pains, may bring them on by overloading 
the stomach, or taking improper articles of diet; but it is to be remembered, that 
pain of the head will cause disturbance of the stomach; and therefore we have no 
reason to suppose that the stomach is in fault. 1 do not think that we ought to 
infer that the stomach originally is in fault, simply because it is disturbed as well as 
the head. In a great many cases, the stomach is not affected until the derange- 
ment of the head has arrived at a certain point; but the state of the stomach will 
bring it on; and so also will costiveness; but it is precisely the same with all other 
affections of the head, and of the alimentary canal. If a person allow himself to 
become costive, he will be almost sure to have an inflammatory headache; and an 
inflammatory headache will induce costiveness. It is quite illogical to say, that so 
many affections of the head arise from the stomach and intestines; and it is just as 
wrong to say, that all affections of the alimentary canal depend on the head; yet 
there are parties who, if they do not say so in plain and distinct terms, neverthe- 
less approximate very closely towards it. 

Treatment of Sick Headache. — This is a most intractable complaint. I have 
known it affect many persons, in whom all the remedies that were employed, failed 
in accomplishing any material good. If tlie system be too plethoric, — if we find 
the pulse full, — if we find the patient eating and drinking too much, we may do 
good to a certain extent, by bleeding and lowering the diet. Now and then the 
pain is so intense, that a degree of phrenitis occurs; and we must then treat it as 
phrenilis. But where it only comes on from time to time, I do not think we can 
easily remove it; though we may lessen it, and prevent it from being as bad as it 
otherwise would. If the patient avoid every thing likely to do harm, and pay 
proper attention to the bowels, this object may be effected. Now and then, the 
stomach is very much out of order, and an emetic may mitigate urgent symptoms; 
but it will not produce material benefit. I have tried iron, sulphate of quinina, 
arsenic, and every medicine that suggested itself to my own mind, or has been 
recommended by others; but it has been in vain. After a number of years, this 
description of headache will sometimes c^ase of its own accord. 



SECTION III.— MORBID APPEARANCES. 

Hii^h Vascularity of the Membranes. — After death we find, with regard to the 
membranes, either a distinct red net-work, or a uniform redness, of greater or less 
extent. The minor degree of inflammation, is where we can discover each vessel 
distinctly; and the higher degree is where there is uniform redness in any portion; 
because the uniformity of the appearance arises from llie excessive number of 
vessels which contain red blood. These patches vary exceedingly in extent and 
frequency. 

Jnflammalion of the Arachnoid. — It is probable that, of the three membranes 
of the brain, the arachnoid is most frequenUy inflamed; and we may have inflam- 
mation, not merely in the enveloping portion, but likewise in tliat which lines the 
ventricles. Either one portion or the other, or both, may be inflamed. When 
this membrane becomes inflamed, it is opaque; and it also becomes tliickened; — 
both which are common effects of inflammation. 

There is generally a certain quantity of serum, either upon or in the brain; and 
in the greater number of cases (as I mentioned'* when speaking of serous mem- 

a See Pas:e 108. 



h 



PHRENITIS. 48 

branes in general) the senim is turbid. Not only, however, is the serum turbid, 
but often larger or smaller portions of fibrin are seen in it. 

Now and then the inflammation is so intense, that layers of lymph are found 
either upon the brain externally, or in the ventricles. Sometimes the fibrin is not 
in the form of layers, but has a jelly-like appearance; and we find this appearance 
most frequently at the base of the brain. Now and then we find absolute adhe- 
sions. In general, when there is such violent inflammation, death takes place too 
soon for the layers of fibrin to become adiierent: but death may not take place so 
rapidly; the process may be slow; the inflammation may not be so acute; and then 
adhesions may be formed. If the disease be rather chronic, this fibrin may become 
very thick and organized; and we may have it to a very great extent. I was 
shown, by a friend of mine, a portion of fibrin which covered nearly the whole of 
the brain; and I should think, that nearer a third than a fourth of it was an inch in 
thickness. It was perfectly organized; and formed an envelope to the brain. Pus 
is sometimes produced; and Dr. Baillie says,* that he once saw pus all over the 
surface of the brain; — secreted, I presume, by the arachnoid. 

Inflammation of the Pia Abater. — If it be the " pia mater" which is inflamed, 
this of course becomes red; there is more or less of fluid under it; and the fluid, 
from being confined under the membrane (like the vitreous humour in the cells of 
its capsule), gives exactly the appearance of jelly. The jelly-like fibrin secreted 
by the arachnoid, of course lies itpon the arachnoid; but the jelly-like matter which 
arises merely from fluid collected in the " pia mater," lies under the arachnoid; — 
the " pia mater" being within. 

Inflammation of the Dura Mater. — When the " dura mater" is inflamed, there 
is redness of it; and now and then it has been said to suppurate, and even to have 
fallen into a state of gangrene. Frequently, a very large quantity of blood is 
observed after this inflammation, between the "dura mater" and the cranium. 
The great turgescence is not confined to the vessels of the "pia mater." Indeed, 
in inflammation of the head, the blood is not confined to the interior, but very fre- 
quently extends to the scalp; so that all the vessels of the scalp are exceedingly 
full: and we find an increased secretion of serous fluid in the scalp itself. When 
the inflammation of the dura mater is local, — the eff'ect of an injury arising either 
from a diseased bone, or external violence, — we know that the superjacent scalp 
becomes so affected, that it is quite cedematous; and this is a point attended to by 
surgeons; — as indicating, after an accident, great afi'ection at a particular spot 
within. In general, if the dura mater be inflamed throughout, there is great turges- 
cence of the vessels of the scalp, and a serous eff'usion into it; but if the inflam- 
mation be local, then we may have, exactly over the spot, absolute oedema of the 
scalp. 

Inflammation of the Substance of the Brain. — When the substance of the 
brain itself is inflamed, we may observe (on slicing it) a very large number of red 
dots, besides those which are always seen; and the latter may be double their 
usual size. We frequently, too, see a large number of minute vessels, which 
ought not to contain blood, like so many fine red hairs, in the substance of the 
brain. Now and then inflammation, when situated within the brain, runs on to 
abscess. This is most usually the case when the inflammation is not general, but 
local. Dr. Baillie says that he once saw the brain in a state of gangrene.* I have 
myself seen the "dura mater" in that state, but I never saw the brain so; — at 
least, if we are to judge of its existence from its being very lacerable, and exceed- 
ingly oflensive. From inflammation, the brain will become exceedinjjly soft, — so 
as to be a mere pap;— something like very thick arrow-root and water. There are 
various degrees, of course; but still the brain is softened. Now and then, we ob- 
serve softened brain and pus together. The brain generally looks of a dead- white 
colour; and,x)f course the pus has more or less of a yellow tinge; but frequently 

* In his " Morbid Anatomy;" Chapter 24; Section 8. 
•' See his " Morbid Anatomy;" Chapter 24; Section 15. 



48S PHRENITIS. 

they are seen together. It is very rare for the brain to become ulcerated on the 
surface; but, now and then, such a condition has been seen. 

^Appearances in Chronic Inflammation. — All these effects that I have mentioned, 
are frequently observed after chronic inflammation of the brain, as well as after an 
acute attack; and after chronic inflammation, there is another effect very frequently 
seen; namely, induration in that part which has been inflamed. Acute inflamma- 
tion generally causes, besides the redness, a great turgescence of the vessels, large 
and numerous red dots, distinct red vessels, a great fulness of the larger ones, per- 
haps more or less effusion, and perhaps abscess. . But besides all this, in chronic 
inflammation, the brain may become hard. Now and then, acute inflammation 
may produce hardening; but I believe it is more frequently the effect cf chronic 
inflammation. 

Infiltrations of Pus, and Abscess. When the substance of the brain has been 
inflamed, and pus has been produced, it is sometimes not collected in a large quan- 
tity, so as to form an abscess; but is seen infiltrated throughout the brain; — so that 
it has been found in the substance of the organ, in innumerable points. Where 
this is the case, the substance of the brain is generally softened; because, in the 
first place, there must be a great degree of inflammation to produce pus; and when 
the pus is infiltrated so extensively, of course there cannot be induration. There 
is a great variety in the degree of this; so that we may have mere drops of pus, in 
the midst of softened portions, and then still larger drops; till we come to such 
large ones that they are, in fact, abscesses. When the pus is collected in the form 
of an abscess, there is a capsule produced, of various degrees of perfection; so that 
sometimes it has been known to have distinct coats. The contents of such ab- 
scesses will sometimes be exceedingly oflensive; although, of course, no air could 
have had access to them. The parts surrounding an abscess in the brain, may be 
in all states; — either perfecdy healthy, or diseased and softened, or altered in colour, 
&c. The matter of the abscess may, of course, remain there, and be found shut up 
all around; or it may work its way, and burst into the ventricle; or it may burst 
into the nose, or into the ear. Abscesses more frequently occur in the hemispheres, 
than in any other part. 

Changes in Consistency. — With regard to consistency, it is to be remembered, 
that the firmness of the healthy brain varies at different parts; so that a degree of 
softness which would be morbid at one part, would be only natural in another. It 
varies, likewise, according to the time at which we examine a body; — a fresh brain 
being firmer than one some days old; for as soon as it is exposed to the air, it be- 
comes very soft. With respect to different parts, I need not say that the "tuber- 
cula quadrigemina" are exceedingly firm. The consistency, too, varies according 
to age. The brain of old people is firmer than that of young persons. There is 
greater variety in the degree of change of consistence after inflammation, than in 
any other disease. 

Softening of the Brain. — When the brain is softened, the part may retain its 
natural colour; or it may be yellow, it may be of a rosy hue, it may be gray, or it 
may be whiter than usual. If the change be not the result of inflammation, the 
patt is generally exceedingly white: but the parts around, which are not yet sof- 
tened, will be found of a rosy colour. But when the brain is softened, — to say 
nothing of inflammation, — the colour may be of all the varieties which I have just 
stated. It may be rosy from inflammation, or it may be perfectly white; — the red- 
ness being only in the surrounding parts. When the brain is inflamed, the softened 
parts may be mixed with pus, or with blood. If there be a vessel of any con- 
siderable size very near, the blood is poured forUi into the softened part. It is the 
gray part, some tliink, which is the most frequently softened; but however this 
may be, every pait of the brain is liable to it. When the membranes have been 
inflamed, it is the cortical part which is most frequently softened. From being in 
a bad neighbourhood, the brain under the inflammation suffers, and becomes 
softened. The softening may occur in one or more spots; and, like the existence 
of pus, it may be exceedingly partial, or may be very general. 



PHRENITIS. 489 

The spinal marrow is also liable to softening; — just in tlie same way as the brain. 
This softening occurs whether there is inflammation or not; and is seen at all ages, 
but more particularly in old men. Generally, around the sofiened part, there is 
congestion and inflammation. Very often we see inflammation; but frequently we 
do not. The part is frequently softened, when no inflammation can be discovered. 
I recollect, distincfly, opening the brain of a young man, whose brain was softened 
in a great many parts. He was not a patient of mine; but a medical man invited 
me to see him. He had had paralysis, and the brain was softenetl; but the part 
was so white, that we could not conceive there had been tlie least inflammation. 
I opened another individual, shortly afterwards, where there were the most intense 
marks of inflammation; — the brain was absolutely red around the softened part. 
This is a proof that, though these appearances are often connected with inflamma- 
tion, yet they are sometimes wholly independent of it. 

Induration of the Brain. — Induration of the brain may, like softening, be very 
local, or only rather local, or it m?i.y he general; and of course it varies very much 
in degree. Sometimes it ainounts to no more than it would, if it had been har- 
dened by acid; or it may amount to the consistency of wax; and now and then the 
hardness is still greater; — assuming a fibro-cartilaginous character. When the 
brain is pretty generally indurated, it is said to be the efiect of an acute in- 
flammation; but, as I before observed,^ acute inflammation more frequently 
produces softening than hardening. However, in this case, hardening is 
more frequenfly thought to be the result of acute than of chronic inflam- 
mation; but it is only the first degree of hardness (namely, that which is equal 
to the consistency induced by acids) that occurs from this process. When the 
hardening is general, we should not suppose that such extreme induration, as to 
be called fibro-cartilaginous, could exist universally throughout the brain; nor, 
indeed, is it the case. The second degree of hardness (ivaxy hardness) is usually 
local; and the same is the case with the fibro-cartilaginous hardness. This is 
exactly what we should ci priori suppose. These two extreme hardnesses are 
almost always the eflfect of chronic inflammation; — perhaps always; but I cannot 
positively say so. It is said that, after fever and general debility, the brain is fre- 
quently found in an indurated state; but I do not know this from my own ex- 
perience. 

Fed Dots. — Then, as to the red dots, they ought to be very numerous, or very 
large, or indeed both, for us to say that there is morbid redness. We find people 
difl^er, every day, about the inflammatory appearances of the substance of the brain; 
— some contending that there are not more red dots than there should be, and 
others that there are. I think, therefore, we ought not to be satisfied, unless there 
are a very considerable number, or they are of very considerable size. They are 
more usually found in the medullary, than in the cortical portion of the brain. 

Summary of the Morbid ^Appearances. — [The diflferent morbid appearances of 
which a description has been given, may be summed up as follows: — 1. Increased 
vascularity; redness, either dotted or uniforiu; no change of consistence or colour; 
no exudation of fluid, or rupture of vessels. [Congestion.) 2. Great increase of 
vascularity; intense dotted redness; spots of ecchymosis, with a striated appear- 
ance, and efTusicm of drops of blood; increased firmness. [First Stage of Inflam- 
mation.) 3. Infiltration of blood, and softening of the cerebral pulp towards the 
centre of the inflamed portion. [Red softening.) Infiltration of pus mixed up 
with the disorganized pulp. [Yellow softening.) The red and yellow softening 
combined. 4. Serous infiltration of the cerebral pulp; softening of a milk-white 
colour, without vascularity. [White softening.) 5. Increased formation of pus, 
of various colours; the wall of the cavity lined with a membrane. [Undefined ab- 
scess; encysted abscess.) 6. Loss of substance on the surface of the brain, or that 
of the ventricles. [Ulceration.) 7. Infiltration of the pulp or its vessels, with 
permanently concrete fluids; conversion into a more or less dense mass. [Indtt- 
ration.)^2 

* See Page 488. ^ " Cyclopeedia of Practical Medicine;" Volume 1; Page 304. 



490 PHRENITIS. 

Precautions necessary in Examining the Brain.— In examining the brain and 
its membranes, with the view of ascertaining the existence of inflammation, we 
mnst carefully remember, that position has a very great effect; that if the head lie 
in the usual recumbent posture, and the body be not opened till several days have 
elapsed after death, extreme congestion may take place at the posterior lobes of 
the brain; — such as might lead us to suppose, that there had been a vast accumu- 
lation of blood during life. If the body have become putrid, this congestion may 
amount to effusion; — at least, the slightest touch will cause blood to be poured forth. 
We should carefully note whether position can have caused that accumulation of 
blood, which we observe on opening the head. We ought also to look at the brain 
the moment we cut it; because, after it has been cut and exposed to the air, it be- 
comes rather redder than before. Our judgment should be formed, therefore, 
immediately on slicing the organ. It is likewise to be borne in mind, that both 
the brain and the spinal marrow, without any accumulation at either part, have a 
redder appearance when deadi has taken place rapidly, than when it has occurred 
slowly. It is said, too, that they are redder in persons who have died from 
asphyxia, than in other persons. We must also remember, that the redness con- 
standy varies in different parts; — that there is, for instance, more redness in the 
"corpora striata," than in many other parts. At the base of the "thalami nervo- 
rum opticorum," there are naturally a number of red vessels; the appearance of 
which we must not mistake for turgescence. We must remember, with respect to 
colour, that the white part of the brain contains more vessels in early life, than in 
old age; when it assumes a yellow hue, and has by no means the same number of 
vessels. We must also remember, that the gray portion of the brain is much more 
" vascular" (as it is termed) than the white portion. When a part is redder than 
usual, there are not more vessels than natural; — the vessels merely contain more 
blood than they ought to do; and therefore the expression " more vascular'''' is, 
strictly speaking, incorrect: but we merely mean, by that phrase, that vessels con- 
tain red blood which ought not to do so; and that those which should, have an 
increased quantity in them. The gray part is generally more vascular than the 
medullary portion. All these things are necessary to be remembered, in forming 
an accurate judgment of the morbid appearances in the head. 

Jinsemia of the Brain. — In many states of the body, the very reverse of all 
these appearances takes place. In some diseases the brain will become bloodless. 
In cases of starvation, it is said, the brain will become colourless. This may be 
expected. When persons die through the want of some natural stimulus to which 
they have been accustomed, there is also this extreme whiteness of the brain. I 
have seen diis condition, quite independenUy of a general cause; quite independ- 
ently of the loss of blood, or the want of food, or the want of stimuli; but from 
local disease of the cerebral arteries. I have seen the arteries diseased; — so that 
they would not admit of a proper quantity of blood passing through them; and the 
brain has consequendy been rendered far whiter than it naturally is. However, 
this whiteness is said sometimes to occur, after there have been signs of irritation 
of the brain; but I should think that it more frequently arises from the want of blooil 
throughout the body, or from causes which prevent the brain from receiving its 
proper quantity of blood. So much, therefore, for the morbid appearances." 

Comparative Frequency of the Several Forms of Cerebral Inflammation. — 
[[Inflammation of the *'dura mater," exclusive of that produced by fractures and 
other surgi(;al affections, is perhaps the most rare variety. The " phrenitis" of old 
authors, — that is, inflammation of the membranes and surface of the convexity of 
the brain, with furious delirium and rapid sinking, — is not, according to our"" ob- 
servation, a frequent aff'ection in this country; but it is much more common in 

' One of the most splendid books on the morbid appearances of the brain, is Dr. Hooper's. 
Some of the plates are rather loo showy; but still they exhibit, extremely*well, the appear- 
ances of iiiftiminiiioii. Representations of this nffectioti, are also given in Dr. Bail lie's 
work on Morbid Anatomy; bat the plates, not being coloured, do not show it very clearly. 

^ Dr. James Hope's. 



PHRENITIS. 491 

tropical climates, where inflammations in general are characterized by intensity and 
rapidity of progress. Inflammation of the central parts of the brain, with or witli- 
out effusion into the ventricles, and not iinfrequently conjoined with meningitis at 
the base or on the hemispheres, — occurring principally in children, and running a 
protracted course of fifteen to thirty days, with two or three well-maiked stages, — 
is an affection which, under the designation of "hydrocephalus," is perhaps not 
surpassed in frequency by any other single variety of cerebral inflammation. Gene- 
ral acute cerebrilis is rare; partial is pretty common, especially with more or less 
meningitis; chronic partial cerebritis is perhaps equally, or even more common.^] 



SECTION IV.— CAUSES. 

Inflammation of the brain is less frequently an idiopathic, than a symptomatic 
aflTection. It is more frequently seen as an accompaniment o^ fever, than of any 
other disease. 

Heat and Cold. — It will arise, like any other inflammation, from cold applied 
to the body, especially when the latter is over-heated. It will occur also from 
simple heat; for if a person in a hot climate be exposed to the direct rays of the 
sun, without any covering on his head, (especially if he be lying down,) inflamma- 
tion of the brain may be the consequence. This is called " insolation." Some- 
times, instead of inflammation, apoplexy is induced; but this more frequently 
occurs when tlie patient is making a violent exertion at the same time. 

Intoxication. — Intoxication will produce inflammation of the brain. Spirituous 
or vinous liquors irritate the brain, or they would not intoxicate; and the irritation 
may amount to such a degree, that inflammation may occur. The same circum- 
stance arises from mental irritation. 

Mental Irritation. — Mental irritation, whether it arises from rage or anxiety, 
causes a great excitement of the brain. Want of sleep, or long-continued watch- 
fulness, will have the same effect. Long-continued excitement, of a less degree, 
may amount to the same thing as violent excitement for a short time. Excessive 
use of the brain cannot take place, without the want of sleep and anxiety. No 
person studies, without being anxious to learn what he studies; and his love of 
study induces him to sacrifice sleep. 

i\^a?T0^2C5.— Narcotics, which stimulate the brain, may also induce this condi- 
tion of tiiat organ. It is very common, after large does of opium, hyoscyamus, or 
stramonium, to find a throbbing in the vessels of the head. After a person has 
taken prussic acid, he may experience throbbing in the head, or throbbing of the 
throat, and more or less delirium. 

Mechanical Injuries of the Head. — Wounds, of all descriptions, are common 
causes of inflammation within the head. Contusions, concussions, penetrating 
wounds, and mechanical injury of the head, may act in two ways: — as exciting 
and as predisposing causes. We may have inflammation directly induced by 
them; or such morbid irritability excited, that any common cause, afterwards 
applied, may easily produce inflammation; — so that when a person has had 
injury inflicted on the head, (whether it be fracture or any thing else,) it is some- 
times very dangerous for him to drink either wine or beer, or spirituous liquors, 
for a very great length of time; or perhaps even to eat meat; for the slightest 
cause, in these circumstances, may give rise to inflammation. This disposition 
will occasionally last for years. I recollect seeing a person who, twenty years 
before, had suffered fracture of the skull; and, on taking a glass of spirits, he 
immediately became almost delirious. I mentioned, wh.en speaking of inflamma- 
tion in genera.], that I had seen delirium induced from rheumatism of the scalp, 
after an injury to the head.'' 

Cessation of an Eruption. — Phrenitis has sometimes arisen from the cessation 

» "Library of Medicine;" Volume 2; Page 46. ^ See Page 113. 



492 PHRENITIS. 

of an ernption. It is said that cessation of itch, has been followed by inflamma- 
tion within the head. 

Removal of a Tumour. — Sometimes it has arisen from the removal of a tumour. 
The tumour has taken off a great deal of excitement. It has required a considera- 
ble quantity of blood to nourish it; and, the tumour being removed, there has been 
so much more energy throughout the system, and the brain has consequently suf- 
fered. This has more frequently occurred, when the tumour has been situated on 
the head itself. This is exacUy what we should suppose. 

JimenorrlKEa and Costiveness. — Analogous to the cessation of an eruption, are 
amenorrhcea, and costiveness. Women, every day, — from the cessation of the 
menses, when they ought to menstruate, — become the subjects of violent head- 
ache, giddiness, and symptoms of that description. Now and then actual inflam- 
mation of the brain will take place. Costiveness frequently induces headache. If 
a person pass his usual time for having a motion, headache takes place; and it is 
said that inflammation of the brain has sometimes been the consequence of mere 
costiveness. 

Iriflamination of the Eye, Ear, or Nose. — Inflammation of the eye, or the ear, 
or the nose, or the frontal sinuses, will sometimes spread to the brain. Phrenitis 
has frequently carried off patients who have had nothing more, at first, than inflam- 
mation of the parts I have just enumerated. Of course, inflammation will spread 
in the head, just as in other parts of the body. When the nose and the sinuses 
have been inflamed, in a great number of cases the bones have been found carious, 
I have several times seen phrenitis arise from disease of the ear. When a person 
has what is called " otorrhea, "* or "otalgia,"" (in common language, a discharge 
from the ear, or ear-ache,) we ought to be on our guard to notice the first symp- 
toms he may mention of pain in the head, or the first anxious look that is dis- 
played. The very slightest symptoms of cerebral affection, when there is a cessa- 
tion of discharge from the ear, ought to put us on our guard. I have seen several 
cases of this description, where persons have had phrenitis after pain of the ear, or 
a discharge from that organ. Some have had deafness; some have previously had 
a pain; and then only discharge. In the first case that I saw, there was a wildness 
in the person's look, and a quick pulse; and 1 expressed to the friends my belief, 
that the person would never go out of the hospital again alive. This circumstance 
is mentioned by several authors; and several instances are quoted by Dr. Cheyne, 
in his work on Hydrocephalus Acutus.*^ In these cases the bone is generally more 
or less carious. That portion of the " dura mater" which lines the petrous portion 
of the temporal bone, is found inflamed, perhaps softened; and perhaps there is 
pus there. 

I mentioned'' that I had once seen the " dura mater" gangrenous; and that was 
in a case of this description. The portion of the brain lying over the ear was like- 
wise altered in colour; — and even underneath there was a very considerable change. 
In a short time the patient became violently delirious; no bleeding, no mercury 
could stop it; and for this simple reason; — there was local disease keeping up the 
inflammation. There was diseased bone, and old ulceration within the ear; and 
we might as well have thought of curing inflammation while a portion of depressed 
bone rested on the brain, or curing an ulcer where there was a piece of carious 
bone to come away, as curing this disease. 

Venereal Nodes. — When the skull has become affected by venereal nodes, it is 
not uncommon for the "dura mater" to become inflamed; and the patient to die, 
with all the symptoms of phrenitis. 

Erysipelas of the Head. — When the external parts of the head, the scalp, or the 
face, are inflamed, it is very common for phrenitis 1o occur. When erysipelas of 
the face and head proves fatal, I believe, in the greater number of instances, it 

» From ou;, the ear; and ^ew, tojl.ov). 

^ From oyf, the ear; and aXyo;, fain. 

e " Essays on Hydrocephalus Acutus; by John Cheyne, M. D." 

d See Page 487. 



PHRENITIS. 493 

does so by inducing inflammation of the brain itself, or of its membranes; — at 
least, in every case of erysipelas of the head wiiich I have opened, I have found 
very considerable effusion, either upon, or within the brain, or both. This is not 
an instance of metastasis, or the occurrence of inflammation in one part from its 
cessation in another; bat appears to be an instance of extension of inflammation; 
for the inflammation of the face, and of the rest of the head, jjoes on just as 
vigorously (in the greater number of cases) when phrenitis has taken place, as it 
did before it commenced. 

Metastasis. — Inflammation of the brain, however, certainly does occur some- 
times, in the way of metastasis. When rheumatism ceases in the joints, or gout 
ceases in some situations, phrenitis occasionally occurs; and it sometimes takes 
place after the cessation of inflammation in the salivary glands; — in the case of 
mumps, or (as it is sometimes called) "cynanche'' parotidea." Phrenitis sometimes 
occurs immediately on the cessation of this species of inflammation; but sometimes 
it occurs on the cessation of inflammation of the testicle; which itself occurs, in the 
first instance, after the cessation of inflammation in the salivary glands. Some- 
times the testes are inflamed intermediately. It is very common, after inflamma- 
tion of the salivary glands, for the testes to become inflamed; and when that 
inflammation ceases, phrenitis sometimes occurs; but sometimes inflammation of 
the brain occurs immediately on the cessation of the mumps themselves. 

Its Occurrence in Fever. — Phrenitis, however, as I before stated, '' is by far the 
most frequenUy seen as an occurrence in fever; and some may choose in this case 
to consider it idiopathic; — excited by the contagion of typhus fever, or malaria, 
or remittent fever, or by excess, or vicissitudes of temperature. Some contend 
that fever itself, in many instances, consists of inflammation of the brain; and if 
they be correct, such phrenitis must be considered idiopathic. If, however, fever 
be a general aff'ection of the system, then the phrenitis would be considered by those 
^vho hold that opinion as syinptoinatic. But these are mere diff'erences of words. 

Predisposing Causes. — Inflammation of the brain is predisposed to, by native 
congenital irritability of that organ. Some persons have extreme irritability of the 
brain. If such individuals be thrown into a passion, or be suddenly and violently 
excited, they are very liable to phienitis. Habits of intoxication, injuries of the 
head, all organic diseases of the head, and especially tumours in or upon the 
brain, necessarily have the same eflect. All these things give a tendency to in- 
flammation of the brain; so that an exciting cause easily becomes eflScient. 



SECTION v.— DIAGNOSIS. 

[We now proceed to point out the diagnosis between the several varieties of in- 
flammation of the brain, and the diseases with which lliey may respectively be 
confounded. These diseases are — mania: continued fever; delirium tremens; 
apoplexy; active determination and congestion of the brain, in various diseases 
of infancy; exhaustion; and hysterical, neuralgic, rheumatic, bilious, and dys- 
peptic headaches. 

JSJania. — JMeningitis of the convexity of the hemispheres, with fierce delirium, 
("phrenitis,") is distinguished from mania by the want of the characteristic symp- 
toms which distinguish the latter; — the more or less complete absence of fever and 
disturbance of the digestive organs, together with its prolonged course. 

Continued Fever. — The diagnosis of meningitis, both superficial and central, 
from continued fever with cerebral disturbances (" typhus mitior;" " flevre ner 
veuse, ou ataxique essentielle,") is certainly very obscure. The symptoms of 
cerebral excitement commence as early in l!ie fever as in meningitis, but more 
commonly they are later; not appearing till after the lapse of two or three days, 
or more. The nature of the symptoms may, at the onset, be much the same in 

a From xwajv, a dog; and a-yx"^, to strangle. *> Sec Page 491. 



494 PHRENITIS. 

both; but the progress of the two affections soon renders manifest a remarkable 
difference between them. The typhus fever is characterized by restlessness in a 
high degree, by anxiety, low delirium, and spasm, in the form of subsultus tendi- 
num, but seldom more; and these symptoms often alternate with intervals of calm- 
ness, and even of sleep, especially in the morning. In meningitis, on the contrary, 
there is comparatively little restlessness, except in the phrenitic variety; when 
there is wild delirium, but not the peculiar restlessness of fever. The muscular 
symptoms are distinct convulsions, spasmodic rigidity, or paralysis; they occur in 
connection with a state either of delirium, decided somnolency, or complete coma; 
and these symptoms are more or less permanent;— -seldom exhibiting intermissions, 
except occasionally in the earliest staj?e. The pulse in fever does not fall below 
its natural standard, display singular fluctuations in frequency, and finally rise to 
an extreme degree of acceleration before the fatal event; — circumstances which are 
highly characteristic of meningitis; nor is the respiration suspirious and irregular 
in fever, as in menmgitis. 

Finally: in the later stages of fever there are — a parched, brown, crusted tongue, 
with sordes on the teeth; dark, offensive faecal evacuations; tympanitic abdomen; 
sometimes petechiee; low muttering delirjum; the supine posture; slipping down 
in bed; — symptoms which, taken in connection with the absence of the pathog- 
nomonic symptoms of meningitis, render the diagnosis so distinct, that the two 
diseases can scarcely be confounded. 

We* have seen cases of general cerebritis present symptoms at the onset very 
like those of low fever; but these may be detected with little difficulty, by observing 
that the headache is more intense and permanent than corresponds with the degree 
of fever, and that it usually increases in intensity as the pulse falls; — a most sus- 
picious circumstance; especially if the pulse also fluctuate, and the respiration be 
suspirious and irregular. Such are the most prominent diagnostic criteria between 
inflammation of the brain and fever. 

Delirium Tremens. — Delirium tremens is distinguished by the absence of the 
headache; by the peculiar tremors; by the singular hallucinations and spectral illu- 
sions, inspiring fear in the patient; by the remarkable wakefulness; by the tracta- 
bility and inoffensiveness of the delirium; by the copious clammy perspirations; 
and by the history being that of habitual inebriation: on the contrary, there is ab- 
sence of the somnolency, coma, convulsive and paralytic affections, and slowness 
of the pulse, which characterize inflammation of the brain. 

Apoplexy. — Apoplexy is distinguished by its invasion being abrupt, the paraly- 
sis sudden and complete, and the course of the disease short and rapid; whereas, in 
partial cerebritis, there are most frequently premonitory symptoms; tonic or clonic 
spasm generally precede the paralysis, which supervenes more gradually; and the 
course of the disease is irregular, and comparatively slow. It must not be forgotten, 
however, that when cerebritis is excited by an apoplectic extravasation, spasmodic 
symptoms, with delirium and fever, may follow the apoplectic phenomena. 

In Infancy. — In infants under a year old, the diagnosis requires the most scru- 
tinizing attention. *' The head hanging over the nurse's shoulders, and the half- 
closed eyelids," says Cheyne, " are alarming symptoms; and in no other complaint 
do we observe the same knitting of the eyebrows unaccompanied with crying.'* 
There is a quiet, vacant, abstracted air in the face, from non-convergence of the 
pupils; very different from the lively, violent, and varying expression, indicative 
of acute pain from other causes than cerebral disease. There are no paroxysms of 
temper, with alternate extension and retraction of the legs, — as in colic and gripes. 
If, in addition to these symptoms, there be unusual wakefulness, or unsound sleep 
with starting and crying, or obstinate screaming without obvious cause; if, while 
awake, the infant seem drowsy, moan, roll its head restlessly on the pillow 
or the nurse's arm, or keep thrusting it backwards against the pillow; if there be a 
shrinking and frowning aversion to light, a contracted or dilated state of the pupil, 

■ Dr. James Hope, 



PHRENITIS. 495 

or disobedienne of it to Wght, and obstinately frequent vomiting not explicable by 
other causes, — we may feel almost certain, in the absence of great and rapid 
exhausting causes capable of producing some of the same symptoms (ilie hydren- 
cephaloid disease,) that we are dealing with the first stage of inflammation. If 
coma, dilated pupil, blindness, and strabismus, with or even without convulsions 
or spasms, have taken place, the nature of the case can scarcely be doubted, aud 
the disease has made considerable advances. 

The same diagnostic symptoms are applicable to children above the age of one 
year; and they are rendered more distir.ct by the declarations or more intelligible 
manifestations of the patient with respect to pain, fever, and other circumstances. 
When Masked by Previous Exhaustion. — The most perplexing cases are those 
in which the cerebral symptoms are unusually masked by great previous exhaus- 
tion and emaciation, from tubercular disease, dentition, and chronic gastro-enteritis 
(" infantile remittent fever;" tabes mesenterica;" "marasmus.") After scarlatina, 
likewise, the utmost attention is requisite for two or three weeks, to detect the very 
first symptom of inflammation of the brain; which, as already stated, generally 
supervenes in connection with inflammatory anascara. The occurrence of severe 
headache should be regarded with the utmost suspicion; — as usually being the ear- 
liest sign. If neglected, convulsions, coma, and other formidable symptoms rapidly 
follow. 

Worms. — Worms are distinguished by the transitory nature of the headache, 
vertigo, dilatation of the pupils, convulsions and vomiting, which they occasionally 
excite; by the absence of fever, of the slow, fluctuating pulse, of the unequal sus- 
pirious respiration; and by the symptoms not presenting the progressive increase 
and regular course usually observed in inflammation of the brain. 

Exhaustion. — Exhaustion, producing some cerebral phenomena resembling 
those of hydrocephalus (whence it has been called "the hydrencepha/oid dise^se,^^) 
is distinguished by coldness and paleness of the surface, in connection with a very 
quick and feeble pulse, and by the occurrence of these symptoms after the opera- 
lion of exhausting causes. 

The diagnosis of nervous, hysterical, neuralgic, rheumatic, and bilious and dys- 
peptic headache, is so simple, as merely to require in the student a competent 
knowledge of these several affections. ''J 

Variety in the Paralytic Symptoms dependent upon the Part ^^ffected. — [Before 
concluding the subject of diagnosis, we* shall briefly allude to the interesting inqui- 
ries of some French pathologists; who have endeavoured to point out the parts of 
the brain aflected in cerebritis, by the various modifications of the paralytic symp- 
toms. Paralysis may affect one extremity or both; — one entire side of the body; 
or the eyes, face, and tongue, either singly, or in a variety of combinations; and 
there are the same diversities in the state of the sensibility and intellectual facul- 
ties. How are these modifications to be accounted for? Several of the older 
writers had conjectured that, if the nervous filaments could be traced up to their 
remote origin i!i the brain, it would be found that each part of the body regularly 
receives its nerves from a determined part of the brain; — so that any lesion of that 
part must necessarily affect the functions of the organ to which it sends its nerves. 
The followinsr are the results of numerous pathological observations made on this 
subject, by MM. Foville, Serres, Pinel Grandchamp, and Bouilhuid. They are, 
of course, to be received with a good deal of reserve; but we*" still think them 
deserving of notice, if it were only to direct others in the j)ath of inquiry. 

I. The paralysis of the organs of speech, depends on diseases of one or both 
anterior lobes of the brain. There are seventeen cases reported in the works of 
I^allemand, Rostan, and Bouillaud, with paralysis of the tongue; in which the 
anterior lobes of the brain were found affected with various degrees of inflamma- 
tion and softening. On the other hand, an examination of about fifty cases, in the 

• " Library of Medicine;" Volume 2; Pages 50, 53, and 54. 
*• Dr. Adair Crawford. 



496 PHRENITIS. 

same authors, without loss of speech or paralysis of the tongue, does not afford a 
single instance of inflammation or softening in the anterior lobes. It should be 
noted, that there may be loss of speech without paralysis of the tongue, — from 
mere loss of memory; and M. Bouillaud's observations led him to think, that the 
anterior lobes of the brain preside over the memory of words, as well as over the 
organs of speech. The above statement, if the facts on which it is founded can be 
relied on, is certainly very remarkable; and is deserving of further investigation. 

We remc^mber an interesting case under the care of Dr. Cuming, of Armagh; in 
which there was disease in the anterior part of the brain, from a blow received on 
the forehead, just above the nose. It was found necessary to remove a portion of 
bone with the trephine; and after a variety of remarkable and untoward symptoms, 
the gentleman perfectly recovered. One of the prominent symptoms was a loss 
of the memory of langunge. 

2. The paralysis of the inferior extremities depends on disease of the middle 
lobes of the brain, and of the "corpora striata." This conclusion is not supported 
by the same number of facts as the former. 

,S. The paralysis of the upper extremities depends on disease of the posterior 
lobes of the brain, and of the optic thalami. This is likewise stated as yet restnig 
only on a small number of facts. The paralysis of one arm only, has been observed 
(in a good many cases) in connection with inflammation at the junction of the 
posterior and middle lobes. When several parts are paralyzed at the same time, 
the morbid alterations of the brain are supposed to be more extensive, or seated 
near the " medulla oblongata." Paralysis of the arm and leg on the same side, or 
hemiplegia, is supposed to follow the combined affection of the " corpus striatum" 
and " thalamus;" or else disease of the " crus cerebri," from which these two 
bodies derive their origin. 

The last speculation on this subject which we* shall refer to, is one relating to 
the respective uses of the cortical and medullary substances of the brain. AVe* 
have seen that the conical substance has been found, in a great many lunatics, 
liighly injected, and often inflamed; while the medullary substance remained 
healthy. M. Foville and Pinel Grandchamp have conjectured, from this and some 
other circumstance, that the cortical substance was the seat of intelligence, while 
the medullary was intended to preside over motion. The principal other grounds 
of this hypothesis are, — the apparent disease of 4he cortical substance; — which has 
been found reduced to a very thin layer, in cases T)f imbecility; and the small size 
of the convolutions, and small quantity of cortical substance, observed in the brains 
of idiots, compared with those of intelligent beings. 

In the article " Encephale," of ihe volume of the " Dictionnaire de Medecine et 
de Chirurgie Pratique," just published, M. Foville — whose recent discoveries, on 
some points of the minute anatomy of the brain, have deservedly attracted much 
attention — enters at considerable length into the examination of the preceding con- 
siderations. He has adduced a number of striking facts and arguments in their 
support; and lays down the following general propositions: — 

1. The joint lesion of the " corpus striatum" and " thalamus" of one side, gives 
rise to the same paralytic symptoms as the lesion of the whole fibrous substance 
of the corresponding hemisphere; of which they are, in some manner, the centres 
or nuclei. 

2. The lesion of the "crus cerebri" is followed by the same paralytic symp- 
toms, as that of the " corpus striatum" and " thalamus;" which are themselves, in 
a great measure, formed by the expansion of the fibres of the crus. 

3. A lesion of the " medulla oblongata" produces all the symptoms which arise 
from the joint affection of the " crura cerebri" and " cerebelli;" and (if we ascend 
still higher in the brain) from that, also, of the " corpora striata," "thalami," and 
hemispheres. 

4. If we direct our attention to the portion of the nervous system below this 

=» Dr. Adair Crawford. 



PHRENITIS. 497 

great centre of the nervous action of the brain, we shall find the cerebral influence 
unimpaired, in all parts superior to any lesion of the spinal marrow; while it is 
completely intercepted in parts inferior to that lesion. 



SECTION VI.— PROGNOSIS. 

Cerebritis is a disease always attended with considerable danger. When once 
fully developed, it had hitherto been generally considered as incurable; but since 
we have been enabled, by a better knowledge of its true nature, to apply with 
promptitude more appropriate remedies, the treatment is often successful, even 
under the most unpromising circumstances. The extremely delicate structure of 
the brain, however, its situation in a bony unyielding case, — without room for ex- 
pansion, or any opening for the exit of effused fluids, — and the great importance 
of the integrity of its functions to the preservation of life, are circumstances which 
must always connect a considerable degree of danger with its inflammatory affec- 
tions.*] 

Prognosis of the different Varieties. — [[Meningitis of the convexity of the 
hemisphere, though extremely rapid and dangerous if neglected, is perhaps the 
most tractable form if promptly and vigorously treated. Internal arachno-cerebritis 
("hydrocephalus") is less tractable and more fatal. Before it was known to be an 
inflammatory disease, the sufferers died, almost without exception; subsequently, 
the mortality has amounted to about two-thirds; but, in consequence of improve- 
ments in diagnosis and the use of mercury, the proportion is now undergoing a 
considerable diminution. Cerebritis is the most dangerous form of cerebral in- 
flammation; in consequence of the facility with which the organ passes into soften- 
ing and disorganization. When chronic, and attended with progressively increasing 
palsy, complete recovery is exceedingly rare. Success in the treatment of chronic 
cerebritis, however, is daily on the increase; — in consequence of its inflammatory 
nature being better understood. Formerly, — under the supposition that the symp- 
toms were nervous, neuralgic, rheumatic, dyspeptic, or from debility, — they were 
treated with tonics, stimulants, and full diet. The general prognosis is more unfa- 
vourable, when inflammation of the brain appears during, or shortly after, other 
serious diseases; especially typhoid fever, the febrile exanthemata, pneumonia, 
apoplexy, epilepsy, and mania; because, in these maladies, the vital powers are 
already more or less exhausted, and in some the blood is diseased; — whence active 
treatment is less easily borne. The same remarks apply to weakly, scrofulous 
constitutions; especially where several of the family have been affected by hydro- 
cephalus. 

Favourable Symptoms. — The particular prognosis, in individual cases, is regu- 
lated by the symptoms. The following are favourable: — return of natural sleep in 
contradistinction to somnolent stupor; return of the several secretions; — namely, 
moisture of the tongue, with cleaning of its points and edges, and removal of dry 
sordes from the gums and lips; genUe perspiration, or at least softness and coolness 
of the skin; a free secretion of natural urine, and an open manageable state of the 
bowels; a simultaneous diminution of the heat of the head; a more equal and 
regular state of the pulse and respiration; and a corresponding amelioration of the 
other bad symptoms. The earlier this improvement takes place, the more favoura- 
ble the prognosis; because, in the first stage, or the early part of the second, the 
disease may not have proceeded beyond vascular turgescence; which, by pressure 
and interruption of the circulation, is capable of producing the worst symptoms 
(convulsions, coma, paralysis, &c.); yet, as the brain is not disorganized, the vas- 
cular congestion is susceptible of removal. An gimelioration in the advanced part 
of the second stage, or later, ought to inspire less sanguine hopes; as eflusioiis of 
serum, lymph, and pus, may have taken place, and may not admit of absorption 

» ''CyclopjEclia of Practical Medicine;" Volume 1; Pages 30G and 307. 
VOL. I.— 32 



498 PHRENITIS. 

or, if the case be cerebritis, the effect may have been softening; — a highly intract- 
able affection. 

Unfavourable. Symptoms. — The unfavourable symptoms are — a continuance, 
notwithstanding suitable treatment, of headache, heat, delirium, and watchfulness; 
or of coma, convulsions, strabismus, spasmodic rigidity, palsy, and a slow irregular 
pulse: finally, the mortal symptoms; namely, an exceedingly rapid and feeble 
pulse; relaxation of all the sphincters, including the "orbicularis oculi;" singultus; 
aphonia;* dysphagia;'* general muscular relaxation, with inability to move; col- 
lapsed cadaverous countenance; &c. Of chronic inflammation of the brain, or acute 
becoming chronic, the prognosis is always doubtful; and the friends should be ap- 
prised, that the disease may induce epilepsy, paralysis, mania, insania, or idiocy/] 

SECTION VIL—TREATMENT. 

Blood-letting, — As to the general treatment of phrenitis, it is perfectly easy. 
In the first place, we should have recourse to copious blood-letting; and my own 
experience leads me to think, that bleeding in the arm is just as good as bleeding 
in the neck. It is not advisable to bleed from the temporal artery, because we 
have to put a bandage on the head afterwards; which occasions more or less aug- 
mentation of the heat; and the bandage itself is often very troublesome. With 
regard to opening the jugular vein, that sometimes causes so much agitation of the 
patient, that it is not a very easy matter to accomplish it ; but there is no difficulty 
in detracting blood from the arm; ajid, besides, I am not aware that there is any 
particular advantage in taking blood from the head. If we make a large orifice 
in the arm, make the patient stand upright, and produce a strong impression, it 
will generally answer every purpose. 

Cold Applications and Quiet, — Cold should be applied to the head. A bladder 
of ice laid upon the head, and a stream of cold water allowed to run upon it, are 
both very serviceable. In a case of violent phrenitis, evaporating lotions are hardly 
sufficient; and it is better to apply ice, or a stream of cold water. The posture of 
the patient should be carefully attended to. The head should be raised as much 
as possible; and silence and darkness are indispensable. 

Purging, Colchicum, Antimony, and Mercury. — I need not say, that active 
purging is likewise required ; and we may give antimony, colchicum, or mercury. 
Antimony is a very good remedy, if given so as to keep the patient in a state of 
constant nausea; colchicum, likewise, is excellent; — on account of its depressing 
the whole system, producing nausea, and purging the patient violently. But alto- 
gether, as I said*^ when speaking of the treatment of inflammation in general, I 
should place the greatest reliance on mercury; and should get the mouth sore as 
quickly as possible. 

Blisters and Low Diet. — Sinapisms to the feet may likewise be exceedingly 
useful; and, after free bleeding, a blister applied to the nape of the neck may be 
advisable. But blisters are, generally, dangerous remedies. After a time, if the 
inflammation be not very violent, a blister may be applied to the forehead; but it 
is not till towards the close of the disease, that I would recommend any blisters to 
be applied to the crown of the head. I need not say, that the patient ought to be 
starved; and that rest should be strictly enjoined. If the disease have arisen from 
the cessation of another disease, we ought (if possible) to re-excite the latter. If 
it have arisen from the cessation of gout or rheumatism, we ought (with this view) 
to apply sinapisms to the extremities. 

Digitalis. — I certainly would not give digitalis in such a case; for it is a narco- 
tic that frequently produces irritation of the brain, when exhibited for other affec- 
tions; and not only so, but it is much less to be depended upon in inflammatory 

a From tt (primative), without; and <pa)vn, the voice. 

^ From Juf, with difficulty; and <^a.ya)^ to eat. 

c " Library of Medicine;'' Volume 2; Page 54. « See Page 127. 



PHRENITIS. 499 

cases, than other medicines. It will, moreover, frequently produce delirium or 
headache. 

Inflammatory Headache. — In chronic inflammatory headache, the same treat- 
ment is required; but it should be carried on, of course, with less vigour. It is 
astonishing vvhai perseverance in bleeding is sometimes required, in order to effect 
a cure in these cases. Blood must be taken every week or ten days; — either from 
the arm, or by cupping, or by leeches. The application of cold, of blisters to 
the nape of the neck and to the forehead, and likewise setons in the neighbour- 
hood of the neck, are all useful. The disease often gives way to mercury, as soon 
as the moutii is tender. I have seen this in dozens, — I might almost say hundreds 
of instances. Bleeding did good to a certain extent only; but as soon as the mouth 
became sore, away went the pain. I need not insist upon low diet, and attention 
to the state of the bowels. 

Blood-letting from Distant Parts. — In some cases, however, which have 
proved rebellious to starvation, the application" of cold, setons, frequent bleedings 
in various ways, and ptyalism long continued, I have seen the disease yield rapidly, 
on taking away blood from a more distant part. I have seen several cases in 
which, on applying cupping-glasses no longer to the nape of the neck, but to the 
hypochondrium, the disease has rapidly given way. Some recommend them to 
the verge of the anus. I have been surprised, on some occasions, to see the disease 
decline immediately, when cupping was instituted on the abdomen. 

Treatment in Vertigo. — The same perseverance in bleeding is frequently ne- 
cessary, when the phrenitis or inflammatory state of the head is not characterized 
by pain^ but simply by giddiness, I have seen some cases of intense vertigo (in 
which there was sufficient strength of body to bleed freely) ultimately give way 
to that measure. In instances where I could not make out any sympathy with the 
stomach and intestines, but where it appeared to be an inflammatory state, — the 
chief symptom of which was vertigo; or where that was almost the only symptom, 
except throbbing of the head, on motion or taking stimuli, — I have seen continued 
depletion efl^ect a cure. If patients feel themselves worse for stimuli, and the pulse 
is sufficiently strong, I would certainly bleed. 

I recollect a case of severe vertigo, in a young man, attended by no other symp- 
tom whatever; and, as he was young and strong, I bled him to between twenty 
and thirty ounces, with no relief whatever, but with no aggravation of the symp- 
toms; and I was obliged to have recourse to this extensive bleeding several times, 
before he was cured. He had been ill, from this giddiness, for many months; and 
used to roll about the room with it; but he recovered simply by repeated bleedings 
to this extent. It is just the same sort of case, as chronic inflammatory headache; 
only that these symptoms arise from the particular part of the head, which the 
inflammation has attacked. 

I had a case, a few years ago, in which this vertigo was acute. A young woman 
was suddenly seized with intense giddiness; but without any pain. There were 
some very odd symptoms about her. Her eyes were pushed far more forward in 
the orbits, than in health; and every event appeared old to her; — so that there was 
an extraordinary aff'ection of the brain. If she put down a tea-cup, she fancied that 
it was years ago; and she could not get over this feeling. These were her symp- 
toms; and, as she was plethoric, and her pulse justified bleeding, she was twice 
depleted very copiously; and, by that simple means, together with purging, she got 
completely well. There was no pain whatever in this affection. 

Vertigo depending on an Opposite State. — It is to be remembered, however, 
that all these aff"ections — whether there be an inflammatory state of the head, or 
inflammatory headache, or simple vertigo — may depend upon an opposite state of 
the brain. I have seen several cases of chronic pain of the head, which have re- 
sisted all anti-inflammatory treatment; but which gave way very speedily to the 
exhibition of iron, quinine, or other tonics, and to full diet. We can only judge 
of these things by observing, not only how long the case has existed, but that the 
pulse is feeble, and that stimulating the patient does not make him worse. If this 



500 HYDROCEPHALUS. 

be the case, we may safely resort to an opposite mode of treatment; and I believe 
iron is the best remedy we can employ. In other cases, it is well to apply cold, 
in the form of a shower-bath; which is a powerful tonic. This state appears to be 
a morbid sensibility, without any great accumulation of blood; and certainly with- 
out any violent action of the brain. With respect to vertigo, I recollect seeing a 
gentleman, who had a constant sensation as if he were going to fall forwards; — a 
sense of plunging as he sat in the chair. He had no pain at all; but he had heat: 
and the throbbing sensation in his forehead was terrific. He was upwards of sixty 
years of age; but he had a florid complexion, and was a strong old gentleman. It 
seemed to me, that the case required antiphlogistic treatment; and I recommended 
that it should be put in practice, and that his diet should be low. I may mention, 
that he was a very excitable person; that although he was so old, he said he had 
not lost any of his vigour; that since he was twenty-five he had not experienced 
the least change; and that in hot weather he experienced the strongest excitement. 
In general, people are not so sensitive at that age; but the slightest effects of 
various agents were distinctly perceptible to him; — in fact, such agents as would 
not have affected other individuals. Seeing all this, and that there was such ex- 
traordinary excitement within the head, I concluded that though he had no pain, 
yet the case was certainly of an inflammatory nature. Antiphlogistic measures 
were put in practice; but, as I understood, without the least benefit. He was 
afterwards allowed meat, wine, and stimulants of all kinds; and I was told that he 
got perfectly well. Here was an instance of vertigo of an opposite kind. It was 
difficult for me to form an opinion, though I had paid great attention to these dis- 
eases; and I formed a wrong judgment. I thought antiphlogistic treatment would 
be best; and it is possible that the other mode might not have succeeded, if anti- 
inflammatory treatment had not been put in practice first. We may have inflam- 
matory pain of the head, of a nature to be benefited rather by stimulants and tonics, 
than by depletory measures; and we may have these partial symptoms of affection 
of the head; — such as vertigo; which must be treated in the same way. 

After-Treatment. — It is to be remembered that, after the acute disease, we may 
have a state in which nourishment, and even opium, are the chief remedies. At 
the close of phrenitis, especially if the evacuations have been copious, there some- 
times will be a continuation of delirium; and if the evacuations be carried to a 
greater extent, they will kill the patient; and sometimes this stafe will come on, 
without any previous active inflammation. In such a case as this, opium is the 
proper medicine; and, for the most part, the patient's diet must be good; but of 
this I will speak hereafter, when I come to consider that affection occurring within 
the head, which has been called "delirium tremens." As it has received a parti- 
cular name, I will speak of it separately; but it is a state which will occur without 
any great tremor, at the close of common inflammation of the brain. 



CHAPTER 11. 

HYDROCEPHALUS. 

[Under this term was formerly comprehended every preternatural effusion of 
serous fluid in the region of the head; — whether external to the cranium, or con- 
tained within it. In process of time, however, it became limited to eflfusion 
occurring within the cavity of the skull. Systematic writers have laid it down, 
that such efl'usion may occur either between the cranium and dura mater, into the 
great cavity of the arachnoid, in the sub-arachnoid cellular membrane, or (finally) 



HTDROCEPHALUS. 501 

into the cavity of the ventricles. But hydrocephalus,^ in the more restricted sense 
in which it is usually understood in this country, means a serous effusion taking 
place into the ventricles, or (which is a much rarer occurrence) into the sac of the 
arachnoid.'' J 

SECTION I.— HYDROCEPHALUS ACUTUS. 

This is another instance of inflammation of the brain; — causing, for the most 
part, great effusion; and as this effusion was formerly noticed more than any thing 
else, the disease does not go, or has not gone, by the name of " infl-ammatiou of 
the brain;" but has received the peculiar appellation of " hydrocephalus aculus." 
Some who have been more precise in their language, have chosen to say " hydre/2- 
cephalus;" and some have called it ^'phrenitic hydrocephalus." 

Mostly occurs in Infancy. — It is a disease seen, in the greater number of in- 
stances, in children. In fact, it particularly occurs in the phrenitis of children; 
but the phrenitis of adults is sometimes attended by very copious effusion. When 
a child has inflammation within the head, it usually goes by the name of " hydro- 
cephalus acutus;" but in its essential character, it is very much the same as the 
common phrenitis of adults. 

Premoyiltory Symptoms. — It frequently comes on, in children, after heaviness 
of the head, dulness of the mind, and a disturbance of sleep; the child frequently 
has frightful dreams, wakes screaming, is found to be restless both up and in bed, 
and to be exceedingly peevish in temper. There is, likewise, a continual knitting 
of the brows; which is a common symptom in inflammatory states of the head. 
The child, too, is frequently observed to walk insecurely; — to totter a little; as if 
it experienced a certain degree of vertigo. Some say they have observed children, 
in these circumstances, have a great trick of putting their hands behind their head, 
and pulling the back of their neck. There is occasionally darting pain in the head; 
and there is feverishness. The body is hot; and the pulse is quick," and exceed- 
ingly various. From feverishness, the child's nose and lips are dry; and this gives 
rise to a degree of itching; — so that the child is continually picking his nose and 
lips. Of course there is thirst, and loss of appetite; and frequently there is fetid 
breath. The stomach and bowels are disturbed; the tongue is white, yellow, or 
brown; nausea is experienced, and also vomiting and costiveness; though occasion- 
ally there is purging and griping. The faeces are observed to be white, and to 
have a sour smell; though, on the other hand, they are sometimes dark and very 
fetid. The abdomen is frequently full, especially at the epigastrium; and there is 
frequently tenderness on pressure; but this is particularly noticed at the epigastrium, 
and the right hypochondrium. 

These premonitory symptoms may go off spontaneously; and if the practitioner 
attend to them, he may remove them; so that nothing follows. AVhenever we see 
such symptoms as these, we must recollect that they may be easily followed by 
hydrocephalus; and it is our duty to attempt to remove them. This may generally 
be accomplished; but if we fail, and hydrocephalus does come on, we have, at any 
rate, done our duty. It is true that hydrocephalus might not have supervened; but 
it was impossible for us to tell that; and it is our business to do what we can to 
prevent it. These symptoms may last only a day or two, and then come on with 
increased severity; or they may last many weeks. 

[Dr. Yeats,*^ who has made the earlier stages of this disease his particular study, 

* From uJmj», water; and Ki<pa.\n, the head. 

■* "Cyclopaedia of Praciical Medicine;" Volume 2; Page 452. 

' This remark is somewhat at variance with the opinions of G<5Hs, and other subsequent 
writers. Golis states that "the pulse, ichlch deviates little or not at all from its iiatural 
quickmss, is found, on an attentive examination, to beat oftentimes a few beats weaker, and 
sometimes to intermit altogether. It is commonly the seventh, ninth, sixteenth, seventeenth, 
or one-and-thiriieth beat, which the finger feels weaker, or not at all." (Golis, on Acute 
Hydrocephalus; translated by Dr. Gooch. Page 12.) 

d " Statement of the Early Svmptoms which lead to the Disease termed ' Water in the 
Brain.' By G. D. Yeats, M. D." 



502 HYDROCEPHALUS. 

places among- the premonitory symptoms occasionally present, tenderness in the 
scalp, stiffness of the neck, increased sensibility of the eyes to light, and in some 
rare cases severe earache. He also draws attention to the remarkable change from 
the healthy appearance which the countenance nndergoes, the transient paleness 
and occasional collapse of the features, the dulness and loss of expression in the 
eyes, and the dark line under them. A teasing cough is sometimes present. There 
is an unusual tendency to constipation. If aperient medicines be given, the con- 
sequent evacuations are both harder and less abundant than they were wont to be 
from a similar dose. In colour they are sometimes lighter than natural, and at 
other times tinged of a dark greenish hue, and accompanied with a slimy matter. 

Dr. Cheyne has the merit of having been one of the first writers who strongly 
directed the attention of the profession to the derangement in the functions of the 
liver and of the alimentary canal, which so often precedes, and not unfrequently 
seems to excite, this affection of the brain. The proportion of cases in which 
the diseased action commences in the abdominal viscera is, he thinks, very con- 
siderable. He was led to this belief, partly, by having observed how usually 
derangement of the above-named organs precedes hydrocephalus; partl)^ from the 
remarkable benefit which, in the early stages of the affection, so often ensues upon 
the use of active purgatives; and, finally, from the frequency with which unequivocal 
marks of disease are discovered in the liver or intestines on dissection. In the 
incipient stage, or while the disease of the brain is as yet only forming, the colour 
of the stools indicates an inactive state of the liver; while, at a subsequent period, 
when hydrocephalus has become fully established, the bile seems to be both vitiated, 
and in excess. The intimate sympathy which exists between the brain and the 
liver, is well known to surgeons; and that between the brain and the stomach and 
intestines, is familiar to every one. When we consider the close and unquestion- 
able sympathy which subsists between the head and the digestive organs, and take 
along with this the greater exposure of the latter to irritating causes and consequent 
functional derangement, we are disposed to think that the now very generally re- 
ceived opinion, as to the frequent origin of hydrocephalus in abdominal disorder, 
is well founded. How this connection is to be explained, matters little. The 
comatose state in which inflammation of the mucous membrane of the bowels in 
infants (about the period of weaning) often terminates, is a striking instance of this 
origin of cerebral derangement. A remarkable diminution of the urinary secretion, 
frequently precedes the oppression of the brain; and may possibly sometimes, as 
Dr. Abererombie has suggested, be in some degree connected with it.*] 

Stages. — When the disease is formed, it has two stages; and it may occur with- 
out any premonitory symptoms. Not only may the latter vary in duration, — from 
a day to a few weeks; but they may last only for an hour or two, and, indeed, 
they may not exist at all; for the chihl may be seized in a moment. 

Symptoms of the First Stage. — When the disease occurs, there is a severe 
pain in the head, — shooting through it; so that the child lays its head in its mo- 
ther's lap; and is continually crying — " Oh, my head!" It is awakened, too, from 
sleep, by this violent shooting pain in the head. The latter is found to be very 
liot; and there is intolerance of light and sound; and, from the sensibility of the 
retina, the pupil is very much contracted. From the extreme irritation of the 
nerves, I presume, there is strabismus; but some ascribe this to paralysis o( cer- 
tain nerves; — so that some muscles get the ascendancy over others. However, it 
appears before there are any signs of paralysis; — during the mere excitement of 
inflammation. Besides the squinting, there are convulsive spasmodic motions of 
other muscles; and frequently there are general convulsions. Sometimes there is 
delirium at last, but sooner in some cases than in others; and the delirium may not 
be constant. In the first instance, it is not constant. The child is observed to 
turn its head contituially about on the pillow; — never to be at ease; and there is a 
peculiar motion of its arms; so that it saws the air with its hands, and tosses them 

* •* Cyclopoedia of Praclical Medicine;" Volume 2; Pages 453 and 454. 



HYDROCEPHALUS. 503 

over its head. Whenever we observe these symptoms, we maybe sure that the 
disease is formed. There is now violent pyrexia; the pulse is rapid and fuli;^ and 
Golis says that the abdomen sinks, and becomes flatter; and that this is a pathog- 
nomonic sign of the disease;* so that if this occur, we may be certain as to the na- 
ture of the disease. Whether he is correct, I cannot tell. There is, in this stage, 
costiveness; and the stools are usually very fetid, and of a very dark colour; — 
something like tar. About this time, the abdomen (especially the epigastrium, or 
the right hypochondrium) is exceedingly tender; and the vomiting which occurred 
as a premonitory symptom, is now perhaps very frequent. These symptoms, like 
the premonitory, may exist for various periods; but, of course, they cannot exist 
so long as the premonitory symptoms may. They may last only a few hours; or 
they may last a day or two; or they may be extended to seven days; but I believe 
they very seldom go beyond that. 

Symptoms of the Second Stage. — After this, comes on the second stage; which 
is that of exhaustion. There is now more or less blindness; and the child is una- 
ble to discern one object from another; and perhaps it cannot perceive the light, 
which is now borne very well. There are no longer twitches; the pupils are no 
longer contracted, but dilated; and sound no longer produces disturbance, but ap- 
pears not to be heard. There is a general insensibility; and the child, from being 
delirious and irritable, is now drowsy; and the convulsions come on with more in- 
tensity; as likewise does the squinting. The pulse is no longer quick, but weak 
and slow; and, in fact, an apopletic State occurs. There is sometimes hemiplegia, 
or local paralysis of the limbs; and there is likewise paralysis of the eyes. Some- 
times the two stages are very distinctly marked; but they certainly run into each 
other; so that both may exist together in a limited degree. This may last for 
three weeks; but it rarely, I believe, extends much longer. The first stage does 
not subside entirely, but there is a great diminution of it; and the second stage 
comes on, but is not fully formed. The first stage, without the second, rarely ex- 
tends beyond seven days; but when the second stage begins before the first has 
come to a close, the two m.ay continue together for two or three weeks. Now and 
then the pulse is quick throughout the disease; and when the apoplectic state comes 
on, the pulse is as rapid as before, or very rapid. 

Symptoms of the Third Stage. — It has been observed, that before death, after 
the second stage has been fully formed, there are again symptoms of excitement; 
so that some writers have divided the disease into three stages. But this, I believe, 
does not occur very frequently. Now and then, however, there is excitement; 
and the pulse, after it has been slow, will become quick. There will appear to 
be some sensibility of the eyes and ears. Even the muscular powers, which have 
been implicated, will be partially restored; and likewise the mind: so that not 
only the delirium, but even the stupor, will pass off; and the child again knows its 
friends and parents. Some of these syniptoms will occur without the others. 
Occasionally the mind will be restored to a certain extent, and the senses return; 
and yet the pulse will continue low. Now and then the pulse will be rapid; and 
no other change occur. But, now and then, this restoration of the powers of the 
mind, and the powers of volition in the muscles, will take place where great effu- 
sion is found after death; and where tliere is every reason to believe that effusion 
existed, at the time that this restoration occurred. The common people term this 
*' a lightning before death;" and we observe, in many diseases, an apparent amend- 
ment just before the fatal event. But when this last change does occur, the pulse 
generally becomes very rapid; and for the most part, whatever restoration there 
may be, there is observed more or less stupor; and perhaps convulsive actions. 

* Giilis says — " The pulse is now like that of an old man; — slow, unequal, and intermit- 
ting;" and he regards it as a palhogiioinonic sign in this (the infiatninaiory) stage, in com- 
plicated cases. See his "Treatise on Hydrocephalus Acutus" (Gooch's Translation); 
Page 26. 

b See " A Treatise on the Hydrocephalus Acutus, or Inflammatory Waier in the Head. 
Bv Leopold Anthony Goli^; Physician and Director to the Institute for the Sick Children 
at Vienna. Traiisla'ted by Robert Guoch, M. D." Page 24. 



504 HYDROCEPHALUS. 

Water-Stroke. — The disease occasionally occurs in a moment; and when that 
is the case, from the idea of water being so prevalent among medical men, it has 
been called, by Dr. Golis, " wasserschlag," or ** water-stroke."^ But it is to be 
remembered, that children sometimes die from this disease without effusion taking 
place; and, on that account, "arachnitis" would, I think, be a much better name 
than "hydrocephalus." Sometimes, in a moment, a child will have a rush of 
blood to the head; it will breathe hard, and die; and, after death, a great collection 
of blood may be found in all the vessels of the head. The disease sometimes, when 
it terminates, leaves more or less paralysis; sometimes it will leave hemiplegia; 
and some patients have recovered with paralysis of one arm, or of one leg. 

Morbid ^Appearances. — After death from hydrocephalus, the same marks of in- 
flammation and congestion in the brain and its membranes may be present, as 
those which are met with in phrenitis. Sometimes we find nothing more; — so 
that the squinting, the dilatation of the pupils, and the coma, are not necessarily 
the result of effusion. There may be no effusion whatever; notwithstanding that 
the child has died from hydrocephalus; and, before death, there were strabismus, 
dilated pupils, and loss of consciousness. Death will arise from the mere irritation 
and excitement which the chihl has undergone; and from the compression, and 
perhaps fulness of the vessels; but it is not necessary that there should be com- 
pression from effused fluid. Frequently we find the same congested and inflam- 
matory state on the scalp, that there is within, and a great deal of serum is effused; 
—just as has been occasionally observed in common phrenitis. 

But sometimes no such appearances are present. I have myself opened children 
who have died of this disease, and have found nothing; — the congestion and the 
signs of an inflammatory state having subsided, I presume, after death; and the 
blood having left those vessels in which it ought not to have existed, and returned 
to its usual route. It is possible for even the marks of inflammation to cease after 
death, before the body is examined. 

Characters and Seat of the Fluid. — If, however, there be fluid, it varies very 
much as to its clearness. Sometimes it is perfectly limpid and uncoagulable. It 
will be found, of course, in the brain or upon the brain; and its quantity is gene- 
rally from two to six ounces. The brain at large is sometimes found cedematous 
after this affection; especially at the "corpus callosum," the "fornix," and the 
"septum lucidum;" and this cedematous state exists either alone, or in conjunction 
with ventricular effusion. In infants there is great ventricular effusion, at the same 
time with oedema of the brain; and not unfrequently the same circumstance is no- 
ticed in adults; but it is generally seen in infants. The brain, after this disease, is 
very often found soft in particular parts (from the inflammation); and it is not an 
uncommon thing to meet with scrofulous tubercles in the brain itself, or its mem- 
branes: — showing the predisposition to disease in the brain. These, of course, 
existed before the hydrocephalus was set up; but they show the tendency to dis- 
ease of the brain. 

The longer the disease has lasted, the greater in general is the turgescence of 
the vessels, and the softer is the brain; — at least according to Dr. Golis;'' who has 
liad more experience, I suppose, in this disease than any one else. He also men- 
tions*" that effusion will sometimes take place in a very iew hours. Now and then, 
we have marks of inflammation in the liver and in the intestines. It is not by any 
means uncommon, for an inflammatory state of these parts to coexist with hydro- 
cephalus. 

Causes. — This disease, as I have already stated,'^ is for the most part an infantile 
disease. Sometimes it occurs about puberty, sometimes afterwards; but it chiefly 
affects children from two to ten years of age. It is an affection that very much 
runs in families; so that we may meet with some who have lost several children by 

a See his " Treatise on Hydrocephalus Acutus" (Gooch's Translation); Page 5. 
'' See his "Treatise on Hydrocephalus Acuius" (Gooch's Translation); Page 183. 
* At Page 19 of his "Treatise on Hydrocephalus Acaius" (Gooch's Translation). 
•» See Page 501. 



* HYDROCEPHALUS. 505 

hydrocephalus. It frequently succeeds other acute diseases, especially hooping- 
cough; now and {\\Qn[ frequently, indeed) it occurs during teething. 

History. — Hippocrates speaks of water in the brain; and mentions many symp- 
toms of acute hydrocephalus; but this particular disease was only first accurately 
described by Dr. Why it, in 1768. He gives a full description of the inflammatory 
symptoms.* Dr. Cook, in his work on Nervous Diseases, states that Dr. Gregory 
used to say it was described by a surgeon at Glasgow, in 1753; and that M. Petit, 
a celebrated surgeon at Paris, gave many of the symptoms in 1718. But its 
description was not thoroughly given, till the latter part of the last century. 

Prognosis. — Our prognosis ought to be exceedingly cautious, even during the 
premonitory stage. It ought to be still more cautious in the first stage of the dis- 
ease itself; and it ought always to be unfavourable in the second stage, although 
this is sometimes recovered from: and so, it is said, is even the third stage, when 
excitement takes place. It is said to have been recovered from spontaneously; but 
I have never seen it. However, children have actually recovered from the disease 
in the very last stage. Even by medicine and the best means, recovery is very 
rare; and perhaps a favourable issue occurs quite as frequently by the spontaneous 
efforts of nature, as by art. Indeed, to show that the disease may be recovered 
from by a child apparendy in the most hopeless state, it is said that there is no one 
symptom which indicates death with certainty, excepting slow breathing. 

Treatment. — The disease is clearly inflammatory; and the treatment of inflam- 
mation is that which is demanded for its cure. From the eflTusion wliich is generally 
produced by the disease, one would suppose that there is an inflammation of the 
arachnoid. The fluid which is efl'used in greatest quantity, is found in the ventricles 
lined by the arachnoid, and upon the brain in the cavity of the arachnoid; and, 
therefore, one would suppose that the chief seat of inflammation is in that mem- 
brane. The eff*usion, I need not say, is the mere result of inflammation. 

Treatment of the Premonitory Symptoms. — During the premonitory symptoms, 
we have first to emply the bowels well, and, for this purpose, calomel in full doses 
answers better than any thing else; — at least, it is best to lay a foundation with it; 
and then to carry it ofl* by another purgative, such as castor oil. It is always best, 
in the first instance, to premise a dose of calomel. Other purgatives then answer 
to a certainty; and the bowels are well cleared. This open state of the bowels is 
to be preserved by doses of mild purgatives, such as castor oil, repeated from time 
to time. Perhaps one or two very full doses of calomel would be advantageous. 
If the calomel should operate too much, it might be useful to give small doses of 
Hydrargyrum cum Greta; but the proper treatment is certainly to empty the 
bowels well; and, if requisite, to give mercury in repeated doses, for the purpose 
of producing a mercurial action on the system. If there be any tenderness of the 
abdomen, this of course should be carefully attended to; and leeches should be oc- 
casionally applied. In such a case, it would be well to avoid giving acrid purga- 
tives; — lest we increase the inflammatory state; and, if mercury be still given, it 
should be in the form of Hydrargyrum cum Greta; or castor oil may be exhibited 
from time to time, in order to empty the intestines. Wherever the abdomen is 
tender, there leeches should be applied. The warm-bath is useful in almost all 
diseases of children; but, to render it advantageous, it should be employed twice a 
day; and I should think it an excellent remedy in the premonitory stage of hydro- 
cephalus. The diet should be mild; and leeches should be applied to the head, 
from time to time. If all this be done, we shall very probably get rid of the morbid 
state; and the disease itself will be prevented. 

Treatment of the First Stage. — But when the disease is fully formed, and not 
merely hanging over the patient, then we must act with the greatest vigour. AVe 
have an acute inflammatory complaint to treat; and therefore we must bleed freely 
and early; and it is admitted, on all hands, that we should exhibit mercury with 
the greatest freedom. Those who are not aware, or do not attend to the circum- 

» " Observations on the Dropsy in the Brain. By Robert Whyit, M. D." 



506 HYDROCEPHALUS. 

Stance, of the power which mercury occasionally exercises over an active inflam- 
matory state of the system, all allow that in this disease it is of the greatest use. 
In the treatment of this disease, all persons praise mercury. As to bleeding, it is 
a very good practice to open the jugular vein, or a vein in the arm, if the child be 
old enough. Abundance of leeches should be applied to the head; while we should 
carefully attend to the abdomen; and if there be tenderness, we should apply them 
there likewise. Very large doses of calomel are borne in this disease; — both from 
the circumstances of the disease being of a highly inflammatory nature; and sub- 
sequently, in the second stage, from the whole system being in a state of torpor. 
During the compression of the brain, or the softening of it, very large quantities 
of calomel are admissible. The bowels, I need not say, ought to be thoroughly 
cleared several times a day; and mercury given as rapidly as possible. The 
bowels will bear many doses of calomel in the twenty-four hours; but if, from 
their irritability, they will not bear calomel, we must try whether Hydrargyrum 
cum Greta will answer better; or we may lose the mercurial effect. It is a good 
practice to rub mercurial ointment into the parts, as fast as it can be done. The 
patient should be kept as upright as possible; and it is desirable, if the child be 
hot, to apply cold to the head; and, in these cases, ice is the best application. 
After proper bleeding, local and general, sinapisms or blisters may be applied to 
the abdomen. In the latter stage of the disease, a blister to the nape of the neck, 
or the warm-bath, may still be of use; but we cannot expect great benefit from 
them, in such an active inflammatory disease as this. A bladder of ice should be 
kept on the child's head, while it is in the bath. 

Treatment of the Second Stage. — In the second stage of the disease, when 
there are signs of torpor and paralysis; — when the pupils are dilated, and the 
patient cannot see; — when the pulse is perhaps slow, and the apoplectic symptoms 
prevail; — the same plan should be pursued, according to the strength of the patient. 
If the inflammation b^ still going on, the signs of compression may not arise from 
effusion, but from the great congestion of blood; — at any rate, the inflammation 
may still exist. When leeches can no longer be applied, still we may continue 
the exhibition of mercury, and antiphlogistic treatment, as far as possible. We 
may now apply a blister to the whole head: there is no danger whatever from it, 
in this stage of the complaint; and it frequendy does great good. When all these 
things have failed, it is said that some children have recovered by the use of ela- 
terium;" and others by the employment of digitalis and squills. If any thing of 
this description be given, it should be in small and repeated doses. If elaterium 
be given with the view of exciting an evacuation of fluid, it is best to put a grain 
into two ounces of liquid; and, if the effusion be going on, to give the child a tea- 
spoonful of the mixture, every now and then, till it operates in the way desired. 
As to digitalis and squills, it is best to give them in small and repeated doses. I 
never myself recovered a child in this state; but difli'erent persons have told me, 
that they have seen a child so recovered. 

Treatment of the Last Stage.— \n the last period of the disease, opium has 
been given with advantage; — not for the purpose of cure, but to procure sleep and 
tranquillity; and it has never been productive of iiarm. In the latter part of the 
disease, it may be necessary to give good nourishment, in order to support the 
patient; and even stimulants maybe required; for, after the disease has existed for 
a length of time, we may have a state of irritation of the brain, arising from mere 
debility. The inflammation may have all subsided; and an opposite plan of treat- 
ment to that which was at first imperiously necessary, may be required. 

[Not only is it now well understood that the great mass of cases formerly 
known as acute Hydrocephakis, are really dependent upon meningeal inflamma- 
tion, but of late years it has been further estabMshed, that this inflammation is com- 
monly connected with a deposit of graiuilations, which there is every reason to 
rf^gard as tuberculous. This circumstance has led to the division of meningitis, 



HYDROCEPHALUS. 507 

into simple and tuberculous. The seat of this deposit is in the pia mater, where 
they are met with in the form of small white granulations, principally along the 
course of the vessels in the fissures of Sylvius, or disseminated at the base of the 
brain and around the annular protuberance and the peduncles. At the same time, 
tuberculous depositions may usually, if not always, be discovered in other parts 
of the body, especially in the lymphatic glands in children, and in the lungs in 
adults. The connection between this form of meningitis and tuberculous deposits 
was first clearly made out by Drs. Gerhard and Rufz. It differs from simple menin- 
gitis in several important particulars. It is met with at all ages, but is particularly 
frequent between the ages of two and fourteen. It is not common in early infancy, 
before the first dentition is accomplished; a period in which, on the other hand, 
simple acute cerebral irritation or inflammation is frequently met with. The latter 
is sudden in its onset, and in early infancy is often the result of intestinal disorder, 
of dentition, &c., or occurs in the course of other diseases. These cerebral disor- 
ders of very early childhood, are moreover rapid in their course, usually terminating 
in death or recovery in a very short time. The commencement of tuberculous 
meningitis, on the other hand, is usually more insidious. Upon strict inquiry, we 
shall often find that the attack has been preceded from lime to time by some slight 
cerebral or nervous symptoms. When the inflammation is fairly formed, it is 
rather of a sub-acute character, and comparatively slow in its progress, terminating, 
in the great majority of cases, in the course of the second or third week. The 
symptoms dependent upon the inflammation of the membranes are of course much 
the same, whether it be tubercular or not; their gradual increase and succession 
being the chief characteristic of the former. The diagnosis, however, may in most 
cases be established with tolerable certainty by a careful consideration of the cir- 
cumstances under which the attack arose, the mode of its commencement, the age 
and constitution of the patient. Thus, if we meet with a case of sub-acute menin- 
gitis in a child who has already completed the first dentition, where the attack has 
not been suddenly developed in the midst of perfect health, under the influence of 
some evident accidental physical cause, such as severe injury to the head or pro- 
longed exposure to the sun, but on the contrary has been preceded by evident signs 
of ill health, there is strong reason to suspect that it is tuberculous. If, in addition, 
we find evidences of a scrofulous or tuberculous tendency in the constitution, 
whether hereditary or acquired, the diagnosis assumes a degree of certainty which 
the subsequent course of the disease will scarcely fail to confirm. The ordinary 
causes of inflammation may, of course, become the exciting causes of tuberculous 
meningitis, but still their influence here is much less decided than in the simple form 
of the disease. The former, indeed, is essentially connected with a general tuber- 
culous diathesis. Its prognosis, of course, is very unfavourable; recovery, indeed, 
being a rare occurrence, after the disease is fairly formed. To the prophylactic 
measures, therefore, we should direct especial attention. Thus, in children of a 
scrofulousL or tuberculous habit, and especially where the disease is known to be 
hereditary, every precaution should be taken to prevent excitement of the brain, 
until towards the period of puberty, when the tendency to the disease is much les- 
sened. At the same time we should endeavour to improve the general health by 
all those hygienic and other measures which are adapted to the tuberculous diathe- 
sis. As regards the treatment of the inflammation, when fairly formed, it is much 
the same as in simple meningitis. — T. S.] 



SECTION II.— CHRONIC HYDROCEPHALUS. 

There is another form in which water or serum is collected within the head. 
When speaking of inflammation and its efl^ects, I stated that efll'usion' was com- 
monly the result of inflammation of serous membranes;" but I also stated, that 



508 HYDROCEPHALUS. 

effusion in a serous membrane will take place frequently with a very slight degree 
of inflammation;* and sometimes there is scarcely any to be discovered; — perhaps 
there is none; — at least, we are justified in saying so. The same is the case with 
respect to sweating. A person may sweat, in acute rheumatism, from the intense 
heat of the body; but a person will also sweat in the agonies of death, and in 
extreme debility. So with regard to purging. Purging frequently depends upon 
an inflammatory state of the mucous membrane; but, in other cases after death 
from purging, no inflammation can be discovered; and the person has been free 
from tenderness during life. 

Nature. — Chronic hydrocephalus illustrates these general remarks. In chronic 
hydrocephalus, there frequently is no sign of inflammation to be discovered; some- 
times there is. Sometimes it is pure dropsy, independent of inflammation; — at 
least, there is no inflammation that can be made out; and it is a very slow disease. 
Sometimes the aff*eclion is connate; — born with the patient. Sometimes it does 
not appear before the first or second year; and it has continued during a tolerably 
long life. A patient has lived with dropsy of the head, till he had attained his 
fifty-fourth year. Gall and Spurzheim mention the case of a woman who arrived 
at this age, in whose head four pints of fluid were found; and the patient did not 
then die of that disease, but of enteritis. 

Quantity of the Fluid. — When the water exists in this chronic form, its amount 
is sometimes very considerable. In the acute disease, where the efl'usion is the 
result of inflammation, there is seldom more collected in a child's head, than from 
two to six ounces; but in the chronic form it is frequently so considerable, that the 
bones separate, and the sutures and fontanels^ do not close. Dr. Baillie, in one of 
his plates, represents the appearance of the skull in this disease. The fontanels 
are much larger than they should be; and they sometimes acquire a very consider- 
able size. The sutures may be found distinct; — each bone in some cases being 
separated. These are very common appearances; and such as any one may see. 

Separation of the Bones after Cohesion. — There is nothing at all surprising in 
the circumstance of the sutures gaping, and the fontanels spreading, when the 
water is collected, provided the bones have never cohered; but it is ascertained that 
the bones and sutures will open, after they have been firmly united together. Dr. 
Baillie, in the fourth volume of the "Transactions of the College of Physicians,"*^ 
mentions an instance of a boy, eleven years of age, in whom the fontanels had 
closed, and the bones become well united by sutures;* but in whom they all sepa- 
rated again. Mr. Ford, who was formerly an eminent surgeon in London, observed 
the same occurrence, in a boy nine years of age; — the bones separated six weeks 
before his death. I do not know that Dr. Baillie was aware of it; but it is to be 
remarked that, in Mr. Ford's case, the serrated processes were much fewer than 
usual; — so that the bones had far smaller points of contact, than they ought to have 
had; and separation, of course, would be more easy. It is most probable that, if 
the water had collected in persons in whom there was the natural quantity of ser- 
rated processes, the bones would not have separated. I think that, in the instances 
of this afl'ection I have met with, I have made the same remark as Mr. Ford; and, 
such being the case, we can conceive that separation would be more easy. Until 
I read Dr. Yeats's book on Hydrocephalus, (in which Mr. Ford's case is men- 
tioned,) I thought that Dr. Baillie's was the only instance on record. 

Occasionally the bones do not give way. There is no dilatation of the cranium 
at all; and it is said that it is even smaller than natural. I presume, in these cases, 
the bone cannot give way; and, of course, in such instances, the brain must shrink: 
the bones, however, generally do give way. 

Nature of the Fluid. — In this disease, the fluid is almost always perfecfly limpid; 
— it is generally as clear as the purest water. On being analyzed, it is found to 
contain scarcely any salt, and scarcely any animal matter, 

» See Page 103. 

^ From " faniaaella," the diminutive of " fons, fontis," a fomitain. 

e Page 1. ^ From "suo/' to join together. 



HYDROCEPHALrS. 509 

Morbid ^Appearances. — When it collects to a very great amount, it is nsuaHy 
found in the ventricles; which are thereby expanded, till the whole brain becomes 
like a bag. On removing the cranium, we find the brain spread out to a great ex- 
tent, with the fluid collected within it; and, on making a section, we find that the 
brain is exceedingly thin, — not thicker than paper; and the fluid immediately 
gushes out. This state of the parts led to the erroneous belief formerly enter- 
tained, that in this disease the brain is destroyed; — as though the person had lived, 
eaten, and drunk, without a brain. However, although some made this assertion, 
and believed that a person lived and talked without a brain, others knew the con- 
trary to be the case; and Morgagni reproached those who published so absurd an 
opinion. If the fluid be collected above the brain, and not in'iX, the mistake may 
easily be made; and it may be imagined that the brain does not exist. I was 
present at an inspection of this description, where a child had a very large head, 
and had evidently laboured under hydrocephalus. On removing the bones, cutting 
into the sac which contained this immense quantity of water, and letting off the 
fluid, there was nothing more to be seen. On looking into the membrane which 
contained the fluid, it was like looking into a well; there was nothing resembling 
brain to be seen; and it was immediately said — " Here is no brain!" But as the 
girl had been eating and drinking, sitting up in bed and talking, like other children, 
till within a ^evr days of her death, that was impossible; and we found the brain 
under all this fluid, perfectly sound. There was a large cyst which had existed 
upon the brain, and spread itself out in every direction, — so as to produce an enor- 
mous size of the head; and there lay the brain, quite litfle comparatively, at the 
very bottom of this cyst. The distension of the cranium, be it ever so great, is 
generally equal in all directions; but now and then it is not so. Gall and Spurzheim 
say, that they saw a learned and well-educated man, with a forehead so high that 
it must have contained three or four pints of water; while the rest of his head was 
not of an unusual size. The only effect in him was, that he very often fell asleep. 
Now and then, the bones of the internal ear become separated by the sac; so that 
deafness is produced. We also observe another eff"ect within the skull. The 
convolutions of the brain being enveloped by the collection of water, there is an 
irregular pressure upon the supra-orbital plates of the frontal bone; and therefore 
there is not that roughness, — that irregularity which is seen in ordinary cases. 
Usually, the upper part of the orbital bone consists of many depressions and ele- 
vations; but in this disease, as the convolutions of the brain are enveloped by 
water, the upper part of the orbital plates are generally perfectly smooth. The 
bones are sometimes thickened; but, in a great number of cases, they become 
thinner than natural. Dr. Gall mentions, that the head of persons in whom this 
disease exists to any extent, is generally scurfy; and, since I read the statement in 
his book, I liave looked out for this circumstance, and found the observation to be 
correct. The skin of the head is generally scurfy, in some part, when the cranium 
is greatly distended. 

Size which the Head may attain. — The size of the head is occasionally enor- 
mous. There was, in St. Thomas's Hospital, a few years ago, a child (named 
EHzabeth Phillips) who was born with a head as large as that of a child seven 
months old. The bones were all distinct; her hair was scanty; and there was an 
abundance of scurf on her head. She was fat, and as lively as other children of 
her age; and there was no symptom indicating the existence of fluid, except the 
size of her head. Though she was only eleven months old, the circumference of 
her head was twenty-seven inches five-eighths; from the top of the nose to the 
occiput, it was twenty-two inches; and from ear to ear, across the top of tiie head, 
it was seventeen inches one-eighth. Considering the age of the child, the measure- 
ment was enormous. 

Cardinal the Idiot. — A few years ago, there was in St. Thomas's Hospital a 
poor man, who has now become a celebrated character; in consequence of a cast of 
his head having been deposited in almost every museum. His head was thirty- 
three inches in circumference; twenty-two inches from ear to ear; and twcnty-ihree 



510 HYDROCEPHALUS. 

inches and a half from the nose to the occiput. He was thirty-three years of age; 
and his cranium was ossified at the sutures. Of course the bones had separated 
originally; but fresh bone had afterwards been deposited in the membrane between 
the frontal, occipital, and temporal bones; — so that he had as perfect a cranium as 
any one else. In him there were found as many as ten pints of water; — nine pints 
on the brain, and one pint in the lateral ventricles; and what was curious in him 
was, that the "corpus callosum" was split by the distension. An opening existed 
in the posterior part of the falx; through which the water (in all probability) had 
passed from within to without. I say — " in all probability;" because, in a great 
number of cases, the water is contained in the ventricles; and it is probable that, in 
this instance, it had made its escape. His brain only weighed two pounds fourteen 
ounces and a half; whereas the water in and upon the brain, amounted to ten pints. 

Andral mentions, that water has been found in the fifth ventricle. I believe it is 
sometimes rather a quirk to ask where the fifth ventricle is situated; but there is a 
little space which may be called " the fifth ventricle;" and Andral says, that Brous- 
sais has found dropsy there. 

Effect upon the Mind. — In this disease, the mind is generally weak. Some- 
times there is downright idiocy; but — as the brain is only expanded, and not de- 
stroyed — there is occasionally considerable intellect. Cardinal (the man at St. 
Thomas's Hospital**) had occasionally epileptic fits; and his mind was certainly 
weak. He prided himself on being able to say "the belief;" but he generally 
stumbled when he got to " Pontius Pilate." If he were asked his duty towards 
his neighbour, he got on pretty well at first; but he soon made a trip; and it was 
also observed, that his memory was not like that of other people. He was an 
idiot; — at least, he was what is commonly called "a soft kind of person." He 
was also exceedingly vain? and pretended to have violent sexual desires; and, not- 
withstanding his great big head, he used to try to get hold of the nurses; so that 
one day we heard he had been behaving very badly; — and then he would say 
" the belief" to you. He could walk, of course; but — being top-heavy, and having 
thin spindle-legs — he did so with the greatest caution, lest he should overbalance 
himself. Now and then, if he was not delirious, he was so ill-tempered, that we 
could scarcely manage him. 

There is a case mentioned by Dr. W. Heberden, in the " Transactions of the 
College of Physicians,"" in which a chronic accumulation of water occurred in a 
man eighty years of age. At least eight ounces of fluid were found in the ven-^ 
tricles, and four ounces on the brain, after death. There was some little organic 
disease about the " plexus choroides;" — a solid tumour of calcareous matter; toge- 
ther with ossification of the basilar and internal carotid arteries, and their cliief 
branches. Now this man, although twelve ounces of fluid were found in his head 
after death, had suflfered nothing, — except that he had been deaf many years (which 
many persons of eighty are) and had vertigo once or twice, — till six weeks before 
his death; and then he had a fit, from which he quite recovered; and was perfectly 
well before he died. This shows how nature will accommodate herself to an in- 
convenience, if it come upon her gradually. There is a singular circumstance 
mentioned by Morgagni. A considerable quantity of water pressed on the brain; 
so much, that had it taken place suddenly, death most probably, would have 
occurred; but from its taking place very gradually, no further mischief was pro- 
duced. 

In Acephalous Monsters. — It is right I should mention, however, that this dis- 
ease may exist when there is no brain. Dr. Gall asserted at first, that when there 
was water in the head, the brain was always present; but he corrected this state- 
ment, in a subsequent edition of his work; and acknowledged that people were 
sometimes formed without a brain. In footuses, where there has been nothing but 
" the medulla oblongata," they have sometimes had water in the head instead of 

« See Pase 509. »» Volume 5: Pasre 173. 



HYDROCEPHALUS. 511 

brain; — not that the brain has been destroyed by the water; but it has been defi- 
cient by original formation; the fetuses have been monsters. 

Very little Inflammation. — In these cases there are generally no marks of in- 
flammation; but we generally find, at last, that there is irritation. The vessels of 
tiie head are enlarged, and the head itself is hot. The person has more or less 
feverishness, and emaciation occurs; which, in the course of a year or two, is 
generally followed by death. In the greater number of cases, this is the course 
of the afTection; but there are cases where no such thing occurs. In Cardinal, 
there were no signs of inflammation at all. He ate and drank just like other 
people. 

Hydrocephalus ivitk Bifid Brain. — In the first volume of the *' Edinburgh 
Medico-Chirurgical Transactions,"* there is Recorded a case, in which a female 
child, only seven months old, had a head which measured twenty-nine inches and 
a half in circumference; and from which there were let out, after death, one hun- 
dred and thirty-six ounces of perfectly clear fluid; such as is usually found in 
chronic hydrocephalus. This fluid was contained in a bag; but then the brain 
was split in two. When the brain is first formed, the two halves are not united; 
but they afterwards come together; — just as in the case of the lips. The portions 
of the lips, however, do not always cohere; and precisely the same occurrence 
takes place with regard to the brain; — so that it remains divided; and the whole of 
the ventricles form a continuous bag with the arachnoid, and the surface of the 
brain. In the case to which I have just referred, on opening the head, a ventricle 
was seen at the bottom; — simply from the brain not having united (as it should 
have done) in the progress of the formation of the body. This was merely a case 
of hydrocephalus; — water in the ventricles; the two halves of the brain not having 
united, as they ought to have done. The rest of the brain was at the bottom. 

Rupture of the Brain. — There is, however, a very curious instance mentioned, 
of the actual rupture of the brain. In the case recorded in the " Edinburgh Me- 
dico-Chirurgical Transactions," there was a deficient cohesion of the brain; but 
in the eighth volume of the " Medico-Chirurgical Transactions of London,"'' a 
case is mentioned where, in this disease, there was so great a distension of the 
brain, that at last it actually ruptured. Both the brain and the membranes gave 
way, under the posterior fontanel; and an external swelling was seen to be pro- 
duced; — so that the whole head became oedematous; and fluid oozed from the 
mouth and nostrils, for eleven months. The child lived that period, after the 
giving way of the brain, and even of the "dura mater;" but of course the rent 
must have been very local. 

Treatment: Tapping. — In this disease, medicine (I believe) is perfectly useless; 
but still mechanical means have been found very beneficial. If a puncture be 
made, and a large quantity of fluid evacuated, the child may die very suddenly, 
almost immediately; but if a minute puncture be made, and a small quantity only 
let out at a time, it may be done with perfect safety, and the head has been known 
to be reduced; but I do not recollect having read of a cure till lately. I never saw 
a case of this kind; but it has been lately said, that some cases have been cured 
by a puncture being made; and a certain quantity only of fluid let out at a time.® 

Pressure by Bandages. — Another mechanical means, also, has been of ver}' 
great use; as I have, in some degree, witnessed myself; — that is, bandao-ino- the 
head. It should be bandaged nicely; — so as to have a uniform pressure ihrouo-h- 
out. I believe it was Sir Gilbert Blane who first suggested, or first attracted par- 
ticular notice to this remedy. He has published some cases where, if there was 
not complete success, yet very great benefit was derived from the plan. I rather 
think it is said, that some cases have been cured by bandaging. Some surgeons, 
instead of applying bandages, have employed adhesive plaster, — so as to confine 
the head; and this has answered still better. The only case in which I have had 

a Page 205. «> Page 51. 

« Dr. Conqnesf, to whom the profession is much indebted for his able and enlightened 
proceedings in this matter, has since published some very satisfactory cases. 



512 APOPLEXY. 

any experience of this, was at St. Thomas's Hospital, in the child of an Irish 
woman. I directed the head to be bandaged; and it not only became smaller, but 
the general health was very considerably improved; — indeed, more so than the 
head. Unfortunately, the bandage was neglected; and the child immediately grew 
worse. The bandaging was again attended to particularly, and the child again im- 
proved; but I do not know the result of the case, because the mother took it away. 
Supporting the body, and pressure of the head by means of equal bandaging, appear 
to be the proper means of treatment; and, after letting out a certain portion of the 
fluid, I presume it would be well to employ bandaging; — thus carrying on the two 
plans together. 



CHAPTER III. 

APOPLEXY. 



In this intense description of sleep, there is a great diminution (or entire loss) of 
sense and motion; slow, laborious, and generally stertorous breathing; — a loss, 
indeed, of all the anrmal faculties. It is generally sudden; whence its name (from 
arto, and Ti-Kriaaoii to strike); — the person being struck down. 



SECTION I.~SYMPTOMS. 

Sudden Seizure, — If a person be upright, or walking about, or sitting, he falls 
down; and sometimes dies on the spot. He is dead in an instant; — as if he were 
shot. If, however, death does not take place instantly, the pulse is generally slow 
and full; the face is livid and flushed, and also swollen. The lips are particularly 
livid; and there is generally a little froth (though not to be compared to what is 
seen in epilepsy) proceeding from the mouth; and a blowing, frequently, from the 
lips and nostrils. The lips do not act in the same way as they do when we are 
in moderate sleep, or when we are awake; but the air forces them open, and their 
elasticity brings them back again; so that the lips are constantly moved, together 
with the "alae nasi." The pupils are usually dilated, and the eye is insensible and 
closed. The cornea looks dull and glassy; the eyes are frequently bloodshot, and 
have a livid tinge, and so has all the rest of the face. The heat is generally in- 
creased; — especially of the head; and it is not unusual to see clammy sweats. 
But these almost always occur during the last period of the disease. There is at 
last a difficulty of swallowing. In some cases, if the attack be very severe, there 
is a difficulty (and perhaps an inability) of swallowing, from the very first; but, at 
any rate, when the disease terminates fatally, there is an inability to swallow at last. 

Seizure^ ivith Premonitory Symptoms. — Although this affection generally 
comes on suddenly, yet it is occasionally preceded, for a length of time, by 
drowsiness. Persons fall asleep in company, and at church, (where they will 
sometimes snore loudly,) even months before the fit. It is common for the attack 
to be preceded by headache; and by a throbbing, and a sense of tension and weight 
of the head. Many complain, previously, of dimness of sight and double vision, 
giddiness and vertigo; and, frequently, the eyes appear red before a paroxysm. 
Some have flashes of light (like stars) before their eyes, deafness, and tinnitus; 
together with dreaming, nightmare, and epistaxis.* It is not uncommon for per- 
sons, before they become apoplectic, to have numbness of the fingers, or of one 
finger, or of some part of the body. Sometimes there is tingling; — in other in- 
stances, slight twitches of the muscles; and occasionally stammering. It is very 
common for impairment of the memory to occur; as well as more or less depression 

* From eTTts-Ta^ao, to distil from. 



APOPLEXY. 513 

of the spirits. It is easy to conceive, that the circumstances which occasion apo- 
plexy will, in a slight degree, cause simple heatlache, or throbbing of the head, or 
double vision, or any of the other symptoms which I have mentioned. Stam- 
mering, an inability to use the muscles of articulation properly, and a loss of 
memory, will also arise from a fulness of the head; and from such a state as, ia 
greater intensity, will produce apoplexy. Sometimes, persons have hemiplegia for 
a longer or shorter lime, before the attack; so that hemiplegia frequently terminates 
in apoplexy. Independently of these symptoms, the invasion of the disease is 
sometimes very slow. Instead of persons being knocked down, the disease will 
come on slowly, whether they have these symptoms or not; — so that, from being 
sleepy, they at last become apoplectic quite insensibly. 

Seizure commencing with Syncope. — The disease comes on in another form 
which it is very important to know; — where it begins with syncope; from which 
the patient frequently recovers, for a longer or a shorter time, till he afterwards 
becomes apoplectic. This form is particularly mentioned by Dr. Abercrombie, in 
his very excellent work on Diseases of the Nervous System. Before the attack of 
apoplexy, there is sudden pain of the head; — a sharp, cutting, severe pain; but in- 
stead of the face being flushed, full, swollen, or livid, it is pale. Perhaps there is 
a little delirium, perhaps a wandering; but a sudden pain occurs in the head; the 
face is pale; the patient feels cold and faint; and there is also vomiting and purg- 
ing. After this attack of syncope, the patient gets up, and may walk about; — but 
in a few minutes, — though sometimes not for a few liours, and sometimes not for 
a few days, — but after this, whatever the interval may be, coma and apoplexy 
gradually take place. The body then acquires its natural warmth; perhaps is as 
hot as in common apoplexy; the pulse is no longer faint, but becomes full and 
slow; and the ordinary state of apoplexy is established. 

This form of the disease is almost always fatal. A rupture takes place withia 
the brain; — not producing immediate effusion, in most cases; but sufficient to cause 
violent pain; and to produce such an influence on the heart, as to impair ils action 
considerably; — so that syncope takes place; and then, after this symptomatic syn- 
cope, blood gradually oozes from the vessels, in different parts of the brain; till, at 
last, pressure takes place, and we have common apoplexy. It is particularly ne- 
cessary to know this form of the disease, before giving a favourable prognosis. 
Seeing the patient is very faint, and hearing of the pain of the head, we might 
think nothing of it; but we must remember, that it may arise from a rupture in 
some part of the brain: and — in a few minutes, hours, or days — effusion will gra- 
dually take place; and that to such an amount, as to produce common apoplexy. 
After the latter disease, there is almost always found rupture and extravasation. 

Duration and Effects. — When the disease does not terminate by instant death, 
it may last for a few minutes, or for some hours, and even days. Persons have re- 
covered after lying in this insensible stale for three days. I believe that when the 
state is not genuine apoplexy, but merely a symptom of what is called " nervous 
derangement," in hysterical women, it may last any length of lime; and persons 
will then recover; but if it be genuine apoplexy, persons seldom recover, if the 
insensible state continue beyond three days. 

When the disease does not destroy life, the symptoms gradually recede, till they 
disappear altogether. Consciousness, perception, a knowledge of existence, and 
an observation of the external world, return; and the power of volition is directed 
to the voluntary muscles. Sometimes, however, there is not a perfect return. 
Power, consciousness, and perception return, except in one part of the body; so 
that, after the disease, one half of the body very frequently remains motionless, 
without being at all subject to the volition of the patient; and sometimes, in addi- 
tion to this loss of power over half the body, there is also a loss o[ sense, — at l(>ast 
with regard to touch. This slate may exist on both sides of the body; but it is 
generally more complete on one side than the other. And this state may gradually 
subside, or continue for an indefinite time. But there is not necessarily an entire 
loss of sense and motion, in this disease; for, in most cases which do not immu- 
voL. I.— 33 



514 APOPLEXY. 

diately terminate fatally, if we pinch or otherwise molest the patient, he will 
evince consciousness by groaning, till within a short period of death: Frequently, 
too, after these attacks, the mental powers are weakened; so that tlie patients are 
never the men mentally that they were before; — never have the same power of at- 
tention, — the same memory, — the same power of mind altogether, that they had 
before the disease. 

If the affection, however, gradually destroy the patient, the power of sensation 
and volition does not return. The power of deglutition, and the power of respira- 
tion remain, unless the disease kill the patient directly; but if the patient remain 
insensible, the power over the muscles of deglutition is gradually lost. He swal- 
lows worse and worse, till he cannot swallow at all; the pulse becomes weaker 
and weaker; the body cooler; respiration quicker, and at length irregular; and thys 
the scene is closed. The heart, however, will beat a few strokes, after the very 
last inspiration has taken place. 

Convulsions. — Sometimes convulsions ensue; and I should presume that, in 
these cases, there is not only compression of the brain, but more or less laceration, 
or even inflammation. There must be some cause of excitement^ besides the com- 
pression which produced apoplexy; — something injuring one portion of the brain 
so much, as to produce convulsions. These convulsions sometimes affect only one 
half of the body. Blood taken from the temporal artery, in this disease, is often 
as dark as venous blood; and the blood taken from the veins, is very often huffy 
and even cupped. 

Contracted Pupil. — Sometimes, in an attack of this disease, the pupil is not di- 
lated; but, on the other hand, extremely contracted; and there is no worse sign in 
apoplexy than this. I recollect a German friend of mine, who had the largest pu- 
pil I ever saw. I have frequently looked at him with astonishment. The iris 
never appeared larger than a thread; — forming a very fine ring. He took it into 
his head not to live any longer; and therefore poisoned himself, by taking half an 
ounce of pulverized opium. I do not know the cause of the act; but, some hours 
after taking tlie opium, he fell into a state of coma. It is a striking circumstance, 
that coma did not come on for a considerable time; and, as he mentioned to his 
friends what he had done, they sent for all the doctors they could find, and for me 
among the rest. He lay upon the bed; and of course we proposed giving him 
emetics; but he, being as much himself as anyone in the room, declared we should 
not give him any thing. We had sulphate of copper and zinc in abundance; and 
endeavoured to put the solution into his mouth, and pour it down his throat; but 
he so kicked, thumped, and beat us, that it required a dozen of us to master him. 
He said that, if he thought proper to die, no person had a right to interfere with 
him. f^inding he would not swallow what was reasonable, we got a stomach- 
pump; and, with great difficulty, we passed it down, and emptied the stomach; 
and then poured in so many wash-hand basins of water in succession, that at last 
the water came out as clear as it went in; so that we completely evacuated the sto- 
mach; — he, all the while, exclaiming against the barbarity of keeping in this world 
a man who had no desire to stay. After all this, apoplexy came on. He became 
senseless; — his pulse slow, his face swollen, his lips livid, and his eyes suffused; 
and there was also stertorous breathing. We opened the jugular vein, and a vein 
in the arm; bled him freely, and dashed pails of cold water on him (which is one 
of the best remedies); but it was all of no use. His passion, I presume, had a 
great deal to do with it; for he was in a violent rage to the last moment. He was 
sensible; and the pupil was so contracted, as to be reduced to the size of a pin's 
point. It would have been difficult to pass through the iris any thing of a larger 
diameter than a pin. I need scarcely say that he died. I believe that when apo- 
plexy has come on from opium, and perhaps from other narcotics, a contraction of 
the pupil has been observed; but when apoplexy is of the ordinary kind, and has 
not arisen Irom narcotics, this symptom is mentioned by authors as being almost 
always a fatal sign. I never saw a patient recover, in whom the pupil was so con- 
tracted; though, of course, I have seen them recover where it was dilated. What- 



APOPLEXY. 515 

ever danger there may be from other symptoms, if the pupil be contracted, we 
ought to give a guarded prognosis. It is mentioned, by many authors, that this 
state of the pupil is unfavourable; and, so far as I have made observation myself, I 
think the statement fully verified. 

Anomalous States of the Pupil. — I may mention, while on this subject, that 
the state of the pupil, in affections of the head, is very various and very singular. 
When apoplexy is produced by external mechanical causes, in injuries of the head, 
notwithstanding the comatose state, the pupils are obedient to light and darkness;-— 
following the introduction or exclusion of the light, just as in health. This has 
been observed by Sir Benjamin Brodie; who has written an interesting paper on 
it, in the fourteenth volume of the " Medico-Chirurgical Transactions."* He also 
mentions having seen dilatation of the pupil alternate with contraction. At one 
time, the pupils were extremely dilated; and at another, extremely contracted; and 
this alternation had been repeated several times. He also mentions (what we might 
expect) that he has seen dilatation cease, when venesection was practised; and then 
when the effect was gone off, the pupils were dilated again. That also we should 
suppose. When a bone compressing the brain was elevated, the dilatation ceased. 
Dr. Hennen states, in his " Military Surgery," (which I need not say is an excel- 
lent work,) that he has seen the pupil dilated when light was admitted, and con- 
tracted when it was removed; and Sir Benjamin mentions seeing eyes in the oppo- 
site states; that while there was a morbid dilatation of one eye, there was a morbid 
contraction of the other; and sometimes he has observed the pupil of one eye only 
to be dilated. These are irregular circumstances; and, as we may meet with one 
or all of them, it is well to know them; otherwise we might pay no regard to them 
when met with. 



SECTION n.— MORBID APPEARANCES. 

Occasional Absence of Morbid Signs. — On opening the bodies of patients who 
have died of this disease, we may perhaps find nothing. I have seen it stated, that 
a person could not have died of apoplexy; because nothing unusual was found in 
the head, after death. But I have opened many persons who have died of apo- 
plexy, and have found nothing that would have led me to suppose they had been 
apoplectic. Most probably there had been extreme fulness of the vessels during 
life; and, after death, the fulness had completely gone off. Sometimes there has 
been a retraction of the vessels; and sometimes copious blood-letting has been had 
recourse to; but the brain has been so compressed, that the removal of blood was 
not sufficient to reinstate the brain in its former powers. Indeed, we frequently 
find, after this disease, that the great turgescence of all parts of the face, will go 
off; — if not entirely, yet to a great degree; and we must suppose, therefore, that 
the same thing may occur internally. I recollect a patient who died of this disease. 
He was lying in the dead-house; but the veins looked so full and tempting, that I beg- 
ged some of them might be opened, and the subject bled freely to a pint; and although 
the face was livid and swollen, the lividity went down, and the face recovered its 
former size. We may therefore presume, that a change may take place in the 
branches of the internal carotids, similar to that which occurs in the branches of 
the external carotids. 

Turgescence of the Vessels. — But, in the second place, we may find great ful- 
ness of the vessels. The sinuses are generally filled with blood; and the vessels 
of the " pia mater" are exceedingly distended; so that they present an obvious and 
decided turgescence. 

Effusion of Serum. — Sometimes we find an effusion of serum in or upon the 
brain. Sometimes there is simply this; but sometimes it is united with a general 

a Page 325. For the facts mentioned (on Sir Benjamin Brodie's authority) in the text, 
see Pages 352 to 354 of that volume of the " Transactions." 



516 APOPLEXY. 

fulness of the vessels. It is said, that if the disease arise after ischuria renah's, 
serum is generally found; but I recollect opening one patient, in whom there was 
neither a fulness of the vessels, nor any serum effused in or upon the brain. I never 
opened more than one who had died of apoplexy after the suppression of urine. 

Extravasation of Blood. — In the fourth place, we sometimes jEind extravasation 
of blood. This may be upon the surface, or in the substance; and, in the latter 
case, I believe it is found, more frequently than otherwise, near the ventricles. It 
is seldom seen in the latter alone. If we find blood effused into a ventricle, it gene- 
rally arises from its having been effused into the substance of the brain near the 
ventricle, and projecting through the cerebral substance; — so as to make its way 
into this cavity. The blood may be effused, of course, in any part of the brain;— 
in the cerebrum, in the cerebellum, and even in the "pons varolii," so as to lace- 
rate it; and if it be effused near a ventricle, it frequently makes its M'ay into it. 
Andral has made a large number of dissections; and states, as the result, that the 
blood almost always finds its way to the ventricles by rupture. Of three hundred 
and eighty-six cerebral haemorrhages read of by him, he finds that two hundred 
and two took place in the substance of the hemispheres; sixty-one in the "corpora 
striata;" and thirty-five in the " thalami nervorum opticorum;" so that the hemi- 
spheres are by far most frequently the seat of haemorrhage. 

Apoplectic Cells. — The new cavities formed by the extravasation of blood, may 
be of all sizes; — varying from the size of a small pea, to that of a walnut; and, in- 
deed, much beyond that. There is great variety, also, in the number of these effu- 
sions. Sometimes we find only one; in other instances we may find two; and in 
some cases we may find several. The blood which is effused, looks, at first, like 
currant-jelly, with a reddish fluid around it. In about a fortnight, this clot becomes 
much firmer; and at length it becomes soft, and has merely a reddish fluid around 
it. It is sometimes completely absorbed; — so that a cavity is left; and that is called 
" an apoplectic cell." This cavity is sometimes lined by a new serous membrane, 
sometimes it contains clear fluid; and occasionally it is empty, and may remain so 
for a great length of time; perhaps for life. It is said, by some, that a coagulum 
may remain for a long time in the brain, without much mischief; but, where it does 
exist, it generally gives rise to paralysis. 

Apoplectic Cicatrices. — When the process of absorption occurs, we find, in the 
first place, that the serum becomes absorbed; that the clot becomes firmer and paler; 
and then, frequently, a number of filaments are produced, running from the walls of 
the cavity. These filaments, at first, are loosely attached; they then become firmer; 
at length sometimes the cavity will shrink; all the parts will contract, and become 
hard together, — so that a cicatrix is produced; and this cicatrix will become very 
firm. Sometimes there is no cell left. The blood is entirely absorbed; a cicatrix is 
produced; the sides of the cavity approach together; the filaments also are contracted, 
I suppose; and the whole becomes quite firm. In these circumstances, there is 
generally a change of colour; — sometimes to green, sometimes to yellow, and some- 
times to purple.* 

Cerebral Softening around the Clot. — When there is a clot efl^used in the brain, 
it is generally found that the substance of the brain around it is softened. Dr. 
Baillie mentioned,*' long ago, that if blood be effused into the substance of the 
brain, the cerebral substance around the clot is very frequently softened. Some- 
times, however, there can be no doubt that a clot is the result of softening. I am 
quite satisfied of this from my own observation; for I have seen a person, with a 
pain in his head, gradually lose his memory, even have a cerebral affection, and 

a Nature makes an attempt to restore the part. — just as she would in any other situation 
in the body. The best representation I know of these morbid alterations, is that by Cruveil- 
hier. One of his plates depicts the progress of ihe changes. Fasciculus 10, Plate 8, Figure 
1 represents the substance of the brain into which there has been an effusion of blood. 
F'i"-ure2 represents a cavity in which a clot had formerly existed; and which, Cruveilhier 
says, was filled with serous fluid when he opened it. Dr. Baillie's plates are not colouredj 
and therefore they do not show the affection so well. 

b In his " Morbid Anatomy;" Chapter 34; Section 24. 



APOPLEXY. 517 

then suddenly become apoplectic and die. On examination, I have seen a portion 
of his brain softened like pap; and in the midst of it an effusion of blood. This is 
nothing more than might be supposed likely to happen. If the cerebral substance 
of the brain be much softened, the large vessels will at least give way, and let out 
blood; so that we may have a softening of the brain, through the presence of blood 
injecting the surrounding substance. I feel satisfied that, through the vessels be- 
coming softened, a clot of blood may be formed; and then we have more or less 
apoplexy. At St. Thomas's Hospital, I opened a man who came in with hemi- 
plegia; which is much the same thing in point of pathology. He came in with 
paralysis of the left side; — the arm, the leg, and the whole of the side, were para- 
lyzed. In the posterior part of the right "thalamus nervi optici," there was found 
a cavity; the brain was evidently injured; and the part looked just like an ulcer in 
a mucous membrane. I presume that, in this cavity, blood was effused; it coagu- 
lated, and was then partly absorbed. It produced a destruction of the cerebral 
substance around it; and the blood, being partly absorbed, gave rise to the dark 
colour. I have always seen the injury on the opposite side to that on which the 
paralysis occurred. 

Occasional Presence of Inflammation. — Sometimes, besides congestion and 
effusion, we 'find marks of more or less inflammation. The membranes are 
thicker than they should be; — looking as if chronic inflammation had been going 
on. In the man just referred to, the arachnoid on the surface of the brain was 
quite opaque; and there was also a considerable effusion of serum; but then he 
died from an inflammatory attack of the brain. His head suddenly became very 
hot; he became stupid; and then effusion took place into the substance of the brain, 
and likewise into the ventricles. This was a subsequent process; and is a very 
common mode in which paralytic persons die. There is a disposition to disease. 
In most chronic diseases effusion takes place; and, there being no strength of con- 
stitution, the patients die. They sink from inflammation within. 

Diseased State of the Vessels. — This laceration, — this rupture of the vessels 
with effusion of blood, very generally takes place from some disease of the ves- 
sels themselves. Now and then, the vessels within the head have been found 
aneurismal. Very frequently, too, they are found more or less ossified. Some- 
times they become calcareous; — more or less earthy, and very brittle. It is said 
that even the veins outside the head, are occasionally found diseased in a similar 
way. The vessels are so britde that they will crack; and apoplexy takes place. 

Small Vessels usually Ruptured. — Now and then, a very large vessel in the 
head has been found ruptured; — even a large artery. Generally, however, it is 
the small vessels that suffer; but even the sinuses have been found in that state. 
An instance of the lateral sinus being ruptured, is mentioned in the "Journal Uni- 
versel" for 1820. There is another instance mentioned in the same work, of the 
lateral sinus being ruptured, in a person intoxicated. In the " Edinburgh Essays 
and Observations, '"^ there is another instance mentioned, where the lateral sinus 
was ruptured, and apoplexy was the consequence. A practitioner informed me, 
that he was once sent for to a man, who had been carrying a very heavy load; 
and he found the longitudinal sinus ruptured. We must suppose there was a dis- 
position, general or local, to disease of some kind. Usually, it is the small vessels 
that give way; and next to them come the arteries. The sinuses are certainly more 
rarely affected than either. 

Hemorrhage External to the Skull. — The hremorrhage, it is said, is sometimes 
found outside the skull; so that, on removing the skin, the haemorrhage has been 
seen there. This is by no means uncommon after external violence; but, wlien it 
does not arise from that source, it happens from a bone being carious, and a vessel 
of the "dura mater" thus becoming injured. 

Effusion of a Urinous Character folloiving Ischuria. — It is said that, in cases 
where apoplexy follows the suppression of urine, a great quantity of fluid has 

* Volume 5; Part 2; Page 106. (Fifth Edition.) 



518 APOPLEXY. 

been found in the brain; and even fluid of a urinous character. Whether that is 
true, I will not take upon me to say; but some people have even found gin in the 
brain; — at least so it is said. It is stated that an old woman, who had been much 
addicted to drinking gin, died at the Westminster Hospital. She died with her 
stomach full of it; and there was a distinct smell of gin in the ventricles of the 
brain. It is also said, that tincture of assafostida^ has found its way to the ventri- 
cles; or that there has been a strong smell of it in persons who have died apo- 
plectic. An effusion has taken place into the ventricles of persons previously 
taking assafcetida; and it is said that there has been a strong smell of it in the 
brain. These things may be, and I suppose have been; but I have not seen them. 
Certainly, when persons have been unable to make water, and the urine has been 
retained, there can be no doubt that they have occasionally vomited urinous fluid, 
and even expectorated a fluid strongly smelling of urine. If this be the case, it is 
possible that such an occurrence may take place in the ventricles of the brain; but 
I can only say that I never saw more than one instance of apoplexy from ischuria, 
and in that case there was no efl'usion (of any kind) into the brain. 



SECTION III.— CAUSES. 

a. Predisposing Causes. 

Hereditary and Constitutional. — The predisposition to this disease may be 
constitutional, or even hereditary; — an hereditary make of the head, neck, and 
body at large. Men who have a large thick head, are those that are usually afl'ected; 
because that is not the shape for intellect. It is a /ono"-headed man that is gene- 
rally thought clever. Men with short necks, circular breasts, and not very tall, are 
certainly very liable to apoplexy. This is, of course, a constitutional make; and 
if it happen to be hereditary also, the predisposition to apoplexy may be said to 
be hereditary, as well as constitutional. 

Indolence and Excess of Food. — In the next place, indolence of body and mind 
will predispose to it. Persons who satisfy themselves with little exercise, and 
little mental exertion, have more or less congestion; and at last become apoplectic. 
If persons sleep too much, they become more or less plethoric, and liable to become 
apoplectic. Food too rich and too abundant, will have the same efl'ect. It is said 
that Boerhaave had a student, who took it into his head that sleep was the natural 
state; and he slept as hard as he could; till at last, from the want of external ex- 
citement, he fell into apoplexy. 

Hypertrophy of the Brain. — Hypertrophy of the brain tends to produce this 
disease; — an occurrence which we might a priori expect. Over-nourishment of 
the brain is likely to dispose to congestion, and to irregularity of the circitlation. 
I once saw an instance of this kind; and only once. It occurred in a young gen- 
tleman, eleven years of age, who had a head bigger than most men; — in fact, it 
was too large for his body. He was remarkably clever, and was not contented 
with the society of other children, but associated with his father and mother. He 
studied many things; but more particularly political economy. He was seized one 
day with hemiplegia, and had double vision; and the attack was soon followed 
by coma. Previously he had had double vision, and pain of the opposite side to 
that in which haemorrhage afterwards took place. After death, the only thing I 
could discover was congestion in the brain; and I fancied that the *' corpus callo- 
sum" was softened. A few minute tubercles were found in the arachnoid; but 
nothing to cause apoplexy. His brain was far larger than it ought to have been in 
a child of his age; indeed, the brains of very few adults attain so large a size. In 
the "Dictionnaire des Sciences Medicales" (under the article " Rare Cases"), 
there is mentioned the case of a German, who died apoplectic at the age of thirty. 

a From " asa" (Hebrew), to heal. 



APOPLEXY. 519 

He had very powerful menial faculties. His head began to grow at seven years of 
age; and at thirty it was twenty-seven inches five lines in circumference. Tlie 
rest of his body was not proportionate; and, like my patient, he died apoplectic. 

Decline of Life. — Apoplexy is also predisposed to by the decline of life. Of 
those persons who die apoplectic, more than half have passed the meridian of life; 
with the exception of children, who die in consequence of effusion. Apoplexy 
occurs in children, every day, from an inflammatory state of the head, which causes 
more or less effusion; but apoplexy from congestion of blood, and effusion tlirough 
diseased vessels, more frequently lakes place after the middle period of life. 

Cessation of Discharges. — It occasionally takes place from the sudden cessation 
of a discharge; — from the cessation of the menses, or from amenorrhoea; but not 
so frequently as might be imagined. The most we generally see, when women do 
not menstruate regularly, is headache and giddiness. The suppression of heemor- 
rhoidal discharge has produced apoplexy; and the cessation of a long-continued 
cutaneous eruption, will do the same; and likewise metastasis, on the cessation of 
gout; and even, it is said, the removal of tumours. 

Organic Disease of the Head. — Apoplexy is strongly predisposed to, by 
organic disease in the head; — in the brain, or in the membranes, or on the inner 
table of the bones, or in the whole substance of the bones. When there is organic 
disease outside the brain, — whether of the bones, or the pericranium, or the inner 
tables, or the " dura mater," — then a person, from the excitement going on there, 
is very much disposed to this disease. 

Anxiety. — Anxiety of mind has a tendency to produce it. When persons are 
very anxious, they soon experience heaviness of the forehead; and apoplexy is 
soon induced. 

Manner in lohich these Causes Act. — Many of these things act by merely giv- 
ing rise to excessive fulness; and if there happen to be, in the individual who is 
exposed to these predisposing causes, any organic disease of the vessels or mem- 
branes of the brain, it is easy to perceive how easily the excessive load of blood 
there, may occasion apoplexy. When there is organic disease of the vessels, of 
course, it does not require a full habit, full living, a short head, and a thick neck, 
to induce the disease. If any of the vessels be diseased, though a person may be 
as thin as a lamp-post, and nearly as tall, he will be liable to apoplexy; and people 
wonder that a person so spare, should die of such a disease. It is so frequently 
the result of blood being effused through the state of the vessels, that we must 
expect to see this disease in thin people; — not so often as in fat persons, certainly; 
but very frequently. It may arise widiout any fulness of the vessels whatever; 
but simply from one vessel, or a set of vessels, being brittle, or softened, or ulce- 
rated, or labouring under some other disease; and it will arise from mere fulness of 
all the vessels; — the vessels themselves being sound, but suffering more or less 
congestion. We may therefore expect apoplexy in two very opposite descriptions 
of people; and when it arises from the state of the vessels, none of these other 
predisposing causes are required. A person may live the most abstemious life 
possible; and yet the vessels may let out the blood, and the person die apoplectic; 
— so that no exciting cause may be required for it: nor any of those predisposing 
causes which I have mentioned, as operating by occasional fulness of the head. 

h. Exciting Causes. 

Stooping. — As to the exciting causes of the disease, they may be equally influ- 
ential in producing it, whether there is mere fulness, or organic disease of the 
vessels. Stooping, especially if a person make an effort while doing so, is a com- 
mon cause of apoplexy. If there be previously great congestion of blood, even 
without disease of the vessels, stooping will increase it to such a degree, that 
apoplexy may occur. Supposing there is britlleness of the vessels, stooping will 
have the same effect as if there were great congestion. So that a common exciting 
cause of the disease, for the most part, will produce apoplexy, whether it arises 



520 APOPLEXY. 

simply from an over-fulness, or from disease of the vessels; because stooping", for 
example, is a violent effort, which will throw a great quantity of blood on the head; 
and will operate by forcing the blood through, or opening the vessels. 

Heat and Cold. — Exposure to a very great fire, or being in a very close apart- 
ment, are causes of the disease; and so likewise are the rays of the sun; — insola- 
tion. Cold causes stupor. When persons are exposed to intense cold, they be- 
come exceedingly heavy; — they are disposed to sleep; and it requires a strong 
exertion on their part, to prevent them from going to sleep. When they travel 
over regions of snow, and have nearly perished from cold, if they give way to 
sleep, and lie down, they are sure to die. Yet they will be careless; and, though 
their friends tell them of their danger, and entreat them not to lie down, the pro- 
pensity to sleep is so great, that they cannot resist it; and the cold at last produces 
apoplexy. When a person falls into a sound sleep, I believe that death from cold 
is by no means unpleasant. Of course, it is unpleasant to be killed; but when 
persons are benum.bed, they lie down quietly, in an apoplectic state. It is said by 
Portal, a French physician, that he found a ruptureof a vessel in a person who had 
died in this state. It would appear others had observed, that cold killed merely by 
numbness; — taking away all excitement from every part of the body, and the brain 
among the rest. The late Dr. Kellie, in the first volume of the " Edinburgh 
Medico-Chirnrgical Transactions,"* says that he found serous effusion, and great 
congestion of the head, in two persons who were destroyed by cold. 

Tight Bandages on the Neck. — Tight bandages round the neck, have frequently 
produced apoplexy, or threatened to do so; — that is, the person would have had it 
if they had not been loosed. It might be supposed that the tight bandage which 
is applied by Jack Ketch, would occasion this disease; and Sir Benjamin Brodie 
says that, in a person who was hanged, he saw effusion of blood. Dr. Munro, 
likewise, says that he found, in two cases, congestion of the scalp, and congestion 
within the head. But this is not always the case. Persons who are hung, do not 
die of apoplexy; but of a want of breath. Occasionally it has happened that 
apoplexy has been produced; — for Sir Benjamin Brodie (on whom we may place 
implicit reliance) has found not only extreme congestion, but even rupture. 

Drowning. — Sometimes, great cerebral congestion has been found, after drown- 
ing; but there are several authors who deny the truth of this statement. Drs. 
Good, Winslow, and Currie, say that, after drowning, no congestion was found. 
Morgagni says that, after hanging, he found no congestion. De Haen says that, 
after hanging and drowning, nothing was to be found; and so says Dr. Kellie. It 
appears, therefore, that a person may be hanged or drowned, and no congestion or 
rupture take place; but, in other cases, there may be rupture. People, from 
drowning, hanging, suffocation, and cold, do not die necessarily of apoplexy. 
There may be apoplexy in addition; but not necessarily so. I presume that a 
great deal will depend on the strength of the vessels. If the vessels be very strong, 
they will not give way; — they will not allow great congestion to take place; but if, 
on the other hand, they be weak, they will allow it; or, if they be diseased, they 
will allow the blood to be effused. 

Narcotics and Intoxication. — Narcotics will give rise to this disease. They 
produce various disturbances of the brain; — sometimes delirium, sometimes more 
or less phrenitis, and sometimes apoplexy. They cause apoplexy, by inducing 
compression, where there is great congestion of the head; but, independently of 
producing this compression of the vessels, they do harm by their peculiar narcotic 
power; — by destroying the vital powers of the body; just as cold will produce 
death, independently of congestion. Intoxication, too, will frequently produce the 
same effect. 

Other Exciting Causes. — Among the exciting causes of the disease, we find 
mentioned "lying on a millstone;" but I do not suppose that anyone lies down 

» Page 84. 



APOPLEXY. 521 

in such a situation. If it do produce death, it is by the centrifugal force driving all 
the blood to the head; so that apoplexy is induced. 

Anger has sometimes destroyed life by apoplexy. Ischuria renalis has been 
also found to produce apoplexy. 

Inflammation. — Inflammation and suppuration of the brain frequently produce 
apoplexy. The inflammation goes on to such a pitch, that apoplexy at last ensues 
from the congestion. Suppuration within the brain causes such a collection of 
pus, as to compress it; and the compression may produce apoplexy. 

Depressed Bone. — The pressure occasioned by a depressed bone, likewise gives 
rise to apoplexy. After an injury inflicted on the head, persons are frequently 
brought to the hospital perfectly comatose, — in a state of apoplexy; and, when the 
bone is raised, they recover. 

Is the Brain Compressible? — Some, however, deny that pressure will produce 
these effects; — at least, they deny that the brain is ever compressed. They say 
that the cavity of the cranium must always be full; — that if the veins be compressed, 
so that the blood cannot escape, so much less blood goes up to the arteries; or 
that, if we quicken the pulse, and increase the usual quantity of blood in the arte- 
ries, the veins contain proportionately less. Dr. Kellie, who takes this side of the 
question, says that he bled animals to death; and that lie still found a great quan- 
tity of blood in the head; — so that the cavity must be filled. If we press more in 
one way, m»ore comes out the other; or, if we endeavour to withdraw the blood, 
we cannot; because the cavity must be filled, and therefore we can only take away 
a certain portion. 

All this may be true; but yet I should think there may be more blood in the 
head at one time, than at another. The cranium may be full; but I should think 
there may be different degrees of packing. A portmanteau may be filled; but it 
may be packed tightly, or packed loosely; and when we see that, if a person 
stoops, he becomes stupid and sleepy and giddy; and that all the vessels of the 
external part of the head are distended with blood; and when he suffers what, in 
a higher degree, would be apoplexy; — I cannot help thinking, that there is more 
blood in the head at one time, than at another. I should conceive that the cerebral 
substance may be pressed in a different degree. There must be a certain quantity 
of blood in the brain, resisting the entrance of more; but I should think that more 
might be forced upon the brain; — so as to compress the cerebral substance, and 
brinor it into a smaller bulk. 

AVhen the face is red and full, all the external veins turgid, and the person is 
labouring under evident external plethora of the head, while (at the same time) he 
has signs of apoplexy, after death, all the internal vessels of the head are almost 
sure to be found in a state of congestion; and hence, to all appearance, there is 
far more blood in the head at one time than at another. If a person tie his cravat 
tightly, he instantly has the external veins of his face filled; his eyes become red; 
he feels, at the same time, stupid and giddy; and if he do not loosen it soon, he is 
very likely to drop down. Some have defied that there can be congestion of 
blood in the head, from this circumstance; that, after hanging and drowning, there 
has frequently no apoplexy been observed; — no congestion of blood, and no eflu- 
sion; but, I presume, this will all depend on the strength of the vessels, or on the 
vessels not being diseased. If they be in this healthy condition, I presume they 
will resist an overload of blood, and not give way; — that they will not allow either 
rupture, or congestion of blood. It is well known that persons with hypertrophy 
of the left ventricle of the heart, frequently become apoplectic; — there being such 
a quantity of blood forced violently towards the brain. But it is said, that we 
every day see a quantity of blood violently driven up to the head; and yet no 
apoplexy is produced. I presume the reason is, that the vessels are so strong, 
that they will not become over-distended; — they will not give way; whereas, in 
other persons, they are diseased or feeble, and do give way; so thnt congestion is 
produced. I cannot see the force of the argument that has been adduced. I will 
not deny, that there may be only a certain quantity of blood in the head; but I 



522 APOPLEXY, 

do think that the cerebral substance may be more compressed at one time than at 
another; — that the contents of the cranium may be packed more closely. 

Will Pressure cause Jlpoplexy? — Some contend, however, that we are able to 
say nothing about the existence of pressure; or, allowing that pressure does take 
place, they deny that it will produce apoplexy. Serres asserts, that actual com- 
pression does not produce apoplexy. He trephined several dogs, and then wounded 
the brain through the aperture, — so as to produce effusion of blood; and yet, he 
says, apoplexy did not occur. Whether we can depend upon his statements or 
not, I will not pretend to say; because some say we cannot. But if we can, I 
presume the reason there was no apoplexy was simply this; that if an opening 
were made in the cranium, the pressure would be ivithout and not within; be- 
cause the opening would allow the contents of the skull to be pushed forward. 
But, he says, after he had cut a piece of bone, he closed the opening with a 
cork, so as to press on the brain; and no apoplexy was produced. This, how- 
ever, appears to me questionable. That the brain will bear pressure, without 
much efTect being produced,— provided it take place gradually, — is proved by Dr. 
Heberden's case of gradual compression; which I mentioned while describing chro- 
nic hydrocephalus.^ Sudden pressure caused by a less quantity would, I pre- 
sume, have produced apoplexy. Dr. Marshall, formerly a lecturer and anatomist 
in London, mentions the case of a maniac who, a few hours before death, had be- 
come rational; and he found rather more than a pint of serum in and upon the 
brain; — showing what may be borne, if the part be accustomed to it gradually. 

Tumours ivithin the Head. — When there is any tumour within the head, it will 
act (I presume) not merely by being a source of occasional irritation, but by occu- 
pying so much space in the cranium, that the least additional presence of blood 
upon the brain is likely to produce effects, which would not be produced if the 
tumour were not there. If the capacity of the cranium, for example, be at all 
diminished by the presence of a foreign body, of course it can less easily bear any 
additional quantity of blood which may be forced up; and therefore tumours may 
act in two ways; — first, by exciting a sudden determination of blood to the head; 
and, secondly, by filling up the cavity of the cranium so much, that even a little 
additional flow of blood cannot be borne; — there is no room for it. We sometimes 
see cases of persons, who have died with a tumour within the head; which pro- 
duced only occasional paralysis, or occasional loss of motion; — a kind of stupor. 
In such a case it might be said, there was no organic disease; because the symp- 
toms were only occasional. That I know has occurred; and, I presume, from this 
circumstance; — that the tumour has gradually accustomed the part to its presence; 
and when apoplexy and paralysis have occurred, (as they have from time to time,) 
it has not been from the tumour being there; but from an additional flow of blood, 
which could not be borne. Thus the tumour itself was not the cause of the occa- 
sional fits of apoplexy; but it was the additional congestion of blood, which could 
not be borne, in consequence of the presence of the tumour, or something occu- 
pying the cavity of the cranium. For it is a fact, that we sometimes see persons 
with considerable pressure; but as it came on slowly, the apoplexy, or paralysis, 
has only been occasional; — has occurred only when an additional quantity of blood 
has been forced to the head; which could not be borne, on account of the narrowed 
dimensions of the cranial cavity. 



SECTION IV.— TREATMENT. 

In this, as in every other instance of disease, if there be an evident exciting 
cause still in existence, and removeable, we should remove it. 

In Cases of Depression, — Supposing it to arise from the depression of a piece 

a See Page 510. 



1 



APOPLEXY. 523 

of bone, that is a surgical case; and no medicine in the world can remove the 
symptoms, while the bone remains in that position. In all probability, it would 
be a proper practice to attempt the elevation of the bone. The pulse has some- 
times been quite imperceptible, while the bone was depressing- the brain; but im- 
mediately on the bone being elevated, it has become strong. Sir Benjamin Brodie 
mentions such a case.^ He says the pulse was only 40, while the bone was press- 
ing on the brain; but on its elevation, it instantly rose to 60. 

Intoxication. — If we know that the apoplexy has arisen from any thing tal^en 
into the stomach, we should adopt proper steps to evacuate that organ; — that is to 
say, emetics, or mechanical means (the stomach-pump). 

Treatment in ordinary cases. — If it be an ordinary case of apoplexy, however, 
the first thing to be done is to raise the person's head and shoulders, to loosen 
every thing about his neck, and to open a vein in the arm, or the jugular vein. 
As to the quantity of blood to be withdrawn, I need not say any thing; for that 
must depend on numerous circumstances.* The next thing should be to give a 
full dose of purgative medicine; — a drop or two of croton-oil, or a scruple of ca- 
lomel. Perhaps it would be well to give a dose of calomel, whether alone or in 
combination; because early ptyalism, after apoplexy, often appears useful. There 
is effusion left, for which ptyalism is apparently useful; and it is well to lay the 
foundation for it, by beginning with calomel as a purgative. As it is best to open 
the bowels very speedily, a strong purgative injection should next be given. The 
state of the brain causes the heart to be more or less torpid, and likewise the ali- 
mentary canal; — giving rise to a slow pulse, and torpidity of the bowels; and a 
clyster of oil of turpentine (two or three ounces) answers very well. Whether it 
is objectionable on account of stimulating the brain, and producing vertigo, I do 
not know; but I am not aware that I ever saw harm arise from it. A good clyster 
is one of the best things; — sulphate of magnesia or an infusion of the extract of 
colocynth, answers very well. It is made in a moment; and may be exhibited in 
gruel, or barley water. It is very useful to apply water to the head; — much more 
so than a blister. The head generally is hot; and ice, applied in a bladder, is 
exceedingly serviceable. The patient should be kept very low; and sinapisms, 
applied to the feet or legs, may be useful. But the great point is to raise the per- 
son; to keep him as upright as possible; to loosen every thing about the neck; to 
bleed freely; to give an active purgative; and instantly, without waiting for the 
operation of this purgative, to introduce a strong acrid injection into the rectum, 
and to apply ice to the head. It would be well, afterwards, to continue the calo- 
mel till the mouth is tender; and that on two accounts. First, the head is frequently 
hot in this disease; — it is so often an inflammatory disease; secondly, we frequently 
find the blood buffed and cupped;" and I may say, in the third place, we often find 
paralysis occurring; and that appears to be the result of effusion, the excess of 
which should be absorbed. Calomel may be useful in that respect. 

* "Medicc-Chirurgical Transactions;" Volume 14; Pages 355 and 356. 

^ Dr. Marshall Hall has drawn alteniion to an important difference in the treatment of 
mere congestion and of actual rupture. — " In the former there is extreme tolerance of loss 
of blood; in the latter, the system is extremely, and even dangerously, susceptible of this 
loss." He, therefore, attaches importance to " placing the patient in the perfectly upright 
posture, before the blood is allowed to flow: we must watch his countenance, and his breath- 
ing; keep our finger on his pulse; and, the moment the slightest indication of approaching 
syncope takes place, arrest the flow of blood, and place the patient recumbent." (" Princi- 
ples and Practice of Medicine;" Page 256; Section 1177.) 

« According to Dr. Milne Edwards, (" Cyclopaedia of Anatomy and Physiology;" Volume 
1; Page 414,) the buffy coat may appear in "plethoric persons, without the existence of inflam- 
mation. The same author also quotes the experiments performed by M. Raiier, to prove 
that various circumstances, altogether independent of the physiological state of the indivi- 
dual, may also exert a great influence on the formation of the buflV coat. Dr. Babington 
(in the same work, Page 420) states that the buffy coat may even "be absent in the most 
intense inflammation; for the circulation may be so overcharged (either actually or rela- 
tively), or the nervous power so oppressed, that the requisite degree of propulsive force is 
not exerted by the heart and arteries; nor the vital energy, on which slow coagulation 
depends, imparted to the blood. 



524 APOPLEXY. 

at 

Necessity of Caution in the Treatment.— -Gresii care, however, must be taken 
i^ot to carry this too far: for there can be no question that persons will sink after a 
time, entirely from these measures bein^ pushed beyond their proper extent. 
Although we starve the patient the first few days, we must ultimately give him 
support. I am sure that some persons have had apoplexy, from having been bled 
too frequently, even locally; and from having been deprived too long of food. It 
is all very well in the first instance; but if the patient begin to sink, we should not 
continue to evacuate. . It is necessary to get the mouth sore, and then to apply a 
blister behind the ears, and over the head; and after a time, if we please, over the 
whole of the head; but great care must be taken not to evacuate too much. 

Serous and Sanguineous Jipoplexy. — -There was formerly a distinction drawn 
between serous and sanguineous apoplexy; — " serous," where it arose from 
effused serum; and "sanguineous," where there was great congestion of the ves- 
sels, or rupture. Taking this distinction literally, it is altogether absurd; as will 
immediately appear, when we consider the indications of cure. It was supposed, 
than when there was sanguineous apoplexy, we were to bleed, purge, and starve; 
and when it was serous, we were to support the patient well; — because it was a 
case of apoplexy from the oozing of water. That was absurd; because we may 
have serum where the inflammation is more or less severe; — in a case where it is 
quite proper to bleed, purge, starve, and apply cold. Common inflammation of 
the arachnoid membrane, whether it be active or not, will produce it; and, in the 
rsext place, where we have effusion of serum, there is often great congestion of 
blood. We may have it in both cases; and nothing is more common, when a vessel 
is ruptured in the head, than to find serum efl^used upon the brain, and outside the 
head. Serum, in this case, — as in its effusion in all other parts of the body, — may 
be the result either of weakness, of congestion, or of inflammation; and therefore 
we see, that no treatment of apoplexy can be founded on the presence or absence 
of serum, even could we tell it beforehand; any more than an indication of practice 
can be drawn from serum in other parts. Serum may be effused in pen7om7is; 
and yet we may have to treat the case as active peritonitis; or we may have to 
support the patient well, and to give stimuli; and the same remark applies to the 
brain. Hence this distinction is not founded on pathological principles. Where 
a person appears plethoric, we must treat him by depletion; but where he looks 
pale, watery, leucophlegmatic,* and has a weak pulse, (as if the effusion were 
serum,) then we should not employ active depleting measures, but be exceedingly 
careful; and perhaps we may have to support him. There is a distinction to be 
drawn; not because there is serum or no serum; but because in the one case there 
is a state of fulness and congestion, and in the other a state of debility. It is neces- 
sary to consider the powers of the patient. In some of these cases, the patient 
looks as though he would be dropsical in the head; and every other })art of the 
body is pale and white; and if an effusion of serum took place, it would be more 
from weakness than any thing else; yet in such persons as these, after death, we 
continually find congestion, and more or less organic disease, giving rise to the 
effusion of serum. We must depend on the state at large, and proceed on gene- 
ral principles, and not as to whether there may be serum or not; for we cannot 
tell its presence a priori. 

Sfter -Treatment. — After the fit is over, and the patient has recovered, it is 
necessary to pursue the general treatment which was adopted during the fit; only 
on a more moderate scale. If it be necessary to bleed copiously, to treat the case 
very antiphlogistically (or in a very depleting mode), of course the patient should 
be very abstemious in his diet, should keep an open state of his bowels, and use 
(though in great moderation) all those measures which are calculated to prevent a 
phlogistic condition from occurring. If a patient have not borne an evacuation 
during the disease, of course a more generous diet must be allowed; — we need not 
be so strict. Dr. Babington, from his own extensive experience, became convinced 

» From xeyjwf, wKUei and <j)Xsy|a*, phlegm* 



APOPLEXY. 525 

that many persons were made to suffer exceedingly, from having antiplilogistic 
measures carried too far; not only from the very outset, but afterwards. He says 
that he found great advantage, after a lime, from the moderate exhibition of tonics. 

ApofAe.xy from Ischuria. — There is one kind of apoplexy in which it is 
necessary to give a particular remedy, or we shall be sure to lose our patient; and 
that is apoplexy arising from the suppression of urine. I believe, in that species 
of the affection, evacuanls do little or no good; but that cantharides, employed both 
internally and externally, are the proper remedy. It is well to resort to them 
always; and to give a grain two or three times a day. I should not recommend 
the tincture; for 1 believe it is uncertain in its operation. I have given two or three 
drachms, two or three times a day, without any effect; and sometimes I have given 
the same quantity, and found great irritation. I do not think there is a more un- 
certain medicine in the Pharmacoposia, than tincture of cantharides; nor do I think 
there is a more certain one tlian the powder. One or two grains, given every 
night, or night and morning, will be almost sure to make the bladder perform its 
functions. The only experience I have had of cantliarides internally, has been in 
cases of gleet; but it has been unsatisfactory, on account of the people to whom it 
was administered being out-door patients; — so that I had no great control over 
them; and therefore I cannot speak as to its powers. I have no experience of it 
in apoplexy from ischuria. I applied it in one case; but the patient died in twelve 
hours; — so that there was no time for it to do him good. But a gentleman told 
me, that he had seen it successfully exhibited in two cases. In the first case, Sir 
Astley Cooper suggested its employment; and, although an unfavourable prognosis 
had been given, the patient recovered. The second case, shortly afterwards, fell 
under the same gentleman's care; and he adopted the same remedy with equal 
success. It does appear that, in this kind of apoplexy, stimulation of the urinary 
organs is the proper remedy. 

Increase of Apoplexy. — It is said, that apoplexy and palsy have very much 
increased of late years. Dr. William Heberden, the son of the author of the 
*' Commentaries," has written a very excellent paper, upon the increase and de- 
crease of different diseases; and he states, that the increase of apoplexy and palsy 
has, of late, been gradual and constant.** His paper was written about forty years 
ago." Whether people drink more porter and strong malt-liquors now than 
formerly, I do not know. 'JMie upper orders drink less wine; but the lower orders 
may drink more porter. . I do not know how it is to be explained; but there are 
double the cases now, in proportion to the population, that there were a hundred 
years ago. Sir Gilbert Blane mentions, that he had more apoplexy in the hospital, 
than in private practice; and the people who go there certainly drink more porter, 
than their superiors in society. I suppose porter or spirits, or both, have more 
tendency to produce the disease, than wine. If it were the wine which produced 
the disease, as that is now so much less drunk than formerly, the proportion of 
cases would not be what Dr. Heberden has slated. 

* "On the Increase and Decrease of different Diseases, particularly of the Plague." 
" In the year 1801. 



526 CEREBRAL AFFECTIONS FROM REMOTE CAUSES. 



CHAPTER IV. 

CEREBRAL AFFECTIONS FROM REMOTE CAUSES. 

Independently of inflammation and congestion, a highly important series of 
morbid phenomena may arise; presenting many points of resemblance to cerebral 
inflammation and apoplexy; and resulting from peculiar afl*ections of the general 
system, or of various organs. The causes of these aflfections may be reduced to 
the following heads: — 1. Intestinal irritation. 2. Exhaustion from loss of blood. 
3. Excessive study; shock; alcohol. 4. Chlorosis; dropsy; ischuria. 



SECTION I.— CEREBRAL SYMPTOMS FROM INTESTINAL 
IRRITATION. 

I^The first of these affections consists of irritation from indigestible food, scy- 
bala, or other morbid contents of the stomach, or bowels; excited into activity by 
some shock of the system, or of the nervous system; — such as a fall or other acci- 
dent, parturition, &;c. 

Symptoms. — -The symptoms are, rigor, frequently severe heat of surface, and 
violent pain of the head, with intolerance of light and sound; symptoms, in a word, 
of the most acute encephalitis. The breath is tainted, the tongue loaded and swollen, 
and the secretions are morbid; but it would still be difficult to establish a distinct 
and confident diagnosis without the criterion afforded by the eff'ect of blood-letting 
in the erect posture. 

Diagnosis and Treatment. — The first step to be taken, in a doubtful case, is 
very slowly to administer an enema, of from three to three and a half pints of warm 
water; and to examine the state of the fseces, and observe the eff'ect upon the dis- 
ease, and upon the system. If there be scybala, if the symptoms be subdued, and 
especially if there be faintishness, the case is, indubitably, not cerebral inflamma- 
tion, but intestinal irritation. If the case still remain doubtful, we must prepare 
the arm, open a vein, and then place the patient upright, and let the blood flow 
until the lips become pallid; if the case be encephalitis, an extreme quantity of 
blood will flow, — even thirty or forty ounces or more, — before there is any appear- 
ance of syncope; if it be intestinal irritation, syncope occurs before one fourdi of 
that quantity of blood has left the circulating system. The importance of this 
distinction is immense; for the injudicious use of the lancet has, in too many in- 
stances, led to the most serious and even fatal consequences. 

This aff'ection sometimes assumes a far less acute form. P recendy met with 
such a case, which had been mistaken for encephalitis. The patient slowly but 
perfectly recovered from attacks of vertigo, &c., by maintaining a regular state of 
the bowels, by diet, and rest; and afterwards by gende exercise, change of air, 
ifec."] 



SECTION II.— CEREBRAL SYMPTOMS FROM EXHAUSTION. 

Causes of Exhaustion. — [Exhaustion, in early infancy, has its origin (chiefly) 
in diarrhoea, or catharsis; in the later periods of infancy, in the loss of blood, with 
or without a relaxed or evacuated condition of the bowels. The state of diarrhcea 

» Dr. Marshall Hall. 

^ "Diseases and Derangement of the Nervous System; by Marshall Hall, M. D." 
Page 351. 



CEREBRAL AFFECTIONS FROM REMOTE CAUSES. 527 

has generally depended upon improper food, or intestinal irritation. It has very 
frequently succeeded to weaning, or to other changes in the diet, or to constipation. 
The catharsis* has followed the administration of an aperient medicine; which, at 
such a moment of disorder of the stomach and bowels, is likely to act excessively. 
The exhaustion from loss of blood generally follows the inappropriate or undue 
application of leeches, or the use of the lancet. 

In the adult, exhaustion chiefly arises from loss of blood; but it may have its 
origin in undue lactation, leucorrhoea, &c. If the more immediate effects of exhaus- 
tion be well known, the more remote have been overlooked, or mistaken for 
other morbid affections. Yet, to the physician, the symptoms of reaction from loss 
of blood, — so similar to those of some affections of the head, and of the heart, pre- 
sent subjects for his observation of the utmost moment in actual practice. The 
diagnosis of these cases is most important; for the prognosis and treatment alike 
depend upon it. 

The remote effects of exhaustion, are particularly apt — from their similarity to 
inflammatory diseases, and from the present though transient relief afforded by the 
further detraction of blood — to deceive the unwary. They consist in: — 1. Sick- 
ness and vomiting. 2. Excessive reaction; sometimes accompanied with delirium, 
mania, coma, amaurosis, or deafness. 3. The sinking state. Of these, the two 
last claim our special attention. 

Excessive Reaction. — Excessive reaction is formed gradually; and consists, at 
first, in forcible beating of the pulse, of the carotids, and of the heart; and eventu- 
ally, perhaps, of beating or throbbing in the scrobiculus cordis, and in the course 
of the aorta. This state of reaction is augmented, occasionally, by a turbulent 
dream, mental agitation, or bodily exertion. At other times, it is modified by a 
temporary faintness or syncope. There is also sometimes irregularity of the heart, 
and of the pulse. The respiration is apt to be frequent and hurried, and attended 
with alternate panting and sighing; the movement of expiration is sometimes obvi- 
ously and singularly blended with a movement communicated by the beat of the 
heart; the patient requires the smelling-bottle, the fan, and the fresh air. The skin 
is sometimes hot; and there are frequently general hurry and restlessness. In this 
stale of exhaustion, sudden dissolution has sometimes been the immediate conse- 
quence of muscular effort on the part of the patient, or of his being too suddenly 
raised from the recumbent into the erect position. 

Its Resemblance to Arachnitis. — In the more exquisite cases of excessive reac- 
tion, the symptoms are still more strongly marked, and demand a fuller description. 
Sometimes it resembles arachnitis. In those cases, the beating of the temples is at 
length accompanied by a throbbing pain of the head, and the energies and sensibi- 
lities of the brain are morbidly augmented. Sometimes there is intolerance of 
light; but still more frequently intolerance of noise, and of disturbance of any kind; 
requiring stillness to be enjoined, the knocker to be tied, and straw to be strewed 
along the pavement. The sleep is agitated and disturbed by fearful dreams; and 
the patient is liable to awake, or be awoke, in a state of great hurry of mind, some- 
times almost approaching to delirium. Sometimes there is slight delirium, and 
occasionally even continued delirium; more frequently there are great noises in 
the head; — as of singing, of crackers, of a storm, or of a cataract. In some in- 
stances there are flashes of light; sometimes there is a sense of great pressure or 
tightness in one part of the head, or round it; — as if the skull were pressed by an 
iron nail, or bound by an iron hoop. 

The Sinking Slate. — This is adopted, not to express a state of negative weak- 
ness merely, — which may continue long, and end in ultimate recovery, — but to 
denote a state of positive and progressive failure of the vital powers; attended by 
its peculiar effects, and by a set of phenomena very difTerent from those of exhaus- 
tion with reaction. 

If in reaction the energies of the system are augmented, in sinking the functions 

* From KaBai^ae, to purgc. 



52S CEREBRAL AFFECTIONS FROM REMOTE CAUSES. 

of the brain, as also of the kings and heart, are singularly affected. The patient is 
no longer affected by noises as before; there is, on the contrary, a tendency to 
dozing; and gradually some of those effects on the muscular system which denote 
diminished energy of the brain supervene; as snoring, stertor, blowing up of the 
cheeks in breathing, &;c. Instead of the hurry and alarm on awaking, observed in 
cases of excessive reaction, the patient, in the state of sinking, requires a moment 
to recollect himself, and recover his consciousness. He is perhaps affected with 
slight delirium, and is apt to forget the circumstances of his situation; and, inatten- 
tive to the objects around him, to fall again into a state of dozing.^] 

a. Spurious Hydrocephalus. 

History. — It is very necessary to know, that symptoms like those of acute hy- 
drocephalus, or many of them, may occur in a state of the system, where the loss 
of blood, or even purging and starvation, would be fatal. I believe we are indebted 
for our knowledge of this state, to Dr. Marshall Hail. It was imagined (and I 
myself fell" into the error) that Dr. Gooch was the first person who described it; 
but Dr. Marshall Hall wrote to me on the subject; and it appeared, on referring to 
his book, that the priority of discovery was due to him; and that Dr. Gooch was 
himself indebted to Dr. Hall for a knowledge of the fact. It is a condition of which 
I was not aware when I began to practise; but it is of the highest importance to 
be acquainted with it; because inappropriate treatment will, to a certainty, destroy 
life. 

Symptoms. — It now and then happens, that a child becomes exceedingly drowsy, 
has dilatation of the pupils, perhaps squints, and may likewise experience more or 
less delirium; — so as to appear to be labouring under hydrocephalus. But usually, 
in such a state, there is no pain of the head, or it is only transient; and the skin 
is cool, or absolutely cold. The pulse (as in hydrocephalus, and other inflamma- 
tory diseases) is quick; but it is weak; and the face is not flushed as it is in in- 
fl.ammatory diseases; but it is perhaps pale, or flushed only transiently. In this 
state, if we apply leeches, or if we purge, in all probability the patient will sink. 
This state will sometimes happen from the first. A child, perhaps after diarrhcea, 
— after something which has weakened him very much, falls into a state of torpor 
of the brain. It becomes very heavy, stupid, and half blind. The pupils are 
dilated, and there is perhaps even squinting; but I do not know that t!ie latter is 
common. This set of symptoms will come on, at the end of the inflammatory 
stage of hydrocephalus, and sometimes it is the result, as I just now remarked, of 
some previous disease. 

Diagnosis. — [The condition of the cheeks, with regard to colour and warmth, 
may be considered as the pulse of very young infants; — indicating the degree of 
remaining power, or of exhaustion. In the present case, especially, there is no 
symptom so important, — so distinctive. It is from the condition of the cheeks, in 
conjunction with a due consideration of the history^ that the diagnosis of this mor- 
bid state, and the indication of the appropriate remedies, are chiefly to be deduced. 
The general surface, and especially the hands and feet, also afford important sources 
of information, as to the condition of the nervous or vital powers. Next to these, 
the degree of frequency of the pulse, and the character of the breathing, are points 
of the greatest importance. During the stage of irritability, the breathing is quick; 
during that of torpor, it is slower, irregular, suspirious, and (finally) crepitous. 
The pulse changes in its beat;— from being full, becoming smaller; but retaining, 
perhaps, its former frequency. We should be especially on our guard, not to mis- 
take the stupor, or coma, into which the state of irritability is apt to subside, for 
natural sleep, and for an indication of returning health. The pallor and coldness 
of the cheeks, the half-closed eyelid, and the irregular breathing will sufficiently 
distinguish the two cases.''] 

« " Principles of Medicine; by Marshall Hall, M. D." Part 1; Chapter 7. 
*> " Diseases of the Nervous Systemj by Marshall Hall, M. D." 1841. Paragraphs 742 
and 743. 



CEREBRAL AFFECTIONS FROM REMOTE CAUSES. 529 

Morbid Appearances. — When children have died in this state, frequently nothing 
morhid has been found in tlie head; or the vessels of the brain have merely been 
found unusually serous. There may be a little effusion; but, in many instances, 
the vessels have been less distended with blood than usual. 

Treatment. — When a child is in this condition, it is best to give it beef-tea and 
ammonia every three or four hours. The rapidity with which improvement takes 
place, is very great. 

In most inflammatory diseases, a stage may come on, in which perseverance in 
the antiphlogistic plan is highly improper. A state of irritation comes on, in the 
stead of inflammation; and the treatment appropriate to the one, is most inappro- 
priate to the other. I was recently sent for to a person who had evidently laboured 
under phrenitis. He had been bled, purged, and so on; but ihe time had arrived 
for discontinuing antiphlogistic treatment, and adopting the opposite plan. His 
pulse was 120, and feeble; there was no flushing of the face, and no redness of 
the eyes; but there was delirium and feebleness of pulse; — indicating that no more 
evacuations were necessary. So far from that, we agreed to give him a full dose of 
opium. He took four grains, which would have been highly injurious in the inflam- 
matory stage; but it immediately put an end to all the symptoms. He had a quiet 
sleep; and awoke without delirium, and with a strong pulse. Now it is just the 
same in children. After hydrocephalus has lasted some time, we may judge by 
the pulse and paleness of the patient, that evacuations will increase instead of 
Oiminishing the mischief;* and it is right to be aware, that just such a state will 
come on without inflammation. There may be a stale of irritation and debility, 
without inflammation having been present; — as we shall see in the disease called 
" delirium tremens." 

h. Mpoplexia Exsanguinea. 

I stated'' that children were occasionally siibject to hydrocephalus from mere ex- 
haustion; that their pupils became dilated; that they would fall into a state of 
coma, and perhaps be convulsed; and that if we bled them, we should destroy life; 
whereas, if we gave ammonia and beef-tea, and supported them well, they generally 
recovered. In like manner adults will sometimes fall into a state of apoplexy from 
downright exhaustion; and this is called "apoplexia exsanguinea.''^ Dr. Aber- 
crombie says, that he has seen adults comatose and collapsed; the pulse not full; 
the lips not purple; and the face not turgid. 

Symptoms. — It will be recollected that, in apoplexy, the fiice is turgid, and 
more or less livid;'' but, in this form of the disease, the face is collapsed and pale; 
and, notwithstanding the pulse may be full, Dr. Abercrombie states that, in this 
condition, the diagnosis is to be drawn from the paleness of the face. He says, 
that he has seen it arise from neglected diarrhoea. Starvation might probably 
sometimes have the same eff'ect. He says that he has seen the state, in an old 
lady, amount to a loss of memory and squinting; and he mentions one case, in 
which a person was regularly deaf (paralyzed in one of the senses) when in the 
erect posture; — when less blood goes to the brain, and more freely escapes frou) it; 
whereas, as soon as the patient lay down, the deafness ceased, and the face became 
flushed. 

Treatment. — It is very necessary, in looking at a case of apoplexy, to ascertain 
whether it is of the kind we see in nineteen cases out of twenty; or whether it 
arises from a state of exhaustion of the brain. If it be a case of the latter descrip- 

* Of the whole number of fatal cases of diseases in infancy, a great proportion occur 
from this inappropriate or undue appUcation of exhausting remedies. This observatioa 
may have a salutary effect in checking the ardour of many young practitioners; who are 
apt to think, that if they have only bled, and purged, and given calomel enough, thev have 
done their duty; when, in fact, in subduing a former, they have excited a new disease; 
which they have not understood, and which has led to the fatal \esM\\..—'^ Dbcascs of tke 
Nervous System; by Marshall Hall, M.D." 1841. Paragraph, 736. 

»> See Pcige 528. « See Page 512. 

VOL. I. — 34 



530 CEREBRAL AFFECTIONS FROM REMOTE CAUSES. 

tion, — if the face be pale and collapsed, we have reason to believe that the patient 
has had causes of debility applied; and then, certainly, it v\'ouId be necessary to 
give ammonia. Ammonia is preferable to wine; because wine might perhaps 
induce too great a stimulation of the brain, which would last afterwards; whereas 
the stimulus of ammonia is very evanescent. There will of course occur cases, in 
■which we shall be unable to make up our minds as to what ought to be done. 
The same circumstance occurs in the treatment of inflammation. I have already 
stated* that, at last, we are unable to make up our minds, how far there is irrita- 
tion, and how far hiflammation. In such cases it is best to mix the treatment. 
We should evacuate as much as we can; apply blisters rather than leeches, leeches 
rather than cupping, and cupping rather than bleeding at the arm; and, at the same 
time, allow a moderate diet and ammonia. The operation of the latter very soon 
ceases; and, if we see that it does harm, the effect is over, and there is no serious 
mischief. This is the advantage of combining both plans. 



SECTION III.— EFFECTS OF A SHOCK, MENTAL OR PHYSICAL. 

Mental Shoch. — [The effect of a mental shock is, frequently, a state bordering 
on delirium, or mania. Suicide is a frequent event at such a moment. There are 
a sense of weight or pain about the head, and sleeplessness. There is great danger 
of mistaking the symptoms for mere mental affliction. We ought to treat it as a 
serious malady. The timely use of the lancet, would have prevented many an act 
of suicide. 

A. B., aged forty, became ruined in character and fortune; and, when in the 
midst of his difficulties, experienced a sense of heaviness and pressure in the head, 
and passed sleepless nights. After several days he attempted suicide, by dividing 
the muscles and blood-vessels of the arm deeply. He lost a large quantity of 
blood, and became faint. On recovering from this state, he said to his medical 
friend — " Had you bled me a few days ago, I should not have done this act; had 
Sir Samuel Romilly been timely bled, he would still have been alive!" From this 
time ?ll the symptoms subsided. 

1" twice visited, at the distance of ten miles from town. Miss . She was 

of a chlorotic pallor; and had experienced a AearZ-rending disappointment. She 
was in bed; affected with a rather frequent pulse, slight delirium, alternating with 
equally slight coma, or dozing, a mucous rattle in the respiration, a tympanitic 
state of the abdomen, with the discharge of offensive faeces. In spite of every 
remedy, she gradually sunk, and expired. This case appears to have been the 
effect of a mental shock. At least, no other causes of those effects could be dis- 
covered. 

Traumatic Delirium, — To the same class of affections, doubtless, belongs the 
nervous delirium, or "delirium traumaticum," described by Dupuytren, as follow- 
ing serious accidents and operations. It is characterized by sleeplessness, delirium, 
and jactitation; the eyes are injected; the countenance is flushed and animated; 
the forehead covered with profuse perspiration; the patient is insensible to the pain 
of his accident or operation; there is no fever or constipation. The patient may 
fall asleep, avi'-ake composed and rational, relapse, &c. It is a short mania of five 
or six days' duration; and attended by ^reat danger. There are no distinct traces 
of morbid change, on examination. The brain and spinal marrow are found ap- 
parently healthy. The remedy proposed by Dupuytren is a small enema, with 
five or six drops of Tinctura Opii, repeated three or four times, at intervals of six 
hours. 

This affection is frequent after attempts at suicide. The shock of an operation, 
not in itself extremely formidable, has proved fatal. But what is more remarkable 

» See Page 131. b Dr. Marshall Hall. 



CEREBRAL AFFECTIONS FROM REMOTE CAUSES. 531 

I 

is, that this event has frequently been foretold in the most positive terms by the 
patient. These facts cannot be uninteresting to the physiologist and pathologist.^] 

SECTION IV.— DELIRIUM TREMENS. 

I now proceed to speak of a disease which resembles, in many of its symptoms, 
inflammation of the brain; and yet, in a great number of cases, it would prove 
fatal, if treated on the common principles applicable to phrenitis. The disease to 
which I allude, is called " delirium tremens;" which is rather an improper term, 
because the delirium cannot tremble. It would be better to say " delirium cww2 
tremore;^^ but it has derived its name from the patient's being in a state of agita- 
tion, and being delirious. I speak of it now, because it may be readily contrasted 
with the delirium of phrenitis,^ arachnitis,"' and hydrocephalus acutus;'' of which I 
have already spoken. 

Causes. — This state of delirium with universal tremor, is rather the effect of 
morbid irritability than of inflammation. It is such a state as occurs in fever, when 
delirium exists. It is very much the same condition, as that which recurs after 
great loss of blood; in which there is headache, vertigo, and disturbance of the 
mind. It is just such a state, as frequently takes place after active inflammation 
of the brain. When the last stage of phrenitis has arrived, the patient will fall 
into a state of irritation of the brain, which resembles delirium tremens. 

It is a disease which occurs in adults, and not in young subjects; except in 
affections which I have already mentioned as analogous to this.® It generally 
occurs, too, in adults who have been addicted to dram-drinking; — not always, but 
generally. It is said to have appeared sometimes after acute rheumatism, some- 
times after scarlet fever, sometimes after typhus fever, sometimes after injuries of 
the head, and immediately after apoplectic and paralytic fits, and sometimes after 
long continued exposure to lead; but the most frequent circumstance producing the 
disease, is a continued habit of dram-drinking. 

Symptoms. — As the disease is, for the most part, one not of inflammation but 
of irritation, the face is not flushed, but pale. When I described that state in 
infants which is frequently mistaken for arachnitis, and in which stimulants are 
proper, I mentioned that the face is not flushed, but pale; or that if it be flushed, 
it is only transiently.^ Now in this disease the circumstances are quite analogous. 
The eyes are not red, and there is no intolerance of light or noise; — -at least nothing 
worthy of being mentioned, compared with what is seen in phrenitis; and fre- 
quently there is none whatever. The tongue is generally neither dry, brown, 
rough, nor white, — as it is in inflammation; but is usually moist, and covered all 
over with a v/hite, soft, creamy mucus. Generally there is no great heat of body; 
and the skin is not dry, as in most inflammations; but is covered by a profuse 
sticky, clammy perspiration; and sometimes this is of an offensive character. If 
the perspiration be clammy, of course it is a morbid secretion. It is secreted in a 
morbid state, or it would not be clammy; and if it be secreted morbid as to con- 
sistency, it may be secreted morbid as to smell; — so that the perspiration is not 
only clammy, but offensive. This is a very common occurrence. The pulse is 
quick; — a circumstance which may be expected under simple irritation, as well 
as under inflammation; and at last it becomes very rapid; but it is neither full 
nor hard. 

Approach of Delirium. — At length, as in other diseases, the pulse will become 
fluttering; — what is called, by some writers, " pulsus vermicularis;'^ — like the 
undulation of a worm. There is constant watchfulness in the disease; — the patient 
can get no sleep; and there is constant delirious talking. He is constantly en- 
deavouring to get out of bed, and out of the room; but we may easily induce him 

a " Diseases of the Nervous System; by Marshall Hall, M. D." 1841. Passes 357 to 359. 
" See Page 482. « See Page 483. * See Page 502. «^ See Page 529. 

i See Page 528. 



532 CEREBRAL AFFECTIONS FROM REMOTE CAUSES. 

to lie clown in bed, or lead him back to it, if he have escaped. There are no vio- 
lent efforts ill the disease; — no such efforts as are seen in " delirium ferox;^'' but 
he is everlastingly chattering, and everlastingly resdess; so that he will go on talk- 
ing, and trying to get out of bed. He will sit up too in bed; — constantly moving 
his hands and arms backwards and forwards, but not violently; and then, in the 
midst of all this, he tries to leave his bed. The delirium generally respects ima- 
gined wrongs; and an imagined unfortunate state of private affairs. He fancies 
that his affairs are in a dilapidated state; and that different persons are endeavour- 
ing to injure him. There is this extraordinary extravagance al)OUt imagined 
wrongs, and deranged affairs, rather than any preposterous hallucination. There 
is, of course, great anxiety occasioned by the patient dwelling on these topics. 
The attention of the patient may be excited to any subject, for a moment; but, a 
moment afterwards, he has forgotten what the subject was. His ideas roll off 
again to some other matter; and he forgets what he had been talking about. There 
is no spite, — no malice in this disease; the patient does not attempt to injure those 
around him. The whole body is in a state of tremor; and the tongue among other 
parts. There is great debility, with loss of appetite. There is likewise a catching 
of the tendons (called "subsultus lendinum"); and a picking of the bed-clothes, 
It is common, in cerebral affections attended with delirium,* for a person to be 
catching at something which he imagines to be before him; and now and then there 
is hiccup. 

Premonitory Symptoms. — The attack is sometimes very slow, and sometimes 
very sudden. If it come on slowly, there is at first anorexia, loss of appetite, and 
want of sleep at night; besides which, the patient is restless during the whole of 
the day; — fidgety, and plaguing people about him with his own matters. The eye, 
at the same time, is observed to be dull. 

Stages of the Disease. — [Most writers on this subject, have adopted Dr. Blake's 
division of the disease into three stages; — as being best calculated to obviate the 
obscurity and confusion in which its history was formerly involved, and to direct 
us to our mode of treatment. The first stage is characterized by general debility, 
anxiety of countenance, depression of spirits, a slow pulse (frequently as low as 
forty-four in a minute), interrupted slumbers, cramp in the extremities, vertigo, 
nausea, and occasional vomiting. By timely and judicious treatment, its further 
progress may be arrested; and, by subsequent prudence on the part of the patient, 
its recurrence may be prevented. Generally, however, after a shorter or longer 
period, — according to the constitution, age, and previous habits of the patient, — it 
is succeeded by the second stage, or that of delirium: the symptoms of which 
have been already described.'' Either these symptoms increase in violence; and 
others (which very nearly resemble those of the last stage of typhus) supervening, 
the patient dies suddeidy in a convulsion; or the long-continued delirium — with 
subsultus tendinum, picking of the bed-clothes, (fee. — is succeeded by a short in- 
terval of quietude, and he expires without a struggle; or, after two or three days, 
or (it may be) a week, yawning and drowsiness come on, and are followed by 
sleep; which is generally profound and of long duration; — lasting from six to twelve 
or eighteen hours. Tlie patient wakes collected, and gready refreshed; and his 
recovery may be looked upon as almost certain."] 

Diagnosis. — The diagnosis of the disease, therefore, appears to be made out 
from the weakness of the pulse; the want of violence in the patient; the want of 
a flushing in the face, and redness of the eyes; the want of furious delirium; the 
want of sleep; the circumstance of the patient being in a state of tremor of the 
whole body, with a tongue not dry, but covered with a creamy mucus; with a 
skin not dry, but sw/3ating profusely; the circumstance of the patient talking inces- 
sandy about his own affairs, — about some imagined distress; his attempting to get 

* From "deHro," to rave. >> See Page 531. 

e " Cyclopaedia of Practical Medicine;" Volunrie 1; Page 511, 



CEREBRAL AFFECTIONS FROM REMOTE CAUSES. 533 

out of bed; and his being everlastingly restless, but easily managed and laid down, 
or brought back to bed. 

Prognosis.— [Some difficulty will he experienced in forming a just prognosis 
in this disease; — it being so very insidious in ils effects. In giving it we must, of 
course, be guided by the constitution and habits of the patient; as well as by the 
violence of the symptoms with which he is affected. In a worn-out and diseased 
habit, much addicted to the abuse of spirituous liquors or diffusible stimuli of any 
sort, and one that has, perhaps, suffered frequent attacks of this disease, more is 
to be feared; as, in such cases, the indirect debility (or exhaustion) may be such, 
as to require an effort too great for the worn-out nervous system to support, in its 
endeavours to restore order. On the contrary, in a young and healthy subject, this 
disease is seldom fatal when properly treated; but, in either case, we should be 
considerably assisted in forming our opinion, by attention to the favourable or un- 
favourable sytiiptoms already detailed.* 

The stale of ihe pulse, though not always an infallible guide in disease, has been 
to me a comparatively sure one in this complaint; as, when its frequency did not 
exceed one hundred strokes in a minute, I looked on the patient (generally speak- 
ing) as safe; but, on the contrary, when (from its rapidity and the tremor of the 
hands) it could scarcely be counted, I considered him in imminent danger.^] 

Treatment: Opium. — The remedy for the disease is opium, in full and repeated 
doses. One or two grains will not be sufficient. It is necessary to give from three 
to five grains; and to repeat these doses according to circumstances. In some 
cases, it is necessary to give five grains every six or eight hours; and this plan 
must be continued till sleep is procured. Three grains would be a proper dose to 
begin with; and, while the patient continues well, it need only be given in small 
doses; but full doses must be resumed when the symptoms return. Dr. Sutton" 
says, he learned the practice in Kent; where there is a great deal of the affection; — 
on account of the people being so addicted to dram-drinking. Smuggling is car- 
ried on to a great extent, on the east coast of Kent; and the people therefore drink 
to great excess; and delirium tremens consequently prevails extensively. He 
found eminent practitioners adopting two different modes of treatment;- — the one 
antiphlogistic, and the other narcotic; and he soon saw the superiority of the latter. 

I was sent for to a case, which had been phrenitis, and properly treated as such; 
but it afterwards became delirium tremens. The patient's pulse was rapid and 
soft; his tongue not dry and his body not hot; but there were delirium and tremor. 
Four grains of opium were sufficient to send him to sleep; and he awoke almost 
well. 

This treatment with opium, which requires to be backed by good nourishment, 
is the same that should be adopted after profuse haemorrhnge, and after the spurious 
form of hydrocephalus, if I may use the expression; — that state of the system, 
which resembles hydrocephalus in appearance only.*^ It is also the treatment we 
should adopt in delirium mitius; and wherever there is great irritation of the brain 
with debility. 

Recovery from this disease, under the opiate treatment, is very frequent; where- 
as, under any other, patients continually die. However, the affection will cease 
spontaneously, like almost any other complaint. It lasts, in general, from three 
days to a week; and patients may tlien sink gradually, or pretty suddenly; or, at 
the end of that time, they may recover; but it is very rare. Now and then, it has 
been known to be followed by apoplexy or mania. I recollect seeing a case of this 
description, which terminated in complete mania. If the disease yield under the 

a See Paa:es53l and 532. 

b " A Practical Treatise on Delirium Tremens; by Andrew Blake, M. D." Pages 40 to 
42. (First Edition.) 

c " Tracts on Delirium Tremens, Peritonitis, and some other Internal Inflammatory 
Affections; and on Gout; by Thomas Smton, M. D." This work is short and excellent; 
and it will be worth the while of every gentleman to read it. 

d See Page 528. 



534 CEREBRAL AFFECTIONS FROM REMOTE CAUSES. 

nse of oplnm, the opinm may be continued twice a day, for some little time, and 
then relinquished slowly; just as the symptoms of the disease decline. 

Ptyalism, Stimulants, i^'C. — Some writers have recommended a gentle ptyalism 
to be produced; and some, notwithstandino- the profuse sweat, have advised cold 
affusion. I have no experience of either of these modes. Good food undoubtedly 
is necessary; and sometimes it is found requisite to indulge the patient with drams. 
In all cases where patients have acquired bad habits, they must be indulged, when- 
ever a great demand is made upon the system, — as after an operation or an acci- 
dent. The system has become accustomed to drams; and without them it cannot 
conduct its affairs; and we must allow them, or any thing else that has become a 
bad habit. However, good food is generally necessary; — beef-tea and milk. Slops 
the patient cannot take. 

Complicated ivith Inflammation. — Notwithstanding, however, that this is the 
frequent and most common character of the disease, the disease is not always of 
this nature. We may have patients with this mild state of delirium, easily led 
back to bed, easily put down in bed, and trembling from head to foot; with the tongue 
in a state of tremor too; and yet inflammation may be present; requiring to be 
treated as we would treat phrenitis. In such a case as this, we find sufficient 
signs to point out that it is a disease, not of irritation merely, but of inflammation 
in some degree. The patient will be more or less flushed; his pulse more or 
less full and firm; and the delirium will be rather violent. I have seen cases de- 
serving to be called "delirium tremens," in which the patient was trembling, talk- 
ing about his own affairs, believing that he was an injured person, easily led back 
to bed, with a moist skin and a moist tongue; and yet this disease was not benefited 
by opium, and was not cured till bleeding and starvation were had recourse to. It 
is therefore necessary to remember, that we are not to prescribe for a name, but 
for the condition of the patient. There may be a pulse that will justify us, if not 
in bleeding, in purging; — at any rate, in abstaining from opium. Antiphlogistic* 
treatment is sometimes required in this disease; but usually it is only required in 
moderation; and there may be cases where it is perfectly right to employ moderate 
antiphlogistic treatment, and to give opium also. We may administer opium; but 
it will be fruitless, unless we adopt some antiphlogistic measures. We must keep 
the head cool; and ice will effect this purpose best. Leeches may also be applied. 
It is said by Dr. Latham, whose experience must be greater than mine (for I only 
see cases now and then), that blisters are always bad in this disease; and he says, 
that, in decided cases of the affection, — although it may have come on after apo- 
plexy, — opium is equally useful; — provided it is a proper case for opium. The 
circumstance of the affection coming on after apoplexy, does not prevent opium 
from being equally proper; — that is, if the delirium do not arise from inflammation, 
but from mere irritation. After inflammation of any organ whatever, when we 
have put antiphlogistic treatment in force, opium is proper. I mentioned,'' in speak- 
ing of inflammation, that when we have reduced the powers of the patient, and 
mastered the disease, opium answers a good purpose; because a state of irritation 
is likely to come on; but if we gave it before, it would be likely to do harm. This 
disease has nothing peculiar in it; it is merely an instance of a general state of irri- 
tation. Opium is found useful in irritation of almost all the various organs of the 
body; provided that no inflammation exists; or that any which does exist be re- 
moved by proper treatment, before administering the opium. 

Morbid Jippearances. — It is said that after death, a little congestion may be 
found in the head; and sometimes a slight effusion. 

['j'he utility of opium in delirium tremens can scarcely be questioned, but that 
the treatment of the disease by means of this drug is the only method which com- 
mands great success, is far from being in accordance with the experience of many 
practitioners in the United States. Indeed, the plan formerly adopted by some, 
of persevering in the administration of large and repeated doses of opium until 

a From avTi, against; and <j>Xsy4j, to burn, ^ See Page 129. 



CEREBRAL AFFECTIONS FROM REMOTE CAUSES. 535 

sleep is procured, is now very much abandoned. Some, indeed, place their raaia 
reUance on entirely different measures. Thus, Dr. Klapp, of this city, depends in 
great measure upon the use of emetics, whilst Dr. Gerhard has met with the most 
remarkable success from the employment of graduated doses of alcoholic stimulants. 
The results of the latter method, in the men's wards at the J'hiladelphia Alms- 
house, under the charge of Dr. Gerhard, have been such as scarcely to leave room 
for doubt that the disease may very generally be brought to a favourable issue in 
this way. This plan of treatment is objected to, however, on the ground that the 
patient is confirmed in his habits, and more liable to relapse. However forcible 
such an argument in reference to mild cases, it should have no weight in view of 
those severe forms of the disease in which life is in danger. If alcoholic stimulants 
afford the best chance of preventing a fatal result, they must be resorted to without 
reference to ulterior considerations. 

A mixed opiate and stimulant treatment is the one most commonly, perhaps, 
resorted to. Thus, the patient may be put upon the use of carb. of ammonia with 
assafoelida, valerian, or some other antispasmodic, or of alcoholic stimulants, and 
an opiate be administered in the evening, if necessary. At the same time, mustard 
foot-baths, enemata, blisters, cold to the head, (fee, may be advantageously rr- 
sorted to, especially where the bowels are confined, and the head hot, with other 
evidences of vascular excitement. Such is the plan generally resorted to by me 
in the Pennsylvania Hospital; and I think it decidedly preferable to the practice 
formerly adopted, of administering large doses of opium at regular intervals 
throughout every period of the twenty-four hours, until sleep is procured. — T. S.] 



SECTION v.— CEREBRAL SYMPTOMS FROM CHLOROSIS, DROPSY, 

AxND ISCHURIA. 

[Besides those remote causes already mentioned, symptoms of encephalic dis- 
turbance may arise from the presence of various other diseases. 

Chlorosis. — The influence of that ansemial state, which occurs in chlorosis, upon 
the encephalon, well deserves our attention. Dr. M. Hall mentions a case which 
was characterized by the presence of " mild delirium, succeeded by slight coma, 
which was intermittent in its character; the respiration became momentarily sus- 
pended, and the inspiration sudden and sometimes catching; the abdomen tympa- 
nitic, with the escape of much flatus; the pulse 130 or 140, full and throbbing. On 
examination, there was an effusion of opaque lymph under the arachnoid, at the 
summit and base of the brain; together with an efl'usion of serum into each ven- 
tricle. 

*' This case is important in every point of view. It is important with regard to 
the nature of the disease of which it is an example; — demons;raiing, as it does, the 
tendency of that disease to induce, not merely external dropsy, but effusion under 
the arachnoid, into the pleura, and into the pulmonary cellular membrane, &c. It 
is important, too, as an unequivocal representation of the disposition to such orga- 
nic changes, in cases of bloodlessness and exhaustion. It is also important as esta- 
blishing the fact, that not only serous effusion, but the deposition of coagulable 
lymph, may take place, without inflammatory action, in similar circumstances; and 
that consequenUy, such deposit of lymph is no proof of inflammation. 

Dropsy. — "In the midst of dropsy, the patient is not unfrequently attacked with 
symptoms denoting a cerebral or true spinal affection. There are delirium, or coma, 
or convulsions; apoplexy, haemorrhage, hemiplegia; or meningitis. 

''P have particularly noted such an affection in children, in exanthematous 
dropsy. Dr. Wells mentions this affection. •• Dr. Bright gives such a case;" where, 
on examination, 'a slight serous effusion under the arachnoid' was founil. 

» Dr. Marshall Hall. 

b " Transactions of a Society for Promoting Medical and Surgical Knowledge," Volume 
3; Page 177. 

•=" Medical Reports;" Volume 1; Page 97. 



536 TUMOURS IN THE BRAIN. 

Ischuria. — " The next disease to which P must refer, as intimately connertetl 
with the brain, is ischuria, or suppression of urine; to which may be added other 
morbid conditions of this secretion, besides that marked by the presence of albu- 
men. Dr. Prout, Dr. Abercrombie, and Dr. Wilson, have lately treated this 
subject. 

" There is frequently considerable disease of the kidneys. The suppression may 
be partial, or complete; it leads to fever, thirst, a urinous smell of the perspiration 
and taste in the mouth, vomiting, hiccup, delirium, coma, convulsions.""] 



CHAPTER Y. 

TUMOURS IN THE BRAIN. 

I mentioned"" that pus, when formed, might be found either in a cyst or diffused; 
that sometimes the surrounding part is in a slate of irritation, and sometimes per- 
fectly healthy; and that sometimes, by the presence of pus, the surrounding parts 
become diseased. 

Scrofulous Tubercles, — But, besides this, we frequently have tumours of a 
scrofulous nature, in the brain and nerves. These occur most frequently in infancy; 
but they are not so often found in very young infants, as in those a little older. 
They are so much more frequent in infants than adults, that even in phthisical adults 
we seldom see them. They are most usually observed in the hemispheres of the 
bnin; and they are found more frequently in the cervical, than in other portions 
of tfie spinal marrow. I recollect a case of paralysis of the lower extremities, in 
which a scrofulous tumour was found in the cervical region of the spinal marrow. 
It is a constant observation, that scrofulous tumours of this kind, are found more 
frequently in that situation, than in any other. They frequently appear to have 
originated, both in the head and spinal marrow, in the '* pia mater;" which corre- 
sponds with the cellular membrane in other parts of the body. They are not 
numerous in the nervous system; for it is common to find but one. Like the 
tubercles of other parts, they are of all sizes; and they agree with them in another 
respect; — they are sometimes inclosed in a cyst, and sometimes they have none. 
I have seen many preparations, exhibiting a large mass of scrofulous deposit in 
the cerebellum. There was in Bethlehem Hospital an idiot, who laboured under 
St. Vitus's dance. He was also addicted to the vice of masturbation; and in his 
brain there was this appearance; — a scrofulous deposition in the cerebellum. 

The symptoms of a scrofulous tumour will be inflammation, paralysis,*^ and con- 
vulsions.* The nature of the substance deposited can make no difference. If it 
produce irritation, we may have convulsions of various kinds; — epilepsy, St. Vitus's 
dance, and so on; — any convulsions, or spasmodic diseases; and any sort of para- 
lytic affection; together with pain in the head, delirium, and symptoms indicating 
inflammation. 

Scirrhous and Osseous Tumours. — We sometimes find scirrhous tumours in 
the head; and they are sometimes enormously large; — so as to occupy the greater 
part of the hemisphere. They have also been seen to occupy the entire cerebel- 
lum. Sometimes, in the membranes, ihey are of an exceedingly hard character; — 
having undergone a cartilaginous, or fibro-cartilaginous change. Sometimes this 

« Dr. Marshall Hall. 

•» " Diseases of the Nervous System; by Marshall HalJ, M. D." 1841. Pages 355 
and 356. 
c See Pages 488 and 489. ^From " convello," to pull together. 

•^ From 7raj«x««, to weaken. 



TUMOURS IN THE BRAIN. 537 

transformation proceeds even to the formation of bone; — so that bony tumours are 
found within the head, within the brain, and upon the membranes; and there are 
lii^ewise bony tumours in the cerebelhim. We know that it is common to find 
plates of bone along the longitudinal sinus; and sometimes a spicula of bone (an 
exostosis) has been seen. The symptoms of all these tumours are the same. 

Encephaloid Tumours. — Occasionally we have encephcdoid tumours in the 
brain; — a depositton of new matter, which is not seen in the healthy body; and 
which, being like brain though different in its nature, has been called " encepha- 
loid."* Very frequendy, heemorrhage takes place from it; — so that it becomes a 
bloody tumour; and used to be called *' fungus Iisematodes.''^ This most fre- 
quently occurs in young subjects. It was supposed to be the cancer of young sub- 
jects. It is called by Dr. Hooper "haematoma.'"' When cut into, it (like the 
brain) is soft and white; and in some parts it is red. 

Melanosis. — Sometimes we may have that black deposit in the brain, which is 
called *' melanosis. "° This is not a malignant disease; — doing no harm except, 
mechanically, by its bulk; but it frequently coexists with scirrhus, and with en- 
cephaloid disease. 

Scirrhous tumours (that is to say, fibrous formations, transformations, and ossi- 
fications) are found much more frequently in the membranes, than in the brain 
itself; but encephaloid, melanotic, and scrofulous deposits, are found most fre- 
quently in the brain. 

Encysted Tumours. — Encysted tumours, of all kinds, are found in the head, 
and spinal canal. Sometimes these common encysted tumours, or serous cysts 
(called "hydatids" in common medical language, though they are not so), are 
found in the " plexus choroides;" and they are just the same on either side. 
Small cysts are frequendy seen in the membranes, as well as in the " plexus 
choroides;" and sometimes they are found in the substance of the brain itself. 
Dr. Hooper has given some very admirable representations of these cysts. 

Hydatids. — Besides these encysted tumours, real hydatids are occasionally found 
in the substance of the brain, as well as in the spinal marrow; and on the exterior 
of these parasitical animals we occasionally find an appendage, approaching to a 
tail. These animals are also frequently found in the brute creation. Tiie contents 
of the serous cysts (not hydatids) are very various. Like the contents of serous 
cysts in other parts of the body, they are sometimes clear liquid, sometimes soft 
pultaceous substance, and sometimes blood. 

Obscurity of the Symptoms during Life. — No one can tell beforehand, the 
existence of any of these things. Some of the diseases are present, of which I 
formerly spoke; — such as delirium,** convulsions,^ paralysis,^ or pains in the head;= 
sensations of coldness and of heal; — all sorts of uneasy sensations; and we suspect, 
from the continuance of these symptoms, that there must be organic disease. 
When we find paralysis, we suppose that organic disease is coming on; but it is 
almost impossible to say what it is. If we see organic disease in another part of 
the body, ("fungus hasmatodes in the extremities," for instance,) and the patient 
then becomes paralytic, and has convulsions, — we may suppose that the same dis- 
ease which has taken place externally, is coming on in the head; but the symptoms 
will only enable us to say, that we presume there is organic disease. 

All these things (scirrhus, encephaloid matter, melanosis, and scrofulous forma- 
tions) which occur in the head and in the spinal canal, are also frequently found in 
the distant nerves; where they cause only partial palsy. 

» From eyxg<f)aXov, the brain; and n^oj, likeness. 

^ From aifAo. — aifxa.ro;, blood. « From jueXa?, block. 

1 See Page 478. e gee Page 514. ^ See Page 515. e See Page 484. 



538 AFFECTIONS OF THE INTELLECT. 



CHAPTER VI. 

AFFECTIONS OF THE INTELLECT. 

Mental Functions depend on the Size of the Brain. — Having spoken of the 
diseases occurring in the brain, I now proceed to speak of those original aberrations 
of formation which are occasionally discovered. It is well known, that the nervous 
system is more complicated in the series of animals, as we rise from those which 
display the least mental functions, till we arrive at man, who displays the very- 
highest intellectual faculties. The lower the animal is, the smaller is the brain; 
and in the very lowest we have nothing that corresponds to brain; but where there 
is mind, there must be something to direct the functions; — to experience sensation, 
there must be an organ. Accordingly, it is universally allowed, that the nervous 
system receives additions, in proportion as we ascend in the scale of being. 

In the ninety-fourth number of the " Edinburgh Review,"^ which at first was dis- 
posed to laugh at this as nonsense, we find the following remarks: — " As we ascend 
the scale, we are enabled to associate every faculty which gives superiority, with 
some addition to the nervous mass; even from the smallest indications of sensation 
and will, up to the highest degree of sensibility, judgment, and expression. — We 
discern a line of ganglions; then a spinal marrow; a cerebellum is then added; and, 
lastly, a brain. The latter is observed to be improved in structure, and (with re- 
ference to the spinal marrow and nerves) augmented in volume, more and more, 
until we reach the human brain; — each addition being marked by some addition or 
amplification of the powers of the animal; until, in man, we behold it possessing 
some parts of which animals are destitute, and wanting none which theirs possess." 
It may therefore be supposed, that if certain parts of the brain be deficient, the mind 
will, in a correspondent manner, be defective; and this, accordingly, is the case. 
I will first enumerate, as morbid anatomists do, the deficiencies which are found 
in the brain; — not referring at all to phrenology; but taking up the subject as it is 
treated by morbid anatomists. 



SECTION I.— MALFORMATIONS OF THE BRAIN. 

Deficiency of the Convolutions. — In the first place it is found, in the higher 
beings who have a deficiency of the cerebral mass in any respect, that the convo- 
lutions are too small, or that there are too few of them on one or both sides. It is 
well known, of course, that the convolutions give a great extent of surface to the 
brain; — ^just as the " valvulse conniventes" of the intestines, give an increase of 
surface to the interior of that canal; so that if there be fewer convolutions than 
usual, there must be so much less external part of the brain. Thus we find occa- 
sionally, in human beings, that there are too few convolutions on one or both sides; 
or we find them too small. Occasionally, one or two convolutions, usually found, 
have been entirely absent. 

Deficiency of the Hemispheres. — Secondly, all the upper parts of the hemi- 
spheres, down to the vault of the ventricles, have been found to be absent; so that 
the ventricles lie entirely open, or are only covered by a serous membrane;— that 
is to say, in all probability, by the arachnoid coat which lines them. Sometimes 
one lobe of the brain has been absolutely wanting; and sometimes one has been 
only too small. 

Deficiency of the Thalahii, and Corpora Striata. — Thirdly, the " thalami 

» Volume 47; Pages 442 and 443. (May, 1828.) 



AFFECTIONS OF THE INTELLECT. 539 

nervorum opticoriim," and the " corpora striata," on one side or both, have been 
found too small, or have been absolutely wanting; or their place has been supplied 
by a cyst; though sometimes it has not. A deficiency is som.etimes seen in the 
gray substance of the brain; and sometimes in the ivhite substance. If the hemi- 
spheres be wanting, there is nothing beyond the "crura cerebri," except a {e\v 
scattered fibres, — such as are seen in the fostus before the hemispheres are formed; 
and, indeed, there are then no central white parts. 

Deficiency of the Medullary Matter. — Fourthly, the central while parts are 
found, sometimes, in a state of deficient development. Occasionally the " corpus 
callosum" is a mere membrane; and it has been found absolutely wanting, in an 
idiot thirty years of age. In some brutes (for instance, birds and reptiles) the 
same is observed naturally. There is no "corpus callosum," nor any fornix; and 
therefore such a brain as we have mentioned, resembles the brain of some brutes. 

When there is this sraallness or deficiency of certain parts, other parts are not 
naturally so developed in man as they are in brutes. They appear larger in such 
a human being, but it is merely by comparison; and it is found that the parts are 
larger in brutes. They appear larger, if the other parts be wanting; but it is merely 
a deception. We never find the " lubercula quadrigemina" a hollow tube, as in 
birds; — we never find the fourth ventricle so large, as in some brutes. The middle 
lobes of the cerebrum, though naturally smaller in brutes than in man, are in this 
case just as large as those in man. 

Deficiency of the Cerebellum. — The cerebellum is sometimes deficient. It may 
be small, or ihe medullary centre may be small, or the lobes may be small; — they 
have been seen to be a mere sac. This is observed in some brutes; and sometimes 
in the human embryo. The reason of this extraordinary formation is, that de- 
velopment has ceased, in most instances, at a certain period. We know that the 
brain, in the human body, is different at first from what it is at last; and occasion- 
ally the development of it stops; and, as the adult person grows up, we see that it 
is totally different from what it is in other beings. When this is the case, the 
cerebellum is so defective as to be a mere sac; the "tuberculum annulare" is 
wanting, though the middle lobe of the brain is present; because the "tuberculum 
annulare" is found to be in proportion to the size of the cerebellum. Where there 
is no cerebellum, still the " corpora quadrigemina" may exist; because they have 
a relation, not to the cerebellum, but to the spinal marrow. As to the pineal gland, 
we find that in all formations of the brain. 

Absence of the Spinal Marroic. — The cerebrum and cerebellum may be absent, 
although there is the spinal marrow, and the " medulla oblongata;" but if there be 
no spinal marrow, it is found that there is neither cerebrum, nor cerebellum, nor 
" medulla oblongata." As to the spinal marrow itself, it may be entirely absent, 
and sometimes it is found divided, and it is said that when it is divided into two, 
the brain is always absent. Sometimes it is only channelled down the centre; and, 
when this is the case, there are frequently other malformations; — such as a want 
of brain, or a want of bone in the spine. When there is a channel, it is found to 
arise from the want of the cortical substance of the spinal marrow; and the channel 
seems continued all the way up to the fourth ventricle. The division, or the chan- 
nel, may be large or small; and it may not run the whole extent. The channel 
itself is found at all ages. Two instances of maniacs are recorded, in one of 
which two central canals were observed in the spinal marrow, and in another only 
one. Many brutes have this central canal. Sometimes the spinal marrow is not 
wanting, but is very small; and sometimes the smallness is local; — occurring only 
at one spot; just as smalhiess occurs, sometimes, only in one part of the brain. 

Does not Influence the Nerves. — It does not follow that the nerves should cor- 
respond to this deficiency. There may be a deficiency of the nerves, when the 
brain is wanting; and a deficiency, too, when the spinal marroii'i is wanting; but 
occasionally the nerves are found perfect, although the brain and spinal marrow are 
found wanting. There they are, ready for action; but they want the brain and 
spinal marrow to put them in motion. When there is this deficiency in the nervous 



540 AFFECTIONS OF THE INTELLECT. 

system, the correspondinor parts of the body are sometimes small, and likewise 
atrophied; yet occasionally the body is perfectly sound, — in all other respects well 
developed, — even where this deficiency of the nervous system exists; except that 
the heart is never found wliere there is no head. Serres says that he has found a 
heart where there was no head; but nobody else ever did. 

Where there is no head, I believe the lungs are never found; but, nofwithstand- 
ing there may be no head, there is always some rudiment of the alimentary canal; 
and for this simple reason; — it is formed first. 

Causes of these Deficiencies. — The causes of all these wants (smallnesses, and 
deficiencies) in the nervous system are, first, orio^inal defective power; the parts 
are not developed, throui^h some deficiency in the formative power, independently 
of all external circumstances. There is a want of power in particular rudiments 
of the embryo, to develope the various parts. Secondly, they are wanting (I believe) 
through some previous irritation. They have existed; but some irritation has also 
existed, which has wasted them, or arrested their proaress. Thirdly, pressure 
(we know) will cause atrophy in future life; and so it will occasionally prevent the 
development of parts in the foetus. 

Corresponding Deficiency of Intellect. — If the brain be the organ of mind, which 
I suppose no one will doubt at the present day, it follows that this deficient de- 
velopment must be attended, in some way or other, by a correspondent deficiency 
in the mind. If the brain be altogether wanting, there can be no mind at all; and, 
accordingly, we continually find fcetuses formed without any head; and, of course, 
they cannot manifest mind. But some are born, and live some days, with merely 
a little brain (if we may call it brain at all) about the " tuberculum annulare;" and 
they will cry, and suck, but do no more; and presently they die. Some (who 
have just sufficient brain to eat and drink, breathe and grunt) live to be two or three 
years of ajre; while others, with a litde more brain, will never be able to talk; but 
they will laugh, cry, be pleased by certain external objects, and displeased with 
others. Some, again, with more brain, are able to go about; and may be taught 
to do certain things mechanically, as it were; but they never can exercise judg- 
ment. They may be brought to go to bed at a certain time, to get up at a certain 
time, and to eat at a certain time; but they never go beyond that. Others have 
sufficient brain to perform the lower offices of life, but not to perfoim any duties 
that argue the least intellect; and some, who have still more, can perform the 
offices of life, but are known in the world as " innocents;" — very weak persons. 
So we go on. till we come to fair average people; and we pass them, and come 
to very intelligent characters. 

However, these intellectual varieties do not depend upon the development of 
the lohole of the head. It is found, unquestionably, that they depend upon the 
development of the interior part; for many of these weak people have heads suffi- 
ciently large in every part, except the front. On the other hand, persons with a 
very small development of all the parts of the brain except the front, may be suffi- 
ciently clever persons. These are undoubted facts; and whenever we see a defi- 
cient development of the anterior part of the brain, and (necessarily) of the anterior 
part of the head, it may be taken for granted, that the individual can only manifest 
a very limited display of intellect. 



SECTION II.— IDIOCY. 

Under the term " unsoundness of intellect," are comprised idiocy and insanity. 
By *' idiocy," or " idiotism," is meant the absence (or rather the deficiency) of 
intellect; — a deficiency amountinof to such a deirree, as to disqualify an individual 
for the common offices of life. Generally speaking, a madman has a wrong opi- 
nion, or a wrong feeling; but an idiot may be generally said to have none. The 
madman is wrong; but the idiot is defective. 

Legal Definition. — According to our law, " the individual, in order to be 



AFFECTIONS OF THE INTELLECT. 541 

constituted an idiot, must be unable to number to twenty, or to tell his age, or to 
answer any common question; by which it may plainly appear that the person has 
not reason sufficient to discern what is for his advantage or disadvantage." 'J'o 
quote attain from the same work (Burn's "Ecclesiastical Law,") — "That man is 
not an idiot, who has any glimmering of reason; so that he can tell his age, know 
his parents, or such like common matters." 

JSot referable to the External or Internal Senses. — This deficiency of intel- 
lect does not refer to any deficiency of the external senses. Idiots can often hear, 
see, taste, feel, and smell, just as well as other people. Neither does it at all refer 
to what phrenologists call "the knowing faculties;^'' by which a person judges of 
music, colours, distance, size, or number, and can recollect words. An idiot may 
do all these things; — may understand music to a certain extent; may distinguish 
colours very well; and also size, distance, and numbers: but he may be a complete 
fool for all that. Many idiots are defective in these respects. Very great idiots 
know nothing at all; they can merely eat, drink, and slumber. iMany persons 
who can count above twenty are idiots, — notwithstanding what the law says; and 
medical men would declare many persons to be idiots, although they could count 
more than a hundred. Some idiots take a great delight in music. 1 do not know 
that they can ever be great musicians; but they know what music is; — they under- 
stand ii; and some sing very well. Some will sketch, likewise, exceedingly well; 
and some have an excellent memory of words; so that they will remember long 
passages. 

Spurzheim saw, at Hamburgh, a young man, the anterior part of Mdiose brain 
was favourably developed; but whose forehead, above that part, was scarcely an 
inch in height; and in whom the movements of the superior parts of the brain 
were consequently impeded; and he had only the functions of the inferior anterior 
parts. Now this individual recollected names, numbers, and historical facts; and 
repeated them all in a mechanical way; — proving that he had a much belter me- 
mory than many acute men; but the functions of comparison, penetration, and 
sagacity, were utterly wanting. Spurzheim likewise says that he saw, at a poor- 
house, a boy who excelled in verbal memory; but as Xo judgment he was an idiot. 
Dr. Roberts, he says, showed him an idiot, who repeated whole passages from the 
Bible; — simply from having heard them read. He adds, that he saw an idiotic 
child, who sang several airs; and if others began to sing, she accompanied them 
in harmony. It is very possible, therefore, for an idiot to have a pretty tolerable 
share of those particular faculties, by which a person understands distance, knows 
colours, can recollect numbers, calculates, distinguishes one object from another, 
and so on. Neither does the deficiency o^ these things constitute a person an idiot; 
for many very clever persons are deficient in these particulars. Many clever per- 
sons cannot tell red from green; and many clever persons cannot tell " God save 
the King" from " Rule Britannia." Others, again, can never be made to calculate; 
and some persons can scarcely keep their own accounts, though otherwise they are 
reflecting and very clear-headed persons. On the other hand, a pers w may be an 
idiot, though he has these faculties. An idiot may have them; but their absence 
does not constitute a man an idiot. 

Varieties of Idiocy . — There is every degree of deficient intellect; — from the slight- 
est to the most perfect idiotism; — from one in which an individual merely eats, 
drinks, discharges his faeces and urine at all times and in all places, slobbers, and 
grunis; up to that in which a person is merely called " imbecile," — merely (perhaps) 
"a little soft." All these varieties are seen in life. Such a degree as makes a man 
" soft," but will not qualify him to have the legal privileges of an idiol, is por- 
tiayed by Shakspeare, in the "Twelfth Night," and the " Merry Wives of Wind- 
sor." We catmot have a belter description of an idiotic, or weak person, than is 
there given. Sir Andrew Ague-cheek, in the "Twelfth Night," is a very fine 
illustration of idiocy. He says — " Melhinks, sometimes, I have no more wit 
than a Christian, or an ordinary man h;\s; but I am a great eater of beef, and I 
believe tliat does harm to my wit. I would I had bestowed that lime on the 



542 AFFECTIONS OF THE INTELLECT. 

tongues, that I have on fencing, dancing', and bear-baiting. 0, had I but followed 
the arts!"* Then, in the "Merry Wives of Windsor," an equally sagacious 
individual, in the character of Slender, says — " Though I cannot remember what 
I did when you made me drunk, yet I am not altogether an ass. I'll ne'er be 
drunk whilst I live again, but in honest, civil, godly company, for this trick. If I 
be drunk, I'll be drunk with those that have the fear of God; and not with drunken 
knaves.'"" These are two illustrations of individuals, who were weak enough to 
be below other people; and yet not so weak as to be called downright idiots. 

As idiotism (which is, more or less, a deficiency of intellect) varies, so insanity, 
being a disturbance of the mind, must have infinite varieties. Many faculties of 
the mind may not be disturbed at all, and others may be disturbed in various pro- 
portions; therefore the varieties of insanity can never be perfectly described. No 
two sane persons are alike in character, any more than in features; and idiots vary 
in the same way. Many may be idiots to the same degree; but there are various 
other parts of their character which do not correspond. For example: some have 
one of the faculties of which I have been speaking, and which phrenologists call 
»' the knowing faculties," (such as music,) very strong; and others will liave ano- 
ther faculty very strong; and all may have them in various degrees. So again, 
some idiots will have one propensity, — owe feeling, very strong; while others will 
have a different propensity or feeling very strong, and some will have several; — so 
that they vary in their character (to say nothing of idiotism) just like the rest of the 
world. 

Generally conjoined to other Deficiencies. — Although the deficiency of any of 
these knowing faculties, and the deficiency of any feeling (such as good-will 
towards mankind, revenge, passion, lust, and so on), does not constitute idiotism, 
yet if the anterior superior part of the brain be so defective as to constitute the 
individual an idiot, there is seldom so great a defect in that part of the brain, with- 
out there being a good deal wrong in other parts. We never find an exceeding 
degree of monstrosity, without finding minor degrees. When a foetus is formed 
without a heart, there are generally supernumerary fingers and toes. Wherever 
there is a great monstrosity of body, there is almost always a minor monstrosity; 
and so when the head is defective in one part, to such a degree as to constitute 
idiocy, there is generally more or less defect in other parts. Thus it is very com- 
mon to see an idiot with these various knowing faculties defective, as well as those 
which constitute him an idiot; and it is very common for him to have certain pro- 
pensities deficient, or some in excess. There are generally other parts of the brain 
wrong; although the erroneous state of other parts does not constitute the disease. 

Moral Qualities of Idiots. — Some idiots, in conformity with all that I have 
been saying, are exceedingly gentle and good-natured. They never do any harm; 
and do every thing that they are bid. Some, on the other hand, are very pas- 
sionate; — never can be trusted; and if we excite their feelings into violent passion, 
they will take any thing they can procure, and commit murder, if possible. Some 
are exceedingly mischievous and sly, without being passionate. Some are very 
much disposed to steal; and will purloin every thing they can. Others, again, are 
exceedingly low-spirited and gloomy; and some have violent sexual desires. These 
desires frequenUy go wrong; partly from some error in the faculty itself, and partly 
from some deficiency in intellect; so that many of them are, not merely lustful^ but 
beastly in various ways. 

Prone to Imitation. — Some are very prone to imitation; and I knew an instance 
of an idiot, who had all the imitative disposition of a monkey. He was in the 
workhouse at Clapham. When the surgeon went to visit the patients in the 
workhouse, he universally observed what was done; and, as soon as the surgeon 
was gone, he would feel the pulses of the various patients; and get a piece of tape, 
and begin bandaging up their arms, in order to bleed them. Whatever he saw 
done, as soon as he had an opportunity, he regularly went and did the same. 

* Act 1; Scene 3. ^ Act 1; Scene 1. 



AFFECTIONS OF THE INTELLECT. 543 

Cases of a similar description are mentioned by Pinel, and other writers on in- 
sanity. There is no doubt about there being- a propensity in the human mind to 
imiiaie. All acknowledge this; — phrenologists and anti-phrenologists; and tiiis 
was so strong in this idiot, who had no sense to restrain him, that it led him to do 
ridiculous acts. 

Frequently Coexistant tvith other Diseases. — This state of mind (idiotism) is 
very often conjoined — like all diseases of the nervous system — with other diseases 
of the nervous system. It is frequently connected with epilepsy, with chorea, and 
with paralysis; so that we continually see idiots epileptic, or constantly shaking, 
and more or less paralytic. 

Brain Deficient, or of Bad Quality. — When the disease is congenital, there is 
generally a defect of brain at the superior anterior part; and generally the whole 
head is too small. Gall says, that if the head be only from fourteen to seventeen 
inches in circumference, and only from ten to twelve from the root of the nose to 
the "foramen magnum," there is always more or less stupidity; that heads of 
eighteen inches and a half in circumference are small, and give but a mediocrity 
of talent; and that the full size is from twenty-one to twenty-two inches in circum- 
feience. However, idiotism may be produced without a defect of brain. The 
brain may be plentiful enough; but of bad materials. Dr. Spurzheim says that he 
dissected an idiot, two years of age, in whom the gray and white substance were 
of a grayish-blue colour; and, instead of being of the ordinary texture, were of a 
gelatinous quality. Such a brain as that, although there was plenty of it, was not 
of a sufficiently good quality to execute its functions. In such an instance, the 
brain may be very large; but the additional size will not counterbalance the bad 
quality. 

Quality of the Brain changes luith Jige. — It has happened, sometimes, that aii 
individual has been born an idiot, though with a sufficiently well developed head; 
and the brain has appeared suddenly to improve in quality. The brain improves 
in quality, as the body grows. It becomes of a different quality, as age advances, 
to a certain point. It attains a perfection of structure; — not as to size and develop- 
ment merely, but perfection as to quality; and then it afterwards declines (like all 
other parts of the body) in quality and size. In some individuals, the improve- 
ment of quality does not take place at the ordinary period; and the result is, that 
they remain children lono;er than other people; and recover from their idiocy at a 
certain period of life. The same circumstance occurs with regard to puberty. 
Many instances of this are on record. There is a case mentioned by Wilson, of 
puberty not taking place till the individual was twenty-eight years of age. There 
was no beard, or hair on the pubes, and the testicles were small, till the individual 
was twenty-eight; when suddenly he got a pair of whiskers, a tolerable beard, hair 
below, and good testicles; — fell in love, and was married. Now it is just the same 
with the brain altogether. The brain, in some individuals, does not go through its 
changes of structure at the usual period; so that the individual is sometimes idiotic 
during the first part of his existence; and, as he grows up, becomes like other 
people! 

Torpidity of the Brain removed by Accident. — Most frequently, of course, this 
is not the case; — the same defective power of development continues; but to illus- 
trate that a torpid brain has sometimes been excited to action by some external cir- 
cumstance, an instance is mentioned of a boy, who possessed inferior talents till a 
tile fell on his head; when he began to show great intellect. Dr. Mason Good 
says, that he knew a lad cured of his idiocy, by a fall from the first floor to the 
street.* As an instance of a similar kind, I may mention that a German writer 
relates a case of fracture of the skull, by falling from a great height, which cured 
deafness; and, after the fracture, the man became able to speak. 'J'liis was upon 
the same principle as idiots being cured by the fall of a tile or any thing else. In 
the twenty-fifth volume of the "Philosophical Transactions," is related a case 

* "Study of Medicine;" Class 4; Order 1; Genus G; Species 2j Variety 3. 



544 AFFECTIONS OP THE INTELLECT. 

where want of hearing was oured by a fever. The patient was seventeen years of 
age, and had never heard; but fever came on, and produced such excitement, that 
he afterwards heard hke other people; and, having heard, he began to speak;— 
though he had never spoken before. 

In cases of torpichty of the brain, where there is such a degree of inactivity as to 
produoe idiolism, we may expect the head to be of the same size as in other per- 
sons; and it may be large; — from the brain being bhibbery, or from there being a 
collection of water; as was the case with the head of C;\rdinal.* He ought to have 
beaten Lord Bacon, and Sir Isaac Newton too, if intellect depended on the mere 
size of the head. 

Congenital Idiots die early. — When an idiot is so congenitally, he seldom lives 
to be above thirty. The defective power which causes the brain to be in such a 
state, is generally connected with such a want of energy throughout the whole 
body, that tlie patient seldom lives beyond thirty; and the greater the idiocy, caeteris 
paribus, the shorter time does he live. 

Idiocy from Excessive Activity of the Brain. — Just as the brain may be 
originally torpid and inactive, so it may fall into the same state from excessive 
action. Precisely the same effect may be produced, if there be excessive action 
before the brain has acquired its full growth. This is very likely to be the case; 
for many precocious children, who have been shown to the world as prodigies of 
talent, have (through the excessive application imposed upon them by their pre- 
ceptors) become idiotic; and, when they have not become idiotic, they have fre- 
quently died. The powers of the body have been exhausted, and some organ 
more than another has fallen a victim to disease; — so that they have died. Intense 
application will produce temporary idiotism. Many persons who have bent their 
minds upon a particular object, and have worked night and day, have frequently 
fallen into a state of fatuity, which has lasted only for a certain time. The brain 
has been over-fatigued; and, after a time, it has recovered itself. 

Causes of Idiocy in Jifler-Life. — Fatuity or idiocy may come on in after-life 
(when persons have not been born idiotic) from other causes; — for instance, from 
blows; and from any of the diseases which I before mentioned, when treating of 
the morbid anatomy of the brain.'' Any such disease as causes paralysis; — -tumours 
pressing on the anterior part of the head;'' softening of the anterior lobes (those 
parts which, I stated, are deficient when a person is a congenital idiot**); pressure,* 
softening,* or any thing which impedes the funcrtions in any way; — all these will 
produce idiotism. Fever, being so often accompanied by violent irritation of the 
brain, will frequently leave idiocy; and insanity has done the same. When per- 
sons have been long insane, it is very common for them to lose their faculties alto- 
gether. Idiocy is a very common result of insanity. 

Distinction between Fatuity and Idiocy. — The words ^^idiocy^^ and ^' fatuity^* 
are not applied indiscriminately. They are nearly the same thing; but ''idiocy" 
is generally used, by modern writers, for that which is congenital. — born in a per- 
son; while '■'fatuity," I believe, is generally applied to that imbecility which comes 
on in after life. The person not having been an idiot at first, but having become 
so, it is said that " he has become fatuous;" and if insanity have been the particu- 
lar disease which has preceded the imbecility, then the imbecility is called "de- 
mentia" — [unrnindedness). Hence, if a person be born an idiot, his case is one 
of" idiotism;" if imbecility come on afterwards, from a common cause, it is called 
" fatuity;" but if it be preceded by insanity, — if it be nothing but the degeneration 
of insanity, then it is called "dementia." 

Diagnosis. — If there be great deficiency of the anterior part of the head, — if it 
be a question of idiotism and imbecility of mind, the case is very easily ascertained; 
but the head may be large, and yet the person may be an idiot. In the latter case 
we have to question him as to common circumstances, — to ask him how many half- 

• See P^g^ 500. " See Pages 486 and 515. « See Pages 532 and 536. 

<> See Page 540. • See Page 522. f See Pages 488 and 516. 



AFFECTIONS OF THE INTELLECT. 545 

pence there are in a sixpence, and how nnany sixpences in a shilling. If he was 
born in April, ask him whether he was horn the January before; and ihinas of 
that description. We should ask him questions on the most ordinary subjects; 
and generally put money before him, and make him count it; — count it as simple 
pieces of money; a!id then make him show the value of the whole; and we soon 
find out whetlier he is an idiot or not. If he stumble at such questions as these, 
we may give an opinion that he is not qualified to manage his own affairs. 

Prognosis. — But besides such an examination as this, it is right to look at the 
individual's head; and if it appears morbidly small, our opinion as to his idiocy- 
would not be increased, but our prognosis would be exceedingly affected by it. 
If there is an absolute want of brain, we may take it for granted that the prognosis 
ought to be unfavourable. There is little hope of its growing to such an extent, as 
will enable him to be clever, like other people. This will also guide us very much 
in our attempts at benefiting the sufferer. If there is a great deficiency of brain, 
all attempts at benefiting him will be hopeless. The schoolmaster may flog; but 
he will never make any thing of such a head. We might also derive great advan- 
tage from inspecting the head, and observing the general character; so as to give 
directions to his friends how to manage him. We should observe what passion is 
strong enough to render it necessary for those about the person to be on their ffuard 
against it. This will be of use; as well as observing the imperfection of the head, 
for the purpose of ascertaining the degree of idiotism that exists in the individual. 

Treatment. — As to curing the disease, all that can be done is to put the patient 
in as healthful circumstances as possible; — to feed him well, to give him fresh air, 
and improve his body altogether, on the one hand; and to cultivate particularly 
those parts of the mind which are best developed, on the other. If there be found 
any talent for music or calculation, we must make the best of it. A story is told, 
that may be true, of a boy who was an idiot up to eighteen years of age; when he 
saw a beautiful girl, and was struck with love for the first time. It shed such a 
flame tliroughout his brain, that he became as clever as the rest of the boys in the 
village. I have no idea of love being so employed; but if we find a faculty tolera- 
bly strong, it should be made the most of; — whether it be an intellectual or a 
knowing faculty; and if other faculties be not excited by it, yet it may be strength- 
ened, and the individual may be rendered much less deficient than he otherwise 
would be. He may be unable to gain the command of all his fiiculties; but, by 
strengthening one, he may be rendered not so miserable an object, as if he were 
altogether neglected. This is an important point; because to set down an indivi- 
dual as an idiot, when he has some one faculty that might be made something of, 
would be cruel; and if we see th.e development of any thing that would enable us 
to make the experiment, it ought not to be passed by. 

Cretinism. — With respect to the importance of good air and good food, in less- 
ening idiotism, I may mention that particular form of idiotism, called " cretinism;" 
which is produced by bad air or bad water. I should conceive there can be no 
doubt on the subject. It is found in the valleys of the Alps. It is impossible to 
travel in Switzerland among any of the valleys, without seeing plenty of cr.^tins. 
The air is stagnant and wet; — full of the exhalations from marshy ground. The 
water, for the most part, is very bad: and the people are so ignorant, in many 
parts, that they drink water containing a great deal of chalk, although good is to 
be had. They are miserable objects; — mostly always short. In fact, ihev are 
dwarfs; and. in general, have enormous h.eads. Their features are shrivelled; 
they look like decayed autumnal leaves, or something like a shrivelled apple; and 
all of them have noses resembling the "ace of spades." Their limbs are soft and 
flabby; their mouths are wide, — extending from ear to ear; their lips are very 
thick; and they have a dry-looking skin. All of them are more or less idiotic, and 
many of them have a goitre; — an enlargement of the thyroid* gland. 

These poor crealures are found, after death, to have the bones of the head very 

» From ^yjiof, a shield; and tihq, resemblance. 
VOL. I. — 35 



546 AFFECTIONS OF THE INTELLECT. 

thick; and sometimes there is a quantity of water in the head. The cavity of the 
skull is not so large as the external appearance of the head would lead us to sup- 
nose. Sometimes the diminished capacity arises from the excessive quantity of 
bone, and sometimes from a collection of water. In other cases the brain, although 
large enough, is of bad quality. The tongue, in some cretins, is hypertrophied; — 
too laro'e for the mouth; and a large number of them are deaf and dumb. There 
is a great difference in their dispositions. Some should never be trustetl; — they 
are such destructive creatures, that they do all the mischief they can; while others 
are innocent, and as tame as lambs. Some females have a great number of these 
children. They have desires, like other people; and they fall in love with each 
other, and marry. Certainly nobody else would marry them. 

It is said, that if two persons with a bronchocele* marry, their progeny generally 
have a goitre; and if their goiterous progeny marry any other persons with a bron- 
chocele, then the third generation are sure to be idiots. Many persons assert this; 
but I do not know whether it is true; though I have endeavoured to ascertain it. 
There is a great relation between goitre and cretinism, no doubt; and what affects 
the thyroid gland, if it also affects the head and brain, may produce idiotism. 

This is all that need be said about idiocy. It is more an object of curiosity, and 
medical jurisprudence, than of medical treatment; but it is very interesting, both 
in a physiological and a pathological point of view; and sometimes it is important 
in practice. 



SECTION III.— INSANITY. 

Various Terms employed. — I will now proceed to the description of that kind 
of unsoundness of intellect which is called "insanity.'"' Unsoundness of intellect 
comprises idiocy, imbecility, and insanity. Insanity is called " lu!\acy," — " mental 
derangement," — " mental aberration," — " hallucination,"'' — " alienation," — "mad- 
ness." 

Definition, — In describing mental deficiency, I stated that it was not every kind 
of mental deficiency that made an individual imbecile, or an idiot. The various 
feelings of the mind may be deficient, and very inconsiderable; — so inconsiderable 
as to be all but absent; and yet the individual may not be an idiot.*^ I stated that 
certain intellectual faculties (such as the faculty of music or calculation) might be 

deficient, very deficient, and the person not be at all an idiot.*^ So aberration of 

mind, in insanity, does not exist merely because there is something wrong in the 
mind. There may be much very wrong in the mind, and yet the person not be at 
all insane; — just as there may be a great defect in the mind, and yet the person not 
be at all an idiot. 

a. Varieties. 

Dprans;ement of Volition and Sensation. — In the first place, derangement of 
volition does not constitute insanity. A person may have palsy of motion; and 
yet he is not insane. He may wish to move his limbs, and be unable to do so; or 
he may wish to move them in one direction, and they may go in another, in a 
comnletely opposite direction; but he is not, on that account, insane. Neither does 
a want of tiie external senses constitute insanity, any more than it does idiotism. 
There may be merely palsy of the senses; — there may be a want of sensation from 
disease of the external organs of sense; and yet the person may be perfectly rational. 
Neither does it refer at all to the knoiving faculties, such as music and calculation; 
which may be called ^'internal senses."" These may be more or less wrong; and 

' From iSjoyx"?) '^^'^ windpipe; and xflX«, a tumour. 
^ From " in," not; and " sanus," sound. 
c From " hallucinor," bo err. 
d See Pages 541 and 542. 



AFFECTIONS OF THE INTELLECT. 547 

yet the person not be insane. Just, therefore, as the want of effective volition, — 
just as the want of external sensation, — ^just as the want of any one of the knowino- 
faculties, does not make a person an idiot; so a wrong operation of volition over 
the voluntary muscles, — an arm going one way, when the person wishes it to go 
in another, — is not insanity. A person labouring under chorea, or under tetanus, 
is not insane. 

False Perceptions. — A wrong sensation does not constitute a person insane. He 
.may have double vision; — he may see two fingers, when only one is held up; yet 
he is not on that account ing^ne. Neither if a person see images, — figures, — spec- 
tres, is he on that account insane, if he do not believe that their existence is real. 
Some persons see objects which really do not exist; — images of objects which have 
no existence; and they know that such things do not exist; and therefore they are 
not insane. They are aware that there is a mere deception. Some see, in these 
circumstances, appearances of human beings, brutes, and various animals; but they 
are perfectly aware that it is entirely a morbid appearance. 

One of the most remarkable instances of this description, occurred at Berlin; in 
the person of a bookseller named Nicolai. He saw an immense number of objects, 
—people and brutes, — at certain times; but he was aware that it was all the effect 
of morbid excitement. He had gone through considerable mental application; and, 
being aware that this was all a delusion, he was no more insane for seeing them, 
than a person would be for thinking he saw two fingers, when we held up but one.^ 

» I [Nicolai] saw, in a state of mind completely sound, and (after the first terror was over) 
with perfect calmness, for nearly two months, almost constantly and involuntarily, a vast 
number of human and other forms; and even heard their voices; — though all this was merely 
the consequence of a diseased state of the nerves, and an irregular circulation of the blood. 

It being a matter of considerable importance, that an incident of this nature should be 
observed with the strictest attention, and related (together with all collateral circumstances) 
with the most conscientious fidelity, I shall not omit any thing of which 1 retain a clear 
recollection. The truth of what I am going to advance, will not require a further testimony; 
as Dr. Selle — who was my physician, and was daily informed by me of every trifling oc- 
currence and change that happened — is still living; and will, by all who know him, be 
most readily admitted as an unobjectionable witness. During the ten latter months of the 
year 1790, I had experienced several melancholy incidents, which deeply affected me, — 
particularly in September; from which time I suffered an almost uninterrupted series of 
misfortunes, that afflicted me with the most poignant grief, I was accustomed to be bled 
twice a year; and this had been done once (on the ninth of July), but was omitted to be re- 
pealed at the end of the year 1790. I had, in 1783, been suddenly taken with a violent ver- 
tigo; which my physicians imputed to obstructions in the vessels of the abdomen, brought 
on by a sedentary life, and continual exertion of the mind. This indisposition was suc- 
cessfully removed, by means of a more strict diet. In the beginning, I had found the use 
of leeches applied to the arm particularly efficacious; and they were afterwards repeated 
two or three times annually, when I felt congestions in the head. The last leeches which 
had been put on, previously to the appearance of the phantasms of which I am about to 
speak, had been applied on the first of March, 1790; less blood had, consequently, been 
evacuated in 1790, than was usual with me; and, from September, I was constantly occu- 
pied in business that required the most unremitting exertions; and which was rendered still 
more perplexing by frequent interruptions. 

I had, in January and February of the year 1791, the additional misfortune to experience 
several extremely unpleasant circumstances; which were followed, on the twenty-fourth of 
February, by a most violent altercation. M3'' wife and another person came into my apart- 
ment in the morning, in order to console me; but I was too much agitated by a series of 
incidents, which had most powerfully affected my moral feelings, to be capable of attending 
to them. On a sudden I perceived, at about the distance of ten steps, a form like that of a 
deceased person. I pointed at it; — asking my wife if she did not see it. It was but natural 
that she should not see any thing: my question, therefore, alarmed her very much; and she 
sent immediately for a physician. The phantasm continued about eight m'inutes. I grew, 
at length, more calm; and, being extremely exhausted, fell into a restless sleep, which lasted 
about half an hour. The physician ascribed the apparition to a violent mental emoiion, 
and hoped there would be no return; but the violent agitation of my mind had, in some way, 
disordered my nerves, and produced further consequencesj which deserve a more minute 
description. 

At four in the afternoon, the form which I had seen in the morning reappeared. I was 
by myself when this happened; and, being rather uneasy at the incident, went to my wife's 
apartment; but there, likewise, I was prevented by the apparition; which, however, at inter- 



548 AFFECTIONS OF THE INTELLECT. 

Brutus and Socrates are said to have seen, — the one the shade of Caesar, and the 
other " the familiar spirit," as he called it; but if neither the one nor the other 
believed this, they were not mad; or if they merely believed it in accordance with 
the belief of the day, then they were not mad; but if they knew better, and yet 
believed these things, then they were deranged. Hence there may be false percep- 

vals disappeared; and always presented itself in a standing posture. About six o'clock, there 
appeared also several walking figures; which had no connection with the first. 

After the first day, llie form of the deceased person no more appeared; but its place was 
supplied by many other phantasms; — sometimes represennng acquaintances, but mostly 
strangers; those whom 1 knew, were composed of living and deceased persons; but the 
number of the latter was comparatively small. I observed that the persons with whom I 
daily conversed, did not appear as phantasms;— the latter representing, chiefly, persons who 
lived at some distance. 

These phantasms seemed equally clear and distinct at all limes, and in all circumstances; 
— both when 1 was by myself, and when 1 was in company; and as well in the day as at 
night, and in my own house as well as abroad; they were, however, less frequent when I 
was in the house of a friend; and rarely appeared to me in the street. When 1 shut my 
eyes, these phantasms would sometimes vanish entirely; though there were instances when 
1 beheld them with my eyes closed; yet, when they disappeared on such occasions, they 
generally returned when 1 opened my eyes. I sometimes conversed with my phy^iciaa 
and my wife, of the phantasms which at the moment surrounded me. They appeared more 
frequently walking than at rest; nor were they constantly present. They irequeniiy did 
not come for some time; but always reappeared for a longer or shorter period, either singly 
or in company; — the latter, however, being most frequently the case. I generally saw, how- 
ever, forms of both sexes: but they usually seemed not to lake the smallest notice of each 
other; moving as in a market-place, where all are eager to press through the crowd:— /it 
times, however, they seemed to be transacting business with each other, lalso saw, several 
times, people on horseback, dogs, and birds. All these phantasms appeared to me in their 
natural size, and as distinct as if alive;— exhibiting different shades of carnation in the un- 
covered parts, as well as in different colours and fashions in their dresses; though the colours 
seemed somewhat paler than in real nature. None of the figures appeared particularly ter- 
rible, comical, or disgusting;— most of them being of an indifferent shape, and some pre- 
senting a pleasing aspect. The longer these phantoms continued to visit me, the more 
frequently did they return; while, at the same time, they increased in number about four 
weeks after they had first appeared. I also began to hear them talk; the phantoms some- 
times conversed among themselves; but more frequently addressed their discourse to me: 
their speeches were commonly short, and never of an unpleasant turn. At different limes, 
there appeared to me both dear and sensible friends, of both sexes; whose addresses tended 
to appease my grief, which had not yet wholly subsided. Their consolatory speeches were, 
in general, addressed to me when alone. Sometimes, however, I was accosted by these con- 
soling friends, while I was engaged in company; and, not unfrequenlly, while real friends 
were speaking to me. These consolatory addresses consisted, sometimes, of abrupt phrases; 
and, at other times, they were regularly executed. 

Though my mind and body were in a tolerable state of sanity all this time, and these 
phantasms became so familiar to me, that they did not cause me the slightest uneasiness; 
and though 1 sometimes even amused myself with surveying them, and spoke jocularly of 
them to my physician and my wife, I yet did not neglect to use proper medicines; — 
especially when they began to haunt me the whole day, and even at night, as soon as I 
awaked. 

At last, it was agreed that leeches should be again applied to me, as formerly; which 
was actually done on the twentieth of April, 1791, at eleven o'clock in the morning. No 
person was with me, except the surgeon; but during the operation, my chamber was 
crowded with human phantasms, of all descriptions. This continued uninterruptedly, till 
about half an hour after four o'clock;— just when my digestion commenced. 1 then per- 
ceived that they began to move more slowly; soon afterwards, their colour began to fade; 
and, at seven o'clock, they were entirely while. They moved very little, though the forms 
were as distinct as before, — growing, however, by degrees, more obscure; yet, not fewer in 
number,— as had generally been the case. The phantoms did not wiihdraw, nor did they 
vanish;— a circumstance which, previously to that lime, had frequently happened. They 
now seemed to dissolve in the air; while fragments of some of them continued visible a 
considerable time. About eight o'clock, the room was entirely cleared of my fantastic 
visitors. 

Since that time, I have felt, twice or three limes, a sensation, as if these phantasms were 
going to reappear; without, however, actually seeing any thing. The same sensation sur- 
prised me, just before I drew up this account; — while 1 was examining some papers, rela- 
tive to those apparitions, which I had drawn up in the year 1791. — ^''Sketches of the 
Pk'd()<{()j)hy of Apparitions, By Samuel Hibbert, M. D." Chapters 1 a7id 5; Pages 4 to 8, 
and ^l to 44. 



\ 



AFFECTIONS OF THE INTELLECT. 549 

lions, and yet the individual may not be mad; but a person may be mad, and also 
have false perceptions. Many men, absolutely mad, think ihey see things which 
they do not; but many persons, without a false perception, see something that has 
no existence; but, knowing it has no existence, they are not deranged. Again: 
many persons, absohitely mad, never see any unnatural appearances whatever. 

Monomania. — But in a great number of cases of insanity, we find an absurd 
belief; and this may refer to something past. There may be a fixed opinion, 
altogether absurd, upon matters that have passed; and tliere may be also an absurd 
opinion as to something present. For instance: — persons so affected, may see 
things which other people do not; and they may positively believe it. Insanity, 
therefore, may be an absurd belief, as to thinsjs present and things past; and thirdly, 
that absurd belief may refer to a mere abstract opinion. Persons may believe 
something so preposterous, that every body will consider them mad for so doing. 
A case is recorded of a butcher, who firmly believed he saw a leg of mutton hang- 
ing from his nose; and therefore he was certainly mad. Another is told of a baker, 
who fancied himself butter; and refused to go into the sunshine, lest he should 
melt. A painter thought he was soft; — he was so in mind. He thought he was 
so much putty; and that he could not walk without becoming compressed, like 
putty. Others have fancied themselves glass; and would not sit down lest they 
should crack. 

• Case of Luther. — Luther, although so able a man, was mad on some points. 
All people have their weak points; and he had his. He fancied the devil was in 
him; — as did also the Koman Catholics; and that he heard him speak. Luther's 
christian name was Martin; and in Hudibras* there is the following couplet upon 
it: — 

" Did not the devil appear to Martin 
Luther, in Germany, for certain'?" 

It is stated, in a note to this passage, that "Luther, in his works, speaks of the 
devil appearing to him frequently; and how he used to drive him away by scoffing 
and jeering him; for Luther observes that the devil, being a proud spirit, cannot 
bear to be contemned and scoffed." Luther used to talk to the devil; and the 
Popish writers not only believed that the devil was in him; but some of them 
affirm that he was begotten by an incubus (a kind of young devil); and that at 
length, when he died, the devil strangled him.^ 

Dr. Ferriar, of Manchester, had a patient of the same persuasion as Luther. 
He fancied he had swallowed the devil; and he would not discharge the contents 
of his alimentary canal, through a benevolent feeling; — lest he should let him loose 
into the world. I heard a gentleman speak of a man, who would not make water 
lest he should inundate the country. He thought the urine would come from him 
in such torrents, that the country would be washed away. A similar case to this 
was relieved by lighting a fire round the patient, and making him endeavour to put 
it out, lest the house should be burned down. Many persons fancy there are frog'-, 
serpents, and snakes, within them; and one woman fancied there was a whole 
regiment of soldiers in her. One man, named Vicentinus, fancied he was too large 
to go through a door-way; and when he was pulled through he screamed, and 
fancied he was being lacerated, and actually died of fright.*" Another woman, in- 
stead of fancying that she had a regiment of soldiers in her, fancied that she had a 

' Part 2; Canto 3; Lines 155 and 156, The poet adds:— 

" And would havegiiH'd him with a trick; 
^ But Martin was too politic." 

'' We thinke that to be a lie which is fathered upon Luther;— to wit, that he knew the 
devill, and was very conversant vviih him, and had eaten many bushels of sair, and made 
ji'Uie o^ood cheere with him; and that he was confuted, in a dispn'aiion with a real divell, 
about the abolishin2: of private ma^^^e.— Scofs '^ Discovery of IVi/chcrr/ft.^' 

c auoted from Marcus Donatus, bv Dr. A. T. Thoms(in;" in a Lecinre on Medicnl Jnri«;- 
prndence, published in the " Lancei" for March 11, 1837. (No. 700; 183G-7, Volume 1, 
Page 841.) 



550 AFFECTIONS OF THE INTELLECT. 

monster in lier genital?; and when she got rid of this idea, by the conlrivanne of 
her physician, she took another fancy; namely, tiiat she had been dead, and had 
been sent back to the world without a heart, and was the most miserable of God's 
creatures. At the "Retreat," near York, one patient writes — " 1 have no soul. 
I have neither heart, liver, nor lungs; nor any thing at all in my body; nor a drop 
of blood in my veins. My bones are all burnt to a cinder. I have no brain; and 
my head is sometimes as hard as iron, and sometimes as soft as a pudding." One 
man, it appears, thought he had not got his own head. He is described in Moore's 
" Fudge Family atParis.""" He says: — 

" Went to the mad-house. b Saw ihe man 

Who thinks, — poor wretch! — that (while the fiend 
Of discord here full riot ran-^) 
He, like the rest, was guillotined; 

But that when, under Boney's reign, 

(A more discreet, though quite as strong one,) 
The heads were all restored again, 

He, in the scramble, got a wrong one. 

Accordingly, he still cries out — 

' This strange head fits him most unpleasantly;' 

And always runs (poor dev'l !) about, 
Inquiring for his own incessantly." 

Bishop Warburton, in a note to one of his works, speaks of a person who 
thought he was converted into a goose-pie; and Dr. Arnold saw a man who fancied 
himself in the family-way. Pope, in his " Rape of the Lock"*^ describes many 
of these fancies. He says, in giving a sketch of hypochondriacal persons,^ — 

" Unnuraber'd throngs on every side are seen. 
Of bodies changed to various forms by Spleen. 
Here living tea-pots stand; one arm held out, 
One bent;— the handle this, and that the spout. 
A pipkin there, like Homer's tripod, walks; — 
Here sighs a jar, and there a goose-pie talks." 

A man in the University of Oxford, fancied himself dead; and lay in bed, wait- 
ing for the tolling of the bell; but, not hearing it at the time he expected, he fell 
into a violent passion, and ran and tolled it himself. He was then spoken to, on 
the absurdity of a dead man tolling his own bell; and it is said that he returned, 
and was afterwards sound in his intellect. However, he must have been pretty 
nearly in his senses at this time; — he must have been ready f<)r sanity; or such a 
change would not have been effected by a mere mental cause, like tliis. 

Simon Browne, a dissenting minister,^ wrote the best answer^ to Toland's work, 
entitled "Christianity as Old as the Creation;" but, notwithstanding the great 
powers of mind displayed in this work, he thought that, by the judgment of God, 
his rational soul had perished; and that he had only brute life; and he absolutely 
inserted this in the dedication of his work to the Queen.*' This dedication, how- 
ever, was afterwards suppressed.* 

"^ " Letter 9. From Philip Fudge, Esq., to the Lord Viscount Casilereagh," 

'' The Bicetre. c Alluding to the French Revolution. 

^ Canto 4; Lines 47 to 52. ^\n " the cave of Spleen." 

^ "Born at Shcpton Mailer, in Somersetshire, about the year 1680." ("Life and Works 
of William Cowper. Edited by the Rev. T. S. Grimshawe, A.M." Volume 5; Page4n.J 

s " Defence of the Religion of Nature, and the Christian Revelation." 

b Caroline, consort of George the Second. 

■' Madam — Of ail the extraordinary things that have been tendered to your royal hands, 
since your first arrival in Britain, it may be boldly said what now bespeaks 3'our Majesty's 
acceptance is the chief. Not in itself, indeed; it is a trifle unworthy your exalted rank, and 
what will hardly prove an entertaining amusement to one of your Majesty's deep penetra- 
tion, exact judgment, and fine taste; but on account of the author, who is the first being of 



AFFECTIONS OF THE INTELLECT. 551 

Baron Swedenbnrg, a very learned and able man, thonglit that he had commiini- 
calions with the Almighty for thirty years; and that he had been shown, by the 
Almig-hty, the mysteries of nature. Many think he was right; but no one could 
have that idea without some insanity. As some believe this, I mention it as an 
instance (adduced by others) of partial insanity. It is similar to the case of the 
celebrated Pascal; who, while he was working the problem of the cycloid curve, 
with great powers of intellect, was tied (by his own desire) in his chair; lest he 
should fall into a yawning gulf before him. He laboured under this partial insanity, 
while his powers of mind were otherwise as strong, and he was as much in his 
senses, as other people who have no madness whatever. One patient in the 
*' Retreat" near York, wrote the following verses on the patient who described 
himself as having neillier heart, liver, brain, nor any thing else.* 

" A miracle, my friends, come view! — 
A man (admit his own words true) 

Who lives without a soul; 
Nor liver, lungs, nor heart has he; 
Yet sometimes can as cheerfalbe 
As if he had the whole. 

His head (take his own words along) 
Now hard as iron, yet ere long 

Is soft as any jelly; 
All burnt his sinews and his lungs; 
Of his complaints not tifty tongues 

Could find enough to tell ye. 

the kind, and yet without a name. He was once a man, and of some lilde name; but of no 
worth; — as his present unparalleled case makes but too manifest; for, by the immediate 
hand of an avenging God, his very thinking substance has, for more than seven years, beea 
continually wasting away, till it is wholly perished out of him, — if it be not utterly come to 
nothing. None,— no, not the least remembrance of its very rains remains; not the shadow 
of an idea is let^t; nor any sense — so much as one single one, perfect or imperfect, whole or 
diminished — ever did appear to a mind within him, or was perceived by it. Such a present 
from such a thing, however worthless in itself, may not be wholly unacceptable to your 
majesty; — the author beins: such as history cannot parallel; and if the fact — which is real, 
and no fiction or wrong conceit — obtains credit, it must be recorded as the most memorable, 
and, indeed, astonishing- event in the reign of George the Second; — that a tract, composed 
by such a thins:, was presented to the illustrious Caroline; '^ his royal consort'" need not be 
added: fame, if I am not misinformed, will tell that with pleasure to all succeeding limes. 

He has been informed, that your majesty's pietv is as genuine and eminent, as your ex- 
cellent qualities are great and conspicuous. This can, indeed, be truly known to the great 
Searcher of Hearts only. He alone, who can look into them, can discern if they are sin- 
cere, and the main intention corresponds with the appearance; and your majesty cannot take 
it amiss, if such an author hints, that this secret apprt)bation is of infinitely greater value 
than the commendation of men; who may be easily mistaken, and are too apt to flattertheir 
superiors. But, if he has been told the truth, such a case as his will certainly strike your 
majesty with astonishment; and may raise that commiseration in your royal breast, which 
he has in vain endeavoured to excite in those of his friends; who. by the most unreasonable 
and ill-founded conceit in the world, have imagined that a thinking being could, for seven 
years together, Uve a stranger to its own powers, exercises, operations, and state; and to 
what the great God has been doing: in it, find to it. If your majesty, in your most retired 
address to the " King of kings," should think of so singular a case, you may perhaps make 
it your devout request, that the reign of your beloved sovereigfn and consort may be renowned 
to all posterity, bv the recovery of a soul now in the utmost ruin, — the restoration of one 
utterly lost, at present, amongst men. And should this case afiect your royal breast, you 
will recommend it to the piety and prayers of all the truly devout, who have the honour to 
be known to your maiesty: many such" doubtless there are, though courts are not usually 
the places where the devout resoVt, or where devotion reigns; and it is not improbable, that 
multitudes of the pious throughout the land may take a case to heart, that under your 
majesty's patronage comes thus recommended. 

Could such a favour as this restoration be obtained from Heaven by the prayers of your 
majestv, with what transport of gratitude would the recovered being throw himself at your 
feet; and, adoring the divine power and grace, profess himself, Kladam, your Majesty's 
most obliged and duiiful servant, Simon Browne. — Dr. Hawkesworth's'^ Adventurer ;" 
No. 88. 

* See Page 550. 



552 AFFECTIONS OF THE INTELLECT. 

Yet he who paints his likeness here, 
Has just as much himself to fear 

He 's wrong from top to toe. 
Ah, friends, pray help us, if you can; 
And make us each again a man; 

That we from hence may go!"* 

In insanity, therefore, we see that all the facuhies are not deranged. There 
may be merely an absurd belief upon some one point; and the patient may other- 
wise be in his senses. Many, indeed, who are deranged, will read and understand 
what they read. They will paint, exhibit mechanical contrivances, work, and talk 
rationally on many subjects; — nay, some will show extreme sagacity in accom- 
plishing their mad purposes, in concealing their mad impressions, and convincing 
others of the truth of their mad notions. In a case tried before Lord Mansfield, 
the patient'' was so clever, that he evaded all the questions put to him; and seemed 
to every body perfectly sane. Dr. Battie, however, came into court; and, knowing 
the point of the man's derangement, asked what had become of the princess, with 
whom he had been in the habit of corresponding in cherry-juice? Instantly the 
man forgot himself; and said it was true he had been confined in a castle; where, 
for want of pen and ink, he had written his letters in cherry-juice, and thrown 
them into the stream below, where the princess had received them in a boat." 

Increased Power of some Mental Faculties. — This, however, is not all; for 
some persons, in insanity, have some of their mental faculties increased. Dr. Rush 
says, that he had a deranged female patient, who composed and sang hymns and 
songs delightfully; and yet she had never shown any talent for either music or 
poetry before. There was excitement of one part of the brain, while another part 
was going wrong. He knew two cases where, in insanity, a great talent was 
shown for drawing. Dr. Willis had a patient who, in the paroxysms of insanity, 
and then only, remembered long passages of Latin authors, and took extreme 
delight in repeating them; Dr. Cox mentions a musician, who talked madly on all 
subjects but music; and his talent for that appeared increased. His performances 
on the violin were strikingly singular and original. Dr. Rush mentions the case 
of a gentleman who was deranged; but who often delighted and astonished the 
rest of the patients, and the officers of the institution, by his displays of oratory 
when preaching. Pinel, the French physician, mentions the case of a man, who 
was very vulgar at other times; but who, in his paroxysms of insanity, while 
standing upon a table in the hospital, discoursed very eloquently upon the revolu- 
tion; and with the dignity and propriety of language of the best educated man. 

Similar Occurrences in Fever. — Circumstances similar to these, have been seen 
in fever. When the brain is under the excitement of fever, a person who has 
shown but little talent for singing before, may sing very correctly; and sometimes, 
although an individual may be delirious, yet he will speak very eloquendy upon 
certain subjects. This state, however, does not last long. 

General Insanity. — Some patients are not so happily circumstanced as those we 
have mentioned; but, in their insanity, are wrong upon all points. Persons may 
be deranged on only one or more points, while the rest of the faculties are sound; 
or they may be deranged on one or more points, while one faculty (or more) will 

* See "Remarks on Mental Affections," by Thomas Bakewell; published in the " Impe- 
rial Magazine," Volume 4, Column 1002. (No. 4G; November, 1822) Mr. Bakewell is 
the proprietor of a well-conducted Lunatic-Asylum, called " Spring- Vale," near Stone. 

*» Mr. Wood, a merchant of Philpoi Lane, who indicted Dr. Munro for confining him in 
a mad-house, while (as he alleged) perfectly sane. 

•^ This trial having taken place in Westminster, he commenced another action in the city 
of London; and, on this occasion, no effort could induce him to expose his insanity; so that 
he was defeated only by bringing against him the evidence taken at Westminster. — " Inqui- 
ries concernvng the Intellec/val Poverx. By John AbercroviMe, ]yi. D." Pari 3; Section 4; 
Division 2; Subdivisions. {Nintk Edition; Pages 224 and S25.) The case is detailed at 
length in "Elements of Medical Jurisprudence; by Theodric Romeyn Beck, M. D. 
Edited by John Darwall, M. D." Chapter 12; Section 2. 



AFFECTIONS OF THE INTELLECT. 553 

be increased; but patients may be wrong' on all points. In the latter case, tliey 
will ramble from one point to another, display great inconsistency, and exhibit a 
wild association of ideas. They will be incapable of fixing their attention sufR- 
ciently to speak correctly, or to read. So wrong are they that, very likely, they 
do not recognize those with whom they were formerly intimate; or, if they do 
recognize them, it is in a very strange manner; and they have generally a very im- 
perfect memory altogether; most likely, have false ideas of nearly every thing with 
which their memory is charged. Their absurd opinions, too, are general. Perhaps 
they reason very incorrecdy on every thing; or they probably make no attempt at 
reasoning at all. In partial insanity, which is called " monomania, ""^ — insanity 
on a single point, when they do not reason correctly from a starting point, it is to 
be remembered that the starting point itself is partly incorrect. But, in intense 
insanity, they do not make an attempt to reason at all; or they reason in the most 
incorrect manner. 

lajluence of the Propensities and Sentiments. — So much with respect to the 
iine\\eciuA\ facv /ties. But in insanity the propensities and sentiments are fre- 
quendy disturbed. Some are so far disturbed as to be superstitious; some, again, 
are very respectful; some, again, are very impious. There was one madman who 
cursed God for his creation: and especially for having given him a human form; 
and he wished to go to hell, to avoid the disgrace of associating with the Deity. 
A person saying to him it was a bad day, he replied — " Did you ever know God 
make a good one?" Some are thievish: some are modest; some are very silly; 
some are lascivious; some are depraved in their sexual feelings; some are very 
cheerful; some are melancholy; some are fearful. Sometimes violence and tran- 
quillity, or melancholy, alternate. Shakspeare describes these changes: — 

" This is mere madness! 

And thus, awhile, the fit will work on him, 
Anon, as patient as the female dove, 
When that her golden couplets are disclosed,* 
His silence will sit drooping."^ 

Identify of Mania and Melancholia. — There is no real difference between 
*' mania" and " melancholia." The latter term is employed by many writers to 
signify madness connected with great depression of spirits; and it is applied by 
Pinel to partial insanity; — that is, to designate monomania. But this is improper. 
There is no essential difference between mania'' and melancholia.^ One faculty of 
the mind is disturbed in one case; and one in another. One person may be gloomy, 
and another cheerful; but the latter is just as mad as the former. A person may- 
be gloomy to-day, and cheerful to-morrow. 

Influence of the Feelings. — In insanity, every feeling of the mind may, in its 
turn, be excessive; or every feeling may be defective, or at least overcome by other 
feelings; and every feeling may likewise be depraved. In consequence of the 
varied state of feeling in insanity, we have various physiognomies. One madman 
has the physiognomy of pride; — holding up his head as high as he can, and look- 
ing with scorn on those around him. Others have the physiognomy of suspicion — 
a hanging down of the head; in others we see the physiognomy of rage — a frown- 
ing of the eyebrows, and a derangement of the features. The passion displayed 
in insanity, varies according to the state of the feelings. 

The Feelings only affected: Destructiveness. — In some instances of insanity, 
the feelings only are affected. There is no aberration of intellect; but it is a dis- 
ease of some of the feelings. There can be no question that some have an irre- 
sistible desire to commit murder. They are sane in every point but that; but they 
are irresistibly compelled to commit murder; and the moment they have committed 
it, they have confessed it, and expressed the greatest regret. Many have felt the 
fit of desire coming upon them; and have entreated their friends to confine them, 
to prevent them from doing it. This derangement of the feelings will sometimes 

« From fxovoi, one; and " mania," madness. (See Page 510.) 

t" Hatched. c «' Hamlet;" Act 5; Scene 2. 

* From fxaivofjiai, to rage. « From /uEXaj, blade; and x"^",- ^i^<^« 



554 AFFECTIONS OF THE INTELLECT. 

take one turn, and sometimes another. There can be no doubt that some hnve 
felt an impulse to destroy in a particular manner; — by burning. Some have felt 
an impulse to destroy themselves; and others, not only to murder individuals, but 
to muvder particular kinds of individuals; — to murder their children. 

When I was at the University of Cambridg'e, there was a person who was said 
to have attempted, three times, to set the college on fire; and at last he was tried 
for it; but, as he was acquitted, I suppose he had not made the attempt. It was 
ascertained that, wjien he was young, he had attempted to drown a child; yet 
nobody ever suspected him of being mad. 

The murderer of Mr. and Mrs. Bonner, at Chiselhurst, (in Kent,) was a foot- 
man in the family; and, one night, he left his room, went up stairs with a poker 
to the apartment of his master and mistress, and beat their brains out. He was 
asked his reason; but he could give none. He said that he had always been 
treated by them with the greatest kindness; and all he knew was, that he felt sud- 
denly, in the night, a desire to kill them; and he supposed the devil had prompted 
him to the act. No other sign of insanity was delected in him; and as, at that 
time, it was not supposed that such an occurrence could arise from insanity, with- 
out other proofs of insanity being evident, he was hanged. 

Gall mentions the case of a person at Vienna, who went to witness an execu- 
tion; and was seized with a propensity to kill. At the same time, he had a clear 
consciousness of his situation. He expressed the greatest aversion to such a crime. 
He wept bitterl}'-, struck his head, wrung his hands, and cried to his friends to 
take care and fly away. He felt the inclination; he regretted it; and entreated 
every one to prevent it, by putting him in prison. 

Pinel mentions the case of a man, who exhibited no unsoundness of intellect; but 
who confessed that he had a propensity to murder, which was quite involuntary; and 
his wife, notwithstanding his tenderness for her (which was real), was near being 
murdered; — he having had only time to warn her to fly. In the interval he ex- 
pressed the same remorse; felt disgusted with life; and attempted, several times, to 
put an end to his existence. In a work by Mr. Hill, we read of a man who was tried 
at Norwich, in 1805, for wounding his wife, and cutting his child's throat. He hftd 
been known to tie himself with ropes for a week, to prevent him from doing mis- 
chief to others. One of the members of a family in London, whose maid-servant 
was executed for attempting to poison the whole family with arsenic, is said to 
have used these words: — " Do, for God's sake, get me confined; for, if I am at 
liberty, I shall destroy myself and wife. I shall do it unless all means of destruc- 
tion are removed; and therefore do, good friend, have me put under restraint. 
Something from above tells me I must do it; and I shall." Arsenic was put into 
a pudding; and the maid-servant was executed for it; but many persons were per- 
fectly convinced of her innocence. 

Respecting the disposition to destroy by fire. Gall mentions that he saw a person 
in prison at Fribourg, who had set fire to his house four times in succession; and 
who, after he had set fire to it, tried to put it out. Once he seized his child, lest 
it should be burned. The moment he had set his house on fire, he was contented; 
the orgasm was over; and he was as anxious as any one to see it put out. 

Propensity to Steal. — Some have an irresistible desire to steal; without any 
other mark of insanity. Gall says that the first king of Sweden was always steal- 
ing trifles. Instances are mentioned of a German, who was constantly pilfering; 
and of another who had the desire entered the army; — hoping that the severe disci- 
pline there would restrain him; but he gave way to the desire even there, and was 
very near being hung. He then became a friar, with the same hope; but he still 
felt the same desire, and carried all the things he could to the cell; but, as he could 
only get trifles, he was not noticed; and he went on with his propensity. Gall also 
mentions that a person at Vienna, in the habit of stealing, hired a lodging to depo- 
sit his thefts; and, when he had got a stock, he sold them. He only stole house- 
hold matters. The w^ife of a celebrated physician, at Leyden, never went into a 
shop to buy any thing without stealing; and a countess at Frankfort had the same 



AFFECTIONS OF THE INTELLECT. 555 

propensity. Another lady, notwithstanding all the care with which she was 
brought up, had the same desire to pilfer. It is related of a physician, that his 
■wife was always obliged to examine his pockets in the evening, and restore the 
things she found there to his patients. He always took something, as well as his 
fee. Meritz speaks of a criminal who, at the moment he was about to be executed, 
stole the confessor's snuff-box. Dr. Burner, who was one of the physicians to the 
king of Bavaria, speaks of a person whom he knew very well, who enjoyed abun- 
dance, and had been well educated; but who, notwithstanding, was ahvays stealing; 
and was made a soldier by his father, and at last got hanged. The son of a cele- 
brated and learned man, himself very clever, and respectably connected in every 
respect, could not resist this propensity; and I could go on mentioning instances 
without end, of individuals who apparently did this from insanity; — not from any 
criminal motives, but absolutely from a blind desire too strong for them to resist. 

Inordinate Sexual Desire. — The sexual desire has been so inordinately strong, 
in some people, that it has been said that a criminal, going to execution for a rape, 
has been anxious to repeat the crime as he was proceeding to the gallows. I know 
it is so with respect to an irregular mode of ofratilication; — masturbation. 1 was told, 
by a medical man, of an individual who was rather idiotic; and who had the desire 
so strong, that he would entreat his family to run out of the room. He could not 
resist the impulse to gratification; though he cried, and lamented its power over 
him. 

Tioo'fold Definition of Insanity. — The definition of insanity, then, is two-fold. 
It may be stated to be — "an aberration of any mental power from a healthy state; 
with an inability on the part of the individual to discern its iinhealthiness;" be- 
cause, if an individual be aware of the absurdity and non-reality of what he fancies, 
he is not mad. If a person see the devil in the middle of the day, and is sure it 
is not the devil at all, of course he is not mad; but if the man see it, and believe it, 
and endeavour to make others believe it is a reality, — provided he has been better 
educated, — he must be mad. But this is not the whole of the disease; and not the 
form in which it will sometimes appear; and therefore we must include in the 
definition — " without an ability, on the part of the patient, to discover that it 
is an unhealthy state, or to resist it." If an individual have feelings so strong 
that he cannot control them, he is not an accountable being; — he is insane. This 
is the definition of Spursiheim; and it is the best I have seen. I have met with no 
other that satisfies me. It is a general definition; and it includes all the forms we 
can give, in a minute definition of insanity. I have reflected much upon it; and 
tliink it will apply to everv case. 

Intellectual Aberration as to Facts. — "With respect to the first part of the defi- 
nition, — that in which is mentioned an intellectual aberration, — it may relate to a 
matter of external sense, or to a fact which may be present or past; and in that 
case there can be no doubt of a person's insanity. If a person firmly believe some- 
thing to be actually a fact, — to be present, — to be existent, which we know is not 
the case, and which all the vv'orld knows is not the case (as, for example, that a leg 
of mutton is hanging to his nose^); — then we know he must be mad. If the aber- 
ration refer to a matter of fact that is present, we may declare him to be mad; or 
if it refer to something which is past, on which we are equally certain, and on 
which he has had an opportunity of being well informed when in his senses, it is 
fair to conclude that he is mad. If he be certain that he lived two hundred years 
ago, then there can be no doubt that he is mad. 

Intellectual Aberration as to Opinions. — Supposing, however, that it does not 
refer to a fact past or present, but to a mere opinion, then there may be considera- 
ble dinicuUy. In order to constitute him mad, it ought not to be a subject on which 
there is some difl'erence of sentiment among other persons; but an opinion palpably 
absurd to all other people in the situation of life, or superior to him. If we did not 
make an allowance for education, for country, and for external circumstances, every 
sect in religion (for example) might consider the votaries of another sect to be mad. 

» See Pa^e 549. 



556 AFFECTIONS OF THE INTELLECT. 

Every Trinitarian would consider a Unitarian to be mad; and every Unitarian wonld 
consider a Trinitarian to be mad. Qaakers would consider Jumpers to be mad; 
and Jumpers would consider Quakers to be mad. Every allowance, therefore, 
is to be made, in a mailer of opinion, for difference of education and difference of 
sitiiation. 

The notions entertained by one nation altogether, would be considered perfecdy 
absurd by another nation; and therefore it must be an opinion upon matters, on 
which all persons of the same country, age, situation, and education, will allow 
such an opinion to be positively absurd. If, in this country, a woman were to 
insist on burning herself to death after the decease of her husband, we should con- 
sider it insanity; but in India it is not insanity; because the people there have been 
educated in the belief of its propriety. It was mentioned in the House of Com- 
mons by Mr. Buxton, in 1821, that in the Presidency of Fort William, two 
thousand three hundred and sixty-six widows destroyed themselves in the previous 
four years; and some of these were only twelve or thirteen years of age. One was 
only eight: and one only eleven was so obstinate, when she was not allowed to 
burn herself to death, that she fasted from food for four or five days; and, although 
the local authorities prevented her from immolating herself on her husband's grave, 
she saved some of his bones; — in order that, when the first opportunity occurred, 
she might then destroy herself. Now such an act as this would be considered, in 
our country, as downriglit insanity; — it could scarcely arise from any thing else. 

Necessity for well-informed Juries .—^The ignorant have often imputed insanity 
to philosophers. Democritus was pronounced mad, by the common people, be- 
cause he dissected a body, in order to investigate the causes of insanity; but Hip- 
pocrates told the people that they were mad, and not Democritus. In a case of 
this description, a jury who were equally well-informed persons with the philoso- 
pher, would have been ihe only people capable of determining the question. If 
we empannel a jury to determine the madness of a person, they should be equal or 
•superior to him. If we select persons inferior to the person supposed to be mad, 
they (through their ignorance) may conceive him to be mad, when he is only a 
man of knowledge superior to themselves. If the matter, therefore, refer merely 
to opinion, there may be considerable difficulty as to the sanity or insanity of the 
individual; and no one who is not equal to the individual, or even superior to him, 
is capable of judging; and every allowance should be made for education, and for 
all external circumstances. If we take these precautions, we may disregard the 
complaint,— that " the madman was as much in his senses, as the rest of the world; 
but the majority was against him, and therefore he was placed in custody." 

Diagnosis between the Culprit and the Madman. — Supposing, however, that 
it is another form of insanity; a propensity; and a propensity to murder; which 
propensity the patient cannot resist. Here the great difficulty is to ascertain 
■whether this state is real or not; — whether (in case an act of murder has been com- 
mitted) the individual could not have resisted the propensity: — whether he has 
been giving way to some vile feeling, or has been the victim of an irresistible pas- 
sion. Now, in pronouncing a person who has committed a crime to be insane, — 
as having been unable to resist the temptation, — we must ascertain first whether 
there has been any motive or not. If any motive can be discovered, then we may 
be justified in saying that the individual is a culprit, — is not mad. There should, 
in the first place, have been an evident reason for it. Generally, however, where 
there is some irresistible feeling, there is, at the same time, some wrong notion. 
When persons have committed murder, from an instantaneous desire to destroy, 
generally (though by no means always) they had, at the same time, some wrong 
notion; — some imagination that it was a voice from Heaven that called them to 
commit the deed. Hence we have less difficulty than we otherwise should have. 
In many of these cases, where there has been no motive, the patient himself, as 
soon as the deed has been over, has actually declared that he had no motive, and 
has expressed the greatest remorse for what has been done. On other occasions, 
he has laughed at the deed; — considered it a matter of indifference: — not concealed 
it, but given himself up to justice. In other cases, before the deed has been done, 



AFFECTIONS OF THE INTELLECT. 55T 

patients have requested to be confined, and thus prevented from doing what their 
jeeliiio^s prompted. 

Indications afforded by the Shape of the Head. — To those who have paid any 
attention to phrenology,* not only is this not wonderful, but considerable assistance 
may be derived from examining the shape of the head. The shape of the head 
does not show a man to be mad; for a man with a head o{ one shape may become 
insane, as well as a man with a head of another shape. A stomach of one shape 
or size will be subject to dyspepsia, the same as a stomach of another shape or 
size. It is absurd to suppose that, in insanity, there must be a particular shape of 
the head; but it is an unquestionable fact, that if a person have any one peculiar 
feeling of the mind, (which feeling phrenologists believe to be situated in a particu- 
lar part of the brain,) and the correspondent part of the head be correspondeniiy 
largely developed; that strong feeling will take the lead of the other feelings. 
Putting phrenology out of the question, whatever feeling or passion is remarkably 
predominant in an individual, — so as to take the lead, — if the other proportions of 
the brain be too small, such an individual is likely to go mad. Now if it be a fact 
that the brain, in dilTerent parts, corresponds with the natural intensity of the 
different feelings, then that part of the head may be expected (in general) to be 
proportionately large; and if it be said of an individual supposed to be mad, that he 
is the victim of a particular feeling, any one who attended to phrenology would 
certainly examine the head, and see whether there was a large development, cor- 
responding with the passion which appeared irresistible; and if he found such a 
correspondence, that would be an additional reason for inclinmg to the belief, that 
the individual had been the victim of a feeling that was irresistible. 

Case of BeUingharn. — This was shown strikingly in the case of Bellinghani, 
who murdered Mr. Perceval. Bellinghani was a man of weak intellect; and we 
see, from a cast of his head, that the anterior parts of the head were miserably 
developed; whereas the lateral parts (posterior and anterior) were largely developed: 
so that the man's passions were evidently much too strong for him to resist; and 
the passions particularly developed in him, were pride and destructiveness. That 
man was executed, because there was no proof at all that he was insane; but any 
one, oji looking at his head, would incline to a favourable opinion; and though he 
would not set him at large, to do such mischief again, yet he would not deprive 
him of life. There is a large development of pride and destructiveness: and that 
part of the brain, being large, has gained an ascendency over the rest; and has been 
liable to excitement. In a great number of cases of insanity, the character of the 
individual corresponds wiUi the form of the head; and when the question is, 
whether the propensity to the deed which has been done was irresistible, or 
whether the patient could have controlled it, we may find it of great service to 
examine the head. If we have other reasons to believe that the deed has been 
(lone irresistibly, a peculiar development of the head (if it exist) is an additional 
reason. The shape of the head is not to be depended upon solely; but to be taken 
into consideration, in conjunction with other circumstances. 

Has there been Previous Injury of the Head, or Apoplexy? — Another circum- 
stance that would render the existence of insanity probable, woidd be ihe previous 
receipt of an injury of the head. If a person have once sustained such an injury, 
of course the head is very likely to go wrong. If we have no ostensible reason for 
the act, but (on tlie contrary) have reason to believe that the man was ilie vii-tim of 
irresistible impulse: and if we know that he has had an injury of the head fcirmeriv; 
we should then be doul)ly inclined to the opinion of his being insane, and should 
urire the judges to show mercy, on account of the injury in question. Another 
thmg to be considered is, whether he has had a fit of apoplexy or of paralysis; for if 
he have, then the head might be supposed to be going wrong, when the man com- 
mitted the deed. 

Has Insanity existed in his Family? — Another circumstance will be the ex- 

* From <{>;«», ihe mind; and Xoyot, discourse. 



55S AFFECTIONS OF THE INTELLECT. 

istence of insanity in his family. If an individual do a criminal act, and we have 
stront^ reason to believe that he did it through insanity, — allliough he may never 
have had an hallucination; yet, if we find insanity in his family, we may conclude 
the insanity has descended to him. Nay, if we find that no injury of the head has 
ever existed, and there has been 7io insanity in the family; yet if this man was 
insane on a former occasion, then we have strong reason to believe, that this very 
act was only the recurrence of insanity; even tliough ihe previous attack may have 
been short, — though the person's peculiarity of mind have merely amounted to 
great eccentricity. 

These are circumstances that will assist our judgment, when a person has shown 
no hallucination at all; but merely done a deed, which we suspect must be the 
result of insanity. In the first place, there should be no motive for the deed. 
Secondly, it is to be considered whether, at the moment he did it, the person con- 
fessed that he had no motive; and gave himself up to justice. Thirdly, consider 
whether or not the patient was aware that he had done any great injury. In the 
next place, consider whether t,he propensity to commit the act has come on in a 
paroxysm; and the patient has been aware of it, and wished to be confined. Then, 
if there be an agreement of the head with the passion; if there be insanity in the 
family; or the individual have been previously insane; or there have been other dis- 
eases of the nervous system (such as apoplexy or paralysis); — in these circumstances, 
the individual is "mad," in the common acceptation of the term; though he is not 
mad legally. In many of these cases, however, there is not such great difiiculty; 
because, some wrong idea has generally been observed. 

Many Insane Persons not Legally Mad. — Although it is quite necessary to 
prove that a man has been wrong in some of his notions (either relating to facts 
present or past); or in some matters of opinion; — although it is necessary to prove 
that he is absolutely deranged on that one point, or that he is the victim of some 
one irresistible feeling, before we can say, legally speaking, that he is mad; yet 
pathologically we may say, that a great number of people who are at large, are 
insane. A great number of people at large have any thing but a healthy slate of 
the brain. They have one feeling too strong, or they have a ridiculous notion 
upon some point; but it is so slight, that it does not disqualify a person for carry- 
ing on the affairs of life; and therefore it is only said, that such an one is "a 
strange fellow," or "an odd fellow;" and so he passes. Speslung pathologically^ 
then, a large number of people, who go about, are more or less "cracked;" but 
legally speaking, in order to be accounted mad, a man ought certainly to have a 
mental power in a state of aberration from a healthy state, to such a degree as to 
disqualify him from conducting the ordinary business of life; or should be the 
victim of some strong feeling, which leads to the injury of others, or of himself. 

Hypochondriasis. — If it be a mere matter of opinion on which a person is, 
pathologically speaking, mad; — as, for instance, that an individual has an unfounded 
fecir of disease, and of death, — -we call it merely "hypochondriasis;" and it does 
not justify us in calling him "mad." If a man who has nothing the matter with 
him, is satisfied he is in a consumption, because he cougiis twice a day; and, 
because he spits a drachm of mucus in the twenty-four hours, is satisfied that his 
lungs are full of abscesses, this is a morbid feeling; but as it would not lead to a 
criminal act, or to any act which is dangerous to others, we do not say he is 
"mad." We only call the feeling " hypochondriacal;" but the nature of that feel- 
ing is exacdy the same. Many such persons act, on different occasions, very ab- 
surdly. Some will not dress as other people dress; some will not eat as other 
people eat; and they will do a number of things more or less extiavagant; but, as 
the degree of extravagance is less, and as they do no act which is injurious to 
others, we do not call them "madmen." They merely pass as ''eccentric indivi- 
duals;" but some one in the family will carry his eccentricity to a higher pitch; 
and then it is necessary to confine him. It is absolute madness. Suppose a man 
squanders all his money away; — not for the gratification of a particular feeling, but 
in a way which is quite contrary to what all other people do; or suppose he in- 



AFFECTIONS OF THE INTELLECT. 559 

flicts punishment upon liimself, and attempts to murder himself or others, or com- 
mit depredations on the property of others; — we are not justified in saying, legally, 
that he is mad; although, medically, we are quite satisfied that he is in an unsound 
state. 

Suicidal Mania. — But although, when the person suspected of insanity is alive, 
it is necessary to use all these precautions; yet, when the person is dead, we are 
allowed to incline to this opinion on much more general grounds. When a person 
is alive, of course it is a serious thing to treat him as a madman; and, whatever his 
eccentricities may be, we are not allowed to say that he is legally mad, unless per- 
fectly satisfied that he does things not simply injurious, but criminally injurious 
to himself or others. If he be guilty of such acts, we may be justified in saying 
he is mad. But if he has destroyed himself, then, on the slightest grounds what- 
ever, — if he have merely said a word or two of nonsense, we are allowed to say 
that he is legally mad. When a person has committed suicide (which act cannot 
be committed again), the least probability of mental derangement is admitted by 
law. Where a person is alive, it is mercy which induces the law to compel us to 
give evident proof, before a man is pronounced insane; because it would be cruel 
to confine him without: but when a person is dead, it is desirable to prevent his 
being treated as a self-murderer; and it is a mercy to make it appear, as much as 
possible, the result of a morbid state of mind. There can be no doubt, in ray 
opinion, that many criminals are not called "mad," who really are so. I have no 
doubt that thousands, whose crimes were the result of insanity, — who were not 
responsible agents, have been executed unjusdy; and that thousands more will be 
executed. 

Difficulty of Detecting the Hallucination. — There may be extreme difficulty, 
sometimes, in ascertaining that an individual has any absurd belief at all; and there 
is a difliculty on the other side of the question, respecting this absurd belief. Oc- 
casionally, it is almost impossible to ascertain whether a man is mad; — owing to the 
cunning of madmen. When persons are mad, they frequently have sufficient cun- 
ning to deceive any one who is not thoroughly acquainted, not only with the habits 
of madmen in general, but with the belief of the particular individual. It requires 
very great skill, sometimes, to bring a person to speak on the point on which he is 
absurd. 

I have mentioned the case of a man, who underwent a most severe examination 
without exposing liis complaint; until asked by Dr. Battle (who knew the point on 
which he was insane) what had become of the princess, with whom he had corre- 
sponded in cherry-juice.'' We have another instance too striking to be omitted:— 
" I well remember," says Lord Erskine,'' " that since the noble and learned judge" 
has presided in this court/ I examined, for the greater part of a dav, in this very 
place, an unfortunate gentleman, who had indicted a most affectionate brother, to- 
gether with a keeper of a madhouse at Hoxton, for having imprisoned him as a 
lunatic; while, according to his evidence, he was in his perfect senses. I was, 
unfortunately, not instructed in what his lunacy consisted; although my instruc- 
tions left me no doubt of ihe fact; but, not having the clue, he completely foiled 
me in every attempt to expose his infirmity. You may believe that I left no means 
unemployed, which long experience dictated; but without the smallest efl^ect. The 
day was wasted; and the prosecutor, by the most affecting history of unmerited 
sufi'ering, appeared to the judges and jury, and to a humane English audience, as 
the victim of the most wanton and barbarous oppression. At last Dr. Sims, who 
bad been prevented by business from an earlier attendance, came into court. From 
him I soon learned, that the very man whom I had been above an hour examining, 
with every possble effort which counsel are so much in the habit of exerting, 
believed himself to be the Lord and Saviour of mankind; — not merely at the time 
of his confinement, (which was alone necessary for my defence,) but during the 

^ See Page 553. 

^ On the tiial of James Hatfield, for shootinsr at George the Third. 

c Lord Mansfield. ^ The Court of King's (now Queen's) Bench. 



560 AFFECTIONS OF THE INTELLECT. 

whole lime that he had been triumphing over every attempt to surprise him in the 
conceahnent of his disease. I then affected to lament the indecency of my igno- 
rant examination; when he expressed his forgiveness; and said, with the utmost 
gravity and emphasis, in the face of the whole court, — ' I am the Christ;' and so 
the cause ended,"* 

We see, therefore, the extreme difficulty which we may sometimes meet with, 
in detecting the madness of an indivithial; that a very minute inquiry is necessary; 
and that sometimes no minuteness of inquiry will do, unless we are informed of 
the particular point on which the individual is deranged. 

» 

h. Physical Signs of Insanity, and its Progress. 

Besides the varieties of insanity, — the variety of absurd notions, the variety of 
degree, and the absolute extent of this absurdity, (ihe person being absurd on one 
notion, or on every thing; from having little intellectual power left, or very little 
perception on a point;) — besides the variety of the native characters of individuals, 
independent of their sanity or insanity; and the variety that must exist as to 
the derangement of feeling, as well as an excess or defect of feeling; — besides all 
these, there are many other circumstances which occur in insanity. 

Physical Signs. — The head, for example, is frequendy hot (both in the various 
paroxysms, and at the commencement of the disease;) frequently the urine is red; 
the pulse is quick, full and firm; the eyes and cheeks are red; in fact, there is more 
or less of an inflammatory condition of the head. Then there are pains, and all 
kinds of odd sensations in the head; — cracking, bursting, twitching pains of every 
description. Insane persons speak of flashes of light, of double vision, of noises in 
their ears; and nothing is more common than deafness, which is the usual disturbance 
of the external senses in madmen. Sometimes there is a depravation of smell. 
Patients will fancy there is some intolerable stench around them, and will speak 
out of their nose. I believe they are generally very fond of snufl^. Occasionally, 
too, there is a great resistance to external cold; but this is by no means universal; 
for many insane persons, through this notion, have been left to themselves; their 
extremities have mortified; and they have died. Now and then, however, there 
has been observed an extreme insensibility to cold; so that they have exposed 
themselves to frost and snow, without suffering from it in the least. There is ap- 
parently a great insensibility even of the external senses; but this principally arises 
from the abstracti()n of mind which, in general, is kept up within; so that the pa- 
tient does not aitend to what goes on around. On the other hand, however, 
extreme sensibilily has very often been noticed in the disease. Sometimes we 
o'/serve a sort of stupor; and this is not constant, but comes on occasionally. 
There are often various other diseases of the brain; such as epilepsy, paralysis, 
hysteria and catalepsy. The integuments of the head, especially the posterior, 
superior parts, are often loose and spongy; so that if the scalp be gathered up, it 
will be found fuller than usual, and loose. 

The breath is very offensive; and some say there is a peculiar smell of the 
body; — so that we can smell a madman. Some, however, think it very hard that 
a person should be called " mad," because he does not smell like a gentleman. 
The tongue is very frequently foul, and the mouth is filled with a viscid mucus; 
so that madmen are constantly endeavouring to spit it out. I presume there is 
sometimes a depraved habit of spitting about, and making things dirty; but, be- 
sides, that, I have no doubt that the tenacity of the mucus is frequendy a cause of 
it. It causes an unpleasantness; which the ])atient attempts to remove, by hawk- 
ing and spitting. Some spit constantly in Uiis disease, when it is not intense. I 
had a patient who was constantly insane; but who, about every fortnight or ten 
days, had a paroxysm. When he was in a moderately insane state, he spat nearly 

• The foregoing extract, and some further details of Lord Erskine's speech on the occr- 
sion, will be fcnind in Professor Amos's Lecture on Insanity; published in ihe " Medica 
Gazelle," for July 2, 1831. (No. 187; Volume 8; Pages 420 lo 423.) 



AFFECTIONS OF THE INTELLECT. 561 

a pint a clay; but as soon as an aggravation of the symptoms approached, he spat 
less; and as soon as the paroxysm was established, he never spat at all. Then, 
when it was declininir, he began to spit again; and when it was over, he sp >t as 
profusely as ever. We sometimes observe extreme hunger, and extrenve thirst; 
but sometimes there is an absence of both hunger and thirst. The patient seems 
to have no desire for either food of drink. Cosiiveness is very common in the 
disease; and sometimes we observe great muscular strength; so that an exertion is 
made, far beyond what is possible in health. Sometimes insane people scarcely 
sleep at all. They will pass many days, perhaps weeks, with very little sleep; 
sometimes without any. 

Preceding Signs of Insanity. — Insanity sometimes begins suddenly; and this 
is particularly the case where the hullucination relates to a propensity. Persons 
have sometimes been suddenly seized with an irresistible propensity; and other 
forms — where there is an absurd notion, or where there is general delirium — may 
also begin suddenly. For the most part, however, insanity is ushered in by an 
oddity of manner and behaviour. There is a great degree of loquacity noticed. 
Persons talk much more than they are accustomed to do; and will burst into foolish 
j&ts of laughter. On the other hand, they are sometimes observed to be very taci- 
turn. On other occasions persons, before the disease, are observed to be extremely 
passionate; — in a different state as to temper to what they are accustomed to be; 
and some, instead of being passionate, are sulky. Some are extremely civil. I 
have known such civility, as to be quite extravagant. They will beg us to stop to 
dine, when we have dined already: they will beg us to stop to supper; and then 
to take a bed. I have been astonished; and have afterwards learned, that these 
good people were in a madhouse. Frequently, too, there is a quickness of manner. 
There is no loquacity, — no civility; — but a hurried way of doing every thing. 
Frequently there is observed a w^ant of a proper attention to their aflfairs. They 
do not take the same interest in their affairs, that they did before. Again: this dis- 
turbance of feeling is frequendy observed before the full formation of the disease. 
There is a want of affection to relations and friends; and, more or less, a change 
of general habits. These are the chief circumstances which precede the full 
establishment of the disease, when it does not come on suddenly. 

Duration. — With regard to the continuance of the disease, it will vary from a 
few weeks, to the rest of the individual's life. 

Madmen have lived to the age of eighty-seven. Mr. Tuke, in his account of 
the patients at the "Retreat,"^ says that there were eleven patients there, between 
sixty and seventy years of age; four, between seventy and eighty; and one liad ar- 
rived at the age of eighty-seven: yet, upon the whole, there can be no doubt that 
insanity shortens life. If a person in insanity live to a great age, it is lucky (or 
unlucky) for him; but, in a great number of instances, such persons do not live to 
be very old; just as is the case in connate idiocy. Persons who have congenital 
idiocy, generally die before they arrive at the middle period of life. 

Rare in Childhood. — It very rarely, comparatively, occurs in children. The 
unsoundness of intellect in children is, in general, idiocy. Children have very 
weak passions. They are very little influenced by external circumstances, before 
mixing with the world, and forming connexions; and, of course, their passions are 
little liable to be unfavourably excited; and they have much less intellect than 
adults; — ^so that, altogether, they are much less subject to insanity. Still, how- 
ever, children may be insane. x4.1though their unsoundness is usually idiocy^ 
in various degrees, yet occasionally they are insane. Dr. Haslam'' gives cases of 
insanity in a child; and so does Mr. Greenwood. I think I have seen several 
instances of this; where it has been characterized by no delusion, but by very vio- 
lent rage. Whether, when it begins in childhood, it continues for a long life, I do 
not know. I cannot say whether such individuals do, or do not, die prematurely. 

' See Page 551. 

»> See his " Observations on Madness and Melancholy."' Chapter 1. 
VOL. 1.-36 



562 AFFECTIONS OF THE INTELLECT. 

Remissions and Intermissions. — But although insanity may continue during 
the rest of the patient's life, it sometimes has remissions, and even z;z/e?'raissions. 
People are not only much less mad at one time, than at another; but sometimes 
they are not mad at all. These intervals of sanity, are called " /wciV intervals;" 
but, for the most part, a lucid interval is nothing more than the diminution of ex- 
citement. The patient is not less mad, but he is less violently excited than before; 
and therefore it is fancied that he is sound; but, in a great number of these cases, 
we have only to touch the string, and the madness shows itself again; — the patient 
being only more tranquil, — less evidently mad than before. The greatest caution 
is required in believing that a person is in a lucid interval; that is, in believing that 
a person is in an intermission of the disease. 

Sometimes Periodical. — Occasionally the disease is not only intermittent, but 
periodical. I was once shown, in a madhouse, an individual who was said to be 
deranged, for a certain time, every three years. I was applied to by a patient in 
1814; and, as the case struck me, I made a particular note of it. He was forty- 
one years of age; and, five years before, a stone had struck him on the temple. 
The following and three subsequent years, in the month of March, he had pa- 
roxysms of laughing, yawning, stretching, and convulsions; the secretion of urine 
Avas sometimes copious; and sometimes scanty; there was great vivacity of spirits; 
he spoke and believed all sorts of absurdities; and his bowels became costive at 
that time, though at other times they were freely open. This was an instance of 
insanity. He was only mad in March; — the time at which hares are said to suffer 
derangement. The disease evidently arose from the blow inflicted on the temple, 
five years before. 

Alternating ivith other Diseases.^— 'T\\Q disease will sometimes intermit, alter- 
nately with other diseases. It has been observed to alternate with disease of the 
lungs. I was once, when a student, shown a patient in Guy's Hospital, who died 
of phthisis. I understood that he had been previously deranged; and that as soon 
as derangement ceased, phthisis began; but he was previously considered phthi- 
sical. Whether he was in a state of phthisis, I cannot say. 'i'he stethoscope"* was 
not used then, neither was the ear; but he was considered to be in a state of phthi- 
sis. He had pectoral symptoms; the insanity ceased; all the pectoral symptoms 
increased; and he died. 

Usual Mode of Termination. — Insanity may exist for a long time, and then 
cease. Dr. Rush speaks of spontaneous cures after eighteen or twenty years; but, 
in one case, he uiitnessed recovery after nine years' duration. Very often, how- 
ever, insanity terminates in fatuity;'' and when it so ends, the fatuity is called "de- 
mentia."" Idiocy, fatuity, and dementia (I mentioned) were in reality the same 
thing; but if idiocy come on in after life, it is called " fatuity;" and if fatuity be the 
consequence of insanity, it is called "dementia." But it is to be remembered, 
that if madmen live to be old, — and some live to be very old, their mind, deranged 
as it is, must decline in the course of nature; — just as the minds o{ sane people de- 
cline; — just as all our minds will decline; and therefore one can hardly say that 
insanity has produced dementia; for the insane mind must fall into second child- 
hiood, exacdy like the sane one. The disease, however, very frequently termi- 
nates, or is joined at last, by palsy; or perhaps by apoplexy; which proves fatal. 

c. Morbid Appearances, 

Lesions frequently Evade Detection. — When persons die of insanity, we (for the 
most part) find nothing sufficient to explain the symptoms. There is, perhaps, no ap- 
pearance of disease in the head; — especially if the person die early, and be inspected 
very soon after death. But we should remember, tliat although frequently nothing 
is found to explain the symptoms, very few brains are dissected in a proper man- 

• From o-tkQoi;, ike chest; and o-xoTrsa;, to explore. ^ From " fatims," silly. 

« From " de,'' loithout; and " mens— mentis," mind. 



AFFECTIONS OF THE INTELLECT. 563 

ner. Most persons run over an examination of the brain more qnicldy than any 
other part. It takes so much time to open the head, that the rest of the business, 
for the most part, is hurried over; and many who do examine the brain, are not 
qualified for such an examination. Notwithstanding all this, however, there can 
be no doubt that little or nothing is frequently found in the brain of insane persons; 
— ^just as is the case in the stomach, in dyspeptic people. The stomach of a dys- 
peptic person, when opened, could not, in the greater number of cases, be distin- 
guished from that of other persons, who have died with an excellent digestive 
apparatus. After pure asthma, we cannot tell that the individual has been subject 
to the affection. 

Insanity Corporeal, though not necessarily Structural. — The foregoing, there- 
fore, is no argument against the disease being an affection of the brain. A disease 
may be corporeal, and yet not be structural; — no affection of any organ may take 
place. It does not follow, because we say insanity is corporeal, that it is not a 
disease of the mind. We know nothing about that, except as to this world; and 
it is with this world that medical men have to do. It is a corporeal disease; but 
that does not imply that it must be a change of structure. A change of function 
may be quite sufficient. In diabetes, which destroys life, I have frequently opened 
bodies; and have not seen any evidence of organic disease. It is easy to conceive 
that this must be the case, if we remember, that individuals who have been mad 
for years have, just before death, recovered completely. A lady of rank, in whose 
family there is insanity, told me, that her husband had been deranged for a great 
number of years; and at length he died; but just before death he recovered his 
senses. Dr. Marshall, who was formerly a teacher of anatomy in London, men- 
tions a case where recovery from insanity occurred a few hours before death. Now 
if the disease had arisen from a structural affection of the brain, — if the brain had 
been so disorganized that it could not perform its functions, such an event could not 
have occurred. 

Evidences of Cerebral Disease. — Insanity proves itself to be a cerebral affection, 
as much as dyspepsia proves itself to be a disease of the stomach. But we may 
have anatomical proof in these cases; for, when the disease has continued long, 
we generally find some mark of disease in the head. We do not find any thing to 
explain the insanity; but we find something that shows there has been suffering in 
the head. For example: — there is often fluid in excess in the brain, or upon the 
brain; or the membranes of the brain are thicker than usual; or they are opaque. 
The bones of the head aie very frequently thickened likewise; the external table 
remains in its proper situation; but the diploe between the two is increased. A 
deposition takes place there, and the bones become thicker; and, not only so, but 
sometimes they acquire a degree of hardness equal to that of ivory. Insanity, it is 
true, is not situated in the bones of the head; but when there is such thickening of 
the bones, and the tnembranes are thickened, and effusion is found in the mem- 
branes, it shows that the head has been sufl'ering. 

Thick Skulls. — Gall mentions that, in many suicidists, — in fact, he says in all, 
— and frequently in great criminals, where there was no efficient reason for the 
action of which they had been guilty, — where they had been influenced by violent 
feelings only, — he found the bones dense and thick. Greeding mentions that, in 
two hundred and sixteen maniacs, he found the bones of the cranium very thick in 
one hundred and sixty-seven. In one hundred/wrioz^s maniacs, he found in sixty- 
eight that the bones of the cranium were very thick. Out of thirty imbecile indi- 
viduals, he found the bones of the cranium very thick in twenty-two. Gall men- 
tions another interesting fact; which is that, in the extreme old age of maniacs, the 
bones may grow thin again; — just as they do in sane individuals. It is well known 
that, in sane individuals, the bones become very thin in certain parts; and though 
in insanity we may have them thickened, yet they will become thin again. 

Local Lesions of the Brain. — Besides these appearances, we may find various 
diseases in the brain itself; but we must not be surprised if, in cases which are not 
of long standing, we do not find any disease at all. If the case be of long standing, 



564 AFFECTIONS OF THE INTELLECT. 

and the bones are diseased, we may also find disease of other parts. I had a case, 
which occurred in a woman who had a disposition to injure herself: and there was 
violent pain in each ear. She was deformed, and laboured under chronic bron- 
chitis. She was placed near a window, caught cold, and died suddenly. After 

» A female, aged thirty-one, was admitted [into St. Thomas's Hospital] on the fifteenth 
of February [1831]; saying tliat she had been ill two months, it was represented to me 
[Dr. Elliotson] as a nervous case. The symptoms were, a propensity to injure some part 
of herself; and she had " no ease and comfort" (these were her expressions) till she gave 
way to it. " The part that she desires to injure" (says the case-book) " does not continue to 
be the same for above an hour at a time; but, as soon as the desire to injure one part ceases, 
she desires to injure another. The mode in which she is anxious to injure herself, is simply 
by what she calls her own internal efforts. She does not desire to cut herself, or dash her 
head against the wall, or to poison herself; but to injure herself simply by muscular efforts, 
unaided by external objects;— so that she will hold her breath for the purpose of suffocating 
herself; she will twist her head to one side, in order to strain and break all the muscles and 
tendons on the other side of the neck; she will sometimes force her breath into her ears, so 
as to endeavour to burst them; and make all the efforts she can, to strain and force her eyes 
out of her head." She was quite sensible that this was a morbid slate, and lamented it ex- 
ceedingly. She wondered what was the matter with her; and said that, before this affec- 
tion, she had always had a strong mind, and could restrain her feelings; but now she had 
no control over her inclinations. Her spirits were greatly depressed, on account of finding 
herself in this horrid slate. I could discover no oiher morbid condition of the mind. Her 
judgment, on all points, was good; she was under no delusion of any kind; and yet she pos- 
sessed this desire. There could be no condition of the case being feigned; for, while you 
were talking to her, and she to you, you saw her head twist on one side violently; and could 
discern that she was silently making an effort to rupture some part of the neck, or to over- 
strain it; and you would see her eyes close, from the efforts that she appeared to be making. 
Her head was thus constantly in motion; and I thought, at first, she 'had shaking palsy of 
the head, or partial chorea; but that was not the case, for she told me, that it arose from her 
own incessant efforts to strain her head and neck. This appearance of the head was con- 
tinually going on. 

But ihe proof that there wac no deception in all this, was not merely that you saw these 
efforts going on too naturally and too intensely to be counterreited,but there were a number 
of Other symptoms. She was drowsy, had pain in her head, a sensation of pressure there, 
and (she said) a sensation of " opening and shutting" in her head from time to time; but this 
was chiefly felt at the sides of her head, immediately above the ears; and shot across the 
back of the head, in a straight line. This sensation was felt immediately above the ears, 
and extended backwards till the two sensations — the sensations of each side— met. Now 
she might have said that she had this pain when she had not; but it is a remarkable fact, that 
this was an alleged seat of the pain. Moreover, there were sensibly evident symptoms of 
disease; for her breath was excessively offensive; so that (hose who were much about her 
complained of it, and could not long hold their heads near her. Frequently it turned my 
stomach (which is a pretty strong one); and her tongue was excessively foul;— being coaled 
with dirty, thick mucus. She was in a siluation of life, too, which rendered it exceedingly 
improbable that there could be any deception; for she kept a school, and had (in addition) 
a little trade in the way of a peculiar kind of needle-work; and, by means of them both, she 
gained a very excellent livelihood. She was exceedingly respected, in her own neighbour- 
hood, by medical men who knew her, and by every one else. This I learned from the 
medical genlleman who sent her here [St. Thomas's Hospital], to be under my care. She 
had hardly any sleep, when she first came to the hospital. Besides the pain running back- 
wards from each ear, she complained of a strong pulsation in that part. 

You will sometimes meet with a case, where the person has a sound judgment on every 
point, — is not at all insane in his intellectual faculties; but is wrong with respect lo some one 
feeling. He finds it irresistibly violent; and, perhaps, it is vitiated at the same time. Now 
this was the case here. This woman was labouring under a propensity which is called, by 
Dr. Gall, " the propensity to murder,'^ or (in the nomenclature of Dr. Spurzheim, diapproved 
of by Dr. Gall) " destructiveness;" a propensity, whatever name we give il, bestowed upon 
animals in general, for the purpose of destroying other animals for the sake of food, and for 
the purpose of rage; and which exists in us, it has been supposed, in such a form as lo give 
the feelings of rage, anger, or indignation. In this woman there was a diseased manifesta- 
tion of ihis propensity; only it was limited to hurling herself She wished continually to 
injure herself. But there was still a greater limitation of it, and a very striking peculiarity 
in the case; inasmuch as she had constantly a desire to effect Ihe object (according to her 
own account, and as it appeared) only by internal exertion;— not by taking poison, not by 
culling herself with an insirument, not even by using her nails for the purpose of lacerating 
her flesh; but simply by straining, forcing, twisting, stopping her breath, and endeavouring 
to force out her eyes and her ears. A peculiar circumstance was the pain which she felt, 
and the throbbing just over each ear, and extending parlially around the head. Every gen- 
tleman in the habit of going round the hospital, must have heard her say, that the pain 



I 



AFFECTIONS OF THE INTELLECT. 565 

death, over each ear, there were found strong adhesions to the ♦' dura mater;" and 
the brain itself, just over the part, was in a slate of vascularity. In insanity we 
may find different parts of the brain more or less inflamed; and we may find the 
appearances which inflammation more or less induces; such as thickening and 
softening, and various organic affections; — ^just such as would, a priori, be expected. 

Increased Heat of certain Parts of the Head. — I may mention, in connection 
with this remark, that over ihe parts which are particularly excited, we frequently 
find the temperature higher, than at other parts of the head. Nothing is more 
common than to find one part of the head hotter than another. If we iiave been 
studying for some hours, we feel the temperature of the forehead to be much hot- 
ter than it is either at the top, the back, or the sides of the head. So when persons' 
feelings are excited in insanity, a local increase of temperature is frequently in- 
duced. This remark has been made by those, who have more opportunity of 
observing the fact than myself. 

GeorgeCs Researches. — [M. Georget has summed up the morbid changes 
which he considers as authentically connected with madness; and his recapitu- 
lation may be looked upon as a tolerably complete statement of the result of 
anatomical researches into this subject, up to the time when his work on insanity, 
and the article contributed by him to the " Dictionnaire de Medecine," were pub- 
lished. The following are the principal points: — " Irregular conformation of the 
cranium^ the prominences of which are developed irregularly; — those of the right 
side being generally larger than those of the left; — some skulls having the lateral 

was exactly over each ear-^ and, though it extended, shot from that situation. This was no 
imagination of mine. I .did not lead her to any such declaration. I merely asked if she had 
a pain in her head; and she said "yes." I then asked her where it was situated; and she 
pointed out the exact spot. She was repeatedly questioned, by myself and others, after- 
wards; and she always gave the same answer. This was a very striking phrenological 
fact. 

This woman died;— not of this complaint; for of that she was cured, or nearly so. She 
was opened; but I was not present. The brain, however, was preserved; and, on examining 
it, I found nothing; and this was only what might have been expected. In diseases of vari- 
ous parts of the body, you continually open patients, and find nothing;— so many diseases 
are merely functional. In this case nothing was to be expected, because the woman was 
cured; but I understand that the " dura mater" adhered to the brain where the pain was felt; 
that is to say, at the sides, low down; — showing that an inflammatory state had previously 
existed, and had left its common consequence, — adhesion. I should not omit mentioning, 
however, that the character of the insane person, even where disproportionate development 
has not been the predisposing cause, corresponds (in most instances) with the character of 
the head. 

With respect to the treatment of this woman, I considered that an inflammatory affection 
of that part of the head, was the cause of the pain she experienced. I cupped her behind 
the ears, to twelve ounces; and gave her calomel (five grains twice a day), and put her on 
low diet. Leeches were again and again applied to that part. She was admitted on the 
eighteenth of January; and twenty leeches were applied to the seat of the pain every day,- 
till the eighth of February. From the eighth of February, they were applied every other 
day, for a fortnight. Her mouth soon became tender; and, as that took place, her tongue 
became clean, and her breath ceased to be fetid. At last it began to smell of mercury; but 
the odour was quite changed in character, and was supportable. She twisted her head less 
and less, and she slept more, — several hours in the night. The pain in the head left her; 
and she now^ felt relieved from the disposition to strain and injure herself. She was a de- 
formed woman; and the lungs and heart had hardly any room to play. She was subject more 
or less to bronchitis; and was seized wiih an attack, from being placed near a window; and 
it was necessary, on account of this atfection of the chest, to bleed her. She was bled to six 
ounces, recovered from the bronchitis, was now really well, and was to be dismissed on the 
following Thursday. On the Saturday, however, being in the ward just as usual,— she was 
seized (I understand)— for I had left the hospital — with pain in the abdomen; and, in a few- 
minutes, died. The friends came for the body before the inspection conld be completed. 
The head was examined, and also the chest; but nothing morbid was found in either, except 
the adhesion of the " dura mater" to the brain, above the " meatus aiiditorins externus." On 
account of the friends waiting for the bodv, ihe examination of the abcuimen was not pro- 
ceeded with; and therefore, the cause of death is unknown. Whether she died from a rup- 
ture of any part within the abdomen, I do not know; nor have I anv idea of the cause of her 
death; although I am quite satisfied it was in the abdomen.— "Z/0?u/o?i Medical Ga-cltc;'* 
Volume 8; Pages 1G8 to 176. {No. 179; May 7, 1839.) 



566 AFFECTIONS OF THE INTELLECT. 

diameter of equal extent with the anteroposterior, and the cavities of the base irre- 
gular in extent; some skulls (one in twenty) thickened partially or generally, more 
frequently the bones hard, white without diploe, resembling ivory; some very light. 
Dura mater rarely changed; sometimes adherent to the skull, thickened, contain- 
ing deposits of bone. Arachnoid displaying in places additional laminae of a red 
or gray colour; sometimes thickened, but smooth. Pia mater injected or thick- 
ened, and infiltrated with serum; — giving, at first, the appearance of gelatinous 
deposit. Volume of the brain sometimes less than the cavity of die cranium seems 
to require. Some brains very hard; cut with difficulty; the white substance gluti- 
nous, elastic, and suffering distension: more frequenUy the brain is soft; — the gray 
matter being pale and yellowish, and the white substance discoloured, of a dirty 
white, the colour and consistence of these portions almost confounded. The con- 
volutions separated by serosity, and the pia mater thickened. Interior cavities of 
the brain appearing in some instances very large, in others small, often filled with 
a serous fluid, remarkably clear and limpid; plexus choroides exanguious, contain- 
ing hydatiform vesicles. Partial softenings of the brain, erosions, ulcerations of 
the surface of the ventricles. Cerebellum generally softer than the cerebrum, some- 
times partially softened. Mesocephalon, medulla oblongata, and medulla spinalis, 
rarely displaying morbid changes of structure." 

More Recent Researches, — Considerable additions have been made to the mor- 
bid anatomy of the brain, in cases of insanity, since the time of M. Georget. These 
researches have been conducted chiefly by MM. Bayle, Calmiel, Lallemand, Fo- 
ville, and Bouillaud. The two former have principally directed iheir attention to 
the history of general paralysis; and the pathological details given by them have 
reference to this disease, which may be termed an adventitious one; but which is 
so frequently connected with insanity, that its supervention cannot be looked upon 
as a matter of mere contingency. M. Calmiel's observations resolve themselves 
into the general conclusion, that unequivocal signs of chronic inflammation of the 
brain exist in almost every case of this disease complicated with insanity. 

Some of the morbid appearances which M. Calmiel considered as proper to the 
disease, which he terms "paralysie des alienes,"^ are connected by M. Foville 
■with insanity; and are regarded by that writer as ultimate results of that disease 
in its protracted stage; when the brain — having long been disordered in function, 
and especially in the state of the vascular apparatus — passes into a degree of dis- 
organization, no longer compatible with the continued preservation of even phy- 
sical life. 

The changes which the different parts of the encephalon undergo, according to 
M. Foville, resolve themselves into the signs of recent inflammatory action in 
acute cases, and the well-known results of long-continued inflammation in chronic 
and inveterate examples of the same disease. He has noted in the former the 
chief morbid signs in the gray substance of the brain; such are a red colour, uni- 
form, and very intense; numerous mottled spots, varying from a bright to a violet 
red, bloody points: minute extravasations of blood; diminished consistence in the 
thickness of the cortical substance, coincident with a slight increase of consistence 
in its surface; dilatation of the vessels, and resistance of their parietes. In acute 
cases M. Foville has never observed adhesions of the membranes to the cortical 
substance. Such adhesions are very frequent in chronic cases; and hence, as he 
conjectures, may be explained the curable nature oi recent maniacal affections, and 
the hopeless and incurable state of those patients who have long laboured under 
insanity. 

Morbid Jlppearances in the Gray Matter. — The chronic changes of the cortical 
substance, are increased firmness and density of the superficial part; extending to 
no great depth, but uniform, and constituting a distinct lamina or layer of hardened 
consistence; which, torn off", leaves a red, soft, mamrnillated bed of softened corti- 
cal substance beneath. The volume of the convolutions remains natural, or is less 

"• ' 'Paralysis of the insane.-' 



AFFECTIONS OF THE INTELLECT. 567 

than natural; — owing to ji real atrophy, or to the existence of lacnnee; which are 
the results of a minute extravasation. This morbid change ofien extends to three 
or four convolutions on each side of the sagittal* suture; — a chasm, filled with 
serosity, often occupying the place of the absorbed cerebral substance. Coexistent 
with this state of the encephalon, is that species of atrophy of the cranium, ia 
which the diploe disappears; — leaving a superficial depression on the head. 
Another morbid state of the cortical substance, is that of uniform and red ramol- 
lissement; which is a change very distinguishable from that above described. 

Morbid Appearances in the White Matter. — The change of the white substance, 
principally its preternatural hardness and unusual whiteness, resolve tliemselves, 
in M. Foville's opinion, into adhesions between the cerebral fibres and the deposi- 
tion of additional matter;— the results of chronic inflammation. It is well known 
to those who have studied the works of late anatomists on the structure of the 
brain, that M. Foville has attempted to demonstrate in the organization of the cere- 
bral mass the existence of distinct planes of medullary substance, superimposed 
one upon another, and connected in the healthy state by means of a very fine cel- 
lular tissue. These planes, thus easily separable in the healthy state, become closely 
adherent in long-continued cases of madness. M. Foville repeats the observation 
made by many writers; — that the brains of lunatics are so full of serous fluids, that an 
abundant serosity flows from the surface of incisions. He likewise observes the pre- 
sence of small serous cavities, from the size of a millet-seed to that of a nut. This 
was first noted by M. Esquirol. It is the appearance which the late Dr. Sims has 
more recently described, as the spontaneous cure of ramollissement. The section 
of a brain thus perforated, is compared to that of a porous cheese. By M. Foville 
these cavities are supposed to be the relics of extravasation. Perhaps the opinion of 
Dr. Sims will be allowed to be the most probable: — that they are the results of sof- 
tenings of the brain. It must be carefully noted, that these changes in the white 
substance do not belong to insanity, separately existing and uncomplicated with 
paralysis. In persons affected with the "paralysie des alienes,'"* they are almost 
universal. They are likewise found in the brains of old men, whose voluntary 
movements have become uncertain and vacillating; but more in lunatics whose 
muscular powers had remained unimpaired. 

The Membranes. — The changes in the membranes observed by M. Foville may 
be referred, in like manner, to the various results of meningitis: they are thicken- 
ings and adhesions of the dura mater, injections of \\ie pia mater, and opacity and 
increased density of the arachnoid. 

The pathological results deduced from these observations are, that morbid changes 
in the cortical substance are directly connected with intellectual derangement, 
and those of the white substance, with disorders of the motive powers. These 
opinions coincide generally with those of the most accurate morbid anatomists of 
recent times. It must be observed, that all such changes in the brain and the mem- 
branes resolve themselves into the well-known results of inflammation and increased 
vascular action. 

Thoracic Lesions. — Diseases in the thorax are often traced in cases of mental 
derangement. Hypertrophy of the heart is a phenomenon of frequent occurrence. 
M. Georget declares, that in more than three-fourths of the bodies of insane per- 
sons examined by hnu, there had existed or(j;anic disease of the lungs; such as 
chronic pneumonia, or phthisical degenerations. He says, that phthisis is the 
cause of death in more than half the maniacs who die in the Snlpetriere. Cavern- 
ous excavations are found in the lungs of numerous patients; who, during life (unless 
the fact has been ascertained by auscultation), are never known to labour under pul- 
monary disease. 

Mdominal Lesions. — Of abdominal diseases in insane persons, the most fre- 
quent is gastro-enteric inflammation. This has been discovered in a considerable 
proportion of bodies of persons aflTected with mental derangement. One of the 

" From "sagitla," an arrow, " See Fage b06. 



568 AFFECTIONS OF THE INTELLECT. 

most remarkable changes in the necroscopy^ of insane persons, is displacement of 
the transverse colon. This was observed, by M. Esqiiirol, in thirty-three out of 
one hundred and sixty-eight cases of melancholia. The change consisted in an 
altered position of the intestine; which, instead of traversing the abdomen, was 
turned into a perpendicular direction, and precipitated behind the pubes. A similar 
phenomenon has been noticed by Bergmann, Nasse, and Guislain. Organic dis- 
eases of the liver are of very rare occurrence in connection with insanity.''] 

d. Causes of Insanity. 

Hereditary Predisposition.— With regard to the causes of insanity, of course 
they are predisposing and exciting. — just as is the case with other diseases. 
Among the predisposing causes, the most remarkable is hereditary predisposition. 
I should think there is no disease to which the human frame is subject, which can 
be so hereditary as insanity. When I say " disease," I mean disposition to the 
disease; because if a person do not have a disease break out till he is thirty, forty, 
fifty, sixty, or even seventy years of age, yet if the disposition to it be given to 
him by his parents and ancestors, we say it is hereditary. That is the ordinary 
mode of speaking; but some people object to this word ^^ hereditary ^ I should 
suppose, however, that if a man inlierit an estate from his father, even if he do 
not come into its possession till he is ninety years of age, it is just as hereditary as 
if he receive it the day he is born. It is a mere quibble to limit the word "Aere- 
ditary.''^ But insanity, in a large number of cases, is hereditary; and I do not 
think it is so difficult to wear out the hereditary disposition to any other disease, as 
it is that to insanity. It seems to require more of dilution, — more crossing of the 
breed, than any other affection; for it comes on even in the third and fourth cousins, 
and although it may have disappeared in one generation, it so frequently returns, 
that there is the greatest danger of its arising in almost every other descendant. 
Scrofula, gout, and various other complaints, will cease from good management; 
and in favourable circumstances; but as to the disposition to insanity, it is cer- 
tainly one of the most undilutable (if I may use the expression) that can be ima- 
gined. 

Importance of attending to this Cause. — The importance of attending to the 
existence of insanity in families, has been very much dwelt upon by some writers; 
and I must confess that, if I were going to be married, there is no disease that I 
should be more anxious to inquire whether the family was free from, than this. 
Dr. Spurzheim, among others, has written on the subject; but it is just as well 
dwelt upon by Burton, in his "Anatomy of Melancholy," in his usuar facetious 
and singular manner. He enumerates hereditary disposition among the causes of 
melancholia, and says: 

" Parents a Cause by Propagation. — That other inward inbred cause of melan- 
cholia, is our temperature, in whole or part, which we receive from our parents. 
Such as the temperature of the father is, such is the son's; and look what disease 
the father had when he begot him, such his son will have after him, and is as well 
inheritor of his infirmities as of his lands." He then enumerates a number of 
hereditary diseases, and proceeds to remark — " Some other causes are given, 
which properly pertain to, and proceed from the mother. If she be over dull, heavy, 
angry, peevish, discontented, and melancholy, — not only at the time of concep- 
tion, but even all the while she carries the child in her womb, — her son will be 
so likewise affected, and worse. If she grieve over much, be disquieted, or by any 
casualty be affrighted and terrified by some fearful object heard or seen, she en- 
dangers her child, and spoils the temperature of it, for the strange imagination of 
a woman works effectually upon her infant." He concludes thus: " So many 
several ways are we plagued and punished for our fathers' defaults; insomuch that, 

* From viJtfof, dead, and irxoTrjiw, to examine. 

»> " Library of Medicine;" Volume 2; Pages 126 to 128. 



AFFECTIONS OF THE INTELLECT. 569 

as Fernelins truly sailh, — *Itis the greatest part of our felicity to be well-born; 
and it were happy for human kind, if only such parents [persons] as are sound of 
body and mind, should be suffered to marry.' An husbandman will sow none but 
the best and choicest seed upon his land; he will not rear a bull or a horse, except 
he be right-shapen in all parts: or permit him to cover a mare, except he be well 
assured of his breed. We make choice of the best rams for our sheep; rear the 
neatest kine; and keep the best dogs. ' Quanto id diligentius in procreandis liberas 
observandum!' ('And how careful, then, should we be in begetting of our children!') 
In former times, some countries have been so chary in this behalf, — so stern, that 
if a child were crooked or deformed in body or mind, they made him away. So 
did the Indians of old (by the relation of Curtius;} and many other well-governed 
commonwealths, according to the discipline of those times. ' Heretofore, in Scot- 
land,' saith Boethius,* ' if any were visited with the falling sickness, madness, 
gout, leprosie, or any other such dangerous disease, which was likely to be propa- 
gated from the father to the son, he was instantly gelded; a woman kept from all 
company of men; and if by chance, having some such disease, she were found to 
be with child, she with her brood were buried alive.' And this was done for the 
common good; lest the whole nation should be injured or corrupted. * A severe 
doom,' you will say, ' and not to be used among Christians;' yet more to be looked 
into than it is. For now, by our too much facility in this kind, in giving way for 
all to marry that will, — too much liberty and indulgence in tolerating all sorts, there 
is a vast confusion of hereditary diseases; — no family secure; — no man, almost, 
free from some grievous infirmity or other; when no choice is had, but still the 
eldest must marry, as so many stallions of the race. Or, if rich, — be they fools 
or dizzards,*" lame or maimed, unable, intemperate, dissolute, exhaust through 
riot, — as was said, 'jure hereditario sapere jubentur; — ' they must be wise and 
able by inheritance.' It comes to pass ihat our generation is corrupt; we have 
many weak persons, both in body and mind; many feral'' diseases raging amongst 
us; crazed families; — parentes, p er emptor es;^ our fathers bad, and we are like to 
be worse. "^ 

Now this is good advice; for though it is not to be carried to the unwarrantable 
pitch of gelding unfortunate people, yet undoubtedly this matter ought to be 
attended to much more than it is. I think it sinful to marry a person in whose 
family there are many instances of insanity; and it is appalling to read the accounts 
of "deaf and dumb" charities, and " blind" charities; where it is stated that indi- 
viduals have produced child after child deaf and dumb, or blind. I think, when 
one or two children have been produced blind or deaf, that it is wickedness for pro- 
creation to be 'continued. Sometimes as many as six children are born deaf or 
blind in the same family. I should think it would be desirable, in such circum- 
stances, to ascertain (if possible) from which of the family the disease arose; and 
that divorce would then be very allowable; — so that only one should be deprived 
of marriage rites. 

As an illustration of the hereditary nature of insanity, Dr. Burrows says, 
that six cases out of seven, in his private practice, were of that class.' In 
the Salpetriere, there were three hundred and twenty female lunatics; one hun- 
dred and five of whom had the disease hereditarily. Out of two hundred and 
sixty-four cases treated by Esquirol in his private practice, one hundred and fifty 
were hereditary. Where insanity is hereditary, it is very common to see other 
members of the family, not deranged, but afflicted with some nervous disease or 
other. I know one family, where two or three are deranged. The father is 
not deranged; but he speaks badly, and has twitches of the fiice. Two other chil- 
dren of the family are sane; but have twitches of the Aice. Where one is insane, 
another is frequently a little odd in his manner, or odd in his thoughts; but not 

* Tn his " Scotorum Historia." *> Blockheads, 

« Funeral. d " Parents being murderers." 

e "The Anatomy of Melancholy; by Democritus, Junior." Parti; Section 2; Mem- 
ber 1; Subsection 6. 
' See his " Commentaries on the Causes, Symptoms, and Treatment of Insanity." 



570 AFFECTIONS OF THE INTELLECT. 

sufficiently SO to be called "deranged." Where there is insanity in a family, 
some individuals have very strong feelings; but not so strong as to overbalance the 
mind, and produce insanity. 

Moral Causes. — Among the frequent causes of insanity, are what are termed 
^^ moral causes;" — consisting in violent excitement of the feelings; but these, for 
the most part, are innocuous, unless there be hereditary predisposition. A person 
will, in general, bear the most violent excitement from external circumstances, un- 
less there be a predisposition to the disease. We every day see persons suffer the 
greatest reverses, — the most dreadful privations, — the severest bereavements of those 
who are dearest to them; so that they are overwhelmed for a time; but they are 
not ruined in mind for ever. There must be a certain weakness of mind, or a bad 
constitution of mind, or an ill-regulated state of mind, or a disposition to insanity 
in general, for these causes to take effect. At any rate, the mind may be so strong, 
and the faculties so well formed, and so well balanced, that the strongest moral 
causes will not upset the raan. With regard to these causes, it is said that joy has 
excited insanity, even more frequently than grief. Human nature seems doomed 
to suffer. Most of us, every day of our lives, suffer something or other, — little or 
much; and human nature seems more capable of enduring grief than of bearing 

joy- 

Partial Development of the Brain. — There can be no doubt, I think, that one 
predisposing cause to insanity, is a partial development of the brain. In many 
people who are deranged through the feelings, (which is the case with the greater 
part of deranged persons,) certain parts of the brain are more developed than 
others; — so as to be more than a match for the rest of the head; and they have 
suffered so strong an excitement, as to have over-balanced the powers of mind. 
This occurs in a great number of cases. Where there is mental delusion, I believe, 
in most cases, it arises from some strong passion. When a man fancies himself 
an emperor, it is on account of the excessive development of the organ of " self- 
esteem." When a person fancies himself to be the Deity ,^ it is generally from the 
same circumstance. The delusion generally springs from excess of pride. When 
a person is convinced that a conspiracy is formed against him, — that attempts are 
made against his life every day, or attempts are meditated; — when he believes 
things which have no reality, and sees demons'" coming to injure or to destroy him, 
— it is generally from an over-excitement of the depressing passions. That is to 
say, his fear has got the better of his pride; and, being under the influence of fear, 
he afterwards becomes the subject of delusion. 

Exciting Causes: Intense Application to One Point. — With respect to excit- 
ing causes, there can be no doubt that long application to one particular point, is 
occasionally the cause of insanity. It was evidently intended by Providence, that 
we should employ all the faculties with which we are blessed; — not merely that 
we should use one arm, but both; not merely one leg^ but both; not one faculty 
of the mind, but all in their turn; so as to strenathen the whole, and enjoy every 
feeling of the mind, as well as every intellectual faculty. If, then, a person dwell 
intensely upon one idea, — so as not to employ the faculties of his mind at large, 
and employ all the feelings; if one only be engaged to the exclusion of the rest; so 
that ideas of one kind are not counterbalanced by ideas of another; — the person 
may at last persuade himself of any thing, and become mad. We cannot have a 
better illustration of this, than in Johnson's " Rasselas;" where, from a philoso- 
pher studying astronomy; — not hearing discourses on other subjects; not having 
his mind drawn to other topics; not enjoying one of the greatest delights in life, — 
conversation with his fellow-men; but shutting himself up, being abstracted on one 
point (namely, the motion of the heavenly bodies);— he at last became deranged, 
and fancied that he had the command of them. He was cured by being taking into 
society again.'' 

» See Pages 560 and 581. ^ See Page 581. 

"^ I [Imlac] have just left the observatory of one of the most learned astronomers in the 
world; who has spent forty years in unwearied attention to the motions and appearances of 



AFFECTIONS OF THE INTELLECT. 571 

Fever, and Injuries of the Head. — Insanity has frequently been excited by 
fever, and common inflammation of the brain. It has been excited by heal applied 
to the body at large; but particularly to the head; what is called " insolation'^ has 
frequently made men mad. Mechanical injury (as may readily be imagined) has 

the celestial bodies, and has drawn out his soul in endless calculations. I was introduced 
as a man of knowledge, worthy of his notice. I visited him with more and more frequency; 
and was, every time, more enamoured of his conversation. 

I had quickly reason to imagine, that some painful-sentiment pressed on his mind. He 
often looked up earnestly towards the sun, and let his voice fall in the midst of his discourse. 
He would sometimes, when we were alone, gaze upon me in silence, with the air of a man 
who longed to speak what he was yet resolved to suppress. He would often send for me 
with vehement injunctions of haste; though, when I came to him, he had nothing extraor- 
dinary to say: and sometimes, when I was leaving him, would call me back, pause a iQvf 
moments, and then dismiss me. 

At last, the time came when the secret burst his reserve. We were sitting together, last 
night, in the turret of his house; — watching the emersion of a satellite of Jupiier. A sud- 
den tempest clouded the sky, and disappointed our observation. We sat awhile silent in the 
dark; and then he addressed himself to me in these words: — " Imlac, I have long considered 
thy friendship as the greatest blessing of my life. Integrity without knowledge is weak 
and useless; and knowledge without integrity is dangerous and dreadful. I have found in 
thee all the qualities requsitie for trust, benevolence, experience, and fortitude. I have long 
discharged an office which I must soon quit at the call of nature; and shall rejoice, in the 
hour of imbecility and pain, to devolve it upon thee." 

I thought myself honoured by this testimony; and protested, that whatever could conduce 
to his happiness, would add likewise to mine. 

" Hear, Imlac, what thou wilt not without difficulty credit, I have possessed for five 
years the regulation of the weather, and the distribution of the seasons. The sun has lis- 
tened to my dictates; and passed from tropic to tropic by my direction; the clouds at my call 
have poured their waters, and the Nile has overflowed at my command; I have restrained 
the rage of the dog-star, and mitigated the fervours of the crab. The winds alone, of all 
the elemental powers, have refused my authority; and multitudes have perished by equinoctial 
tempests, which I have found myself unable to prohibit or restrain. I have administered 
this great office with exact justice, and made to the different nations of the earth an impar- 
tial dividend of rain and sunshine. What must have been the misery of half the globe, if 
I had limited the clouds to particular regions, or confined the sun to either side of the 
equatorl" 

I suppose he discovered in me, through the obscurity of the room, some tokens of amaze- 
ment and doubt; for, after a short pause, he proceeded thus: — 

" Not to be easily credited will neither surprise nor ofiend me; for I am, probably, the 
first of human beings to whom this trust has been imparted. Nor do I know whether to 
deem this distinction a reward or punishment. Since I have possessed it, I have been far 
less happy than before; and nothing but the consciousness of good intention, could have 
enabled me to support the weariness of unrematted vigilance." 

" How long, sir;" said I, " has this great office been in your hands?" 

"About ten years ago," said he, " my daily observations of the changes of the sky, led 
me to consider whether, if I had the power of the seasons, I could confer greater plenty 
upon the inhabitants of the earth. This contemplation fastened upon my mind; and I sat 
days and nights in imaginary dominion, pouring upon this country and that the showers of 
fertility, and seconding every fall of rain with a due proportion of sunshine. I had yet only 
the will to do good; and did not imagine that I should ever have the poioer. One day, as 
I was looking on the fields withering with heat, I felt in my mind a sudden wish, that I 
could send rain on the southern mountains, and raise the Nile to an inundation. In the 
hurry of my imagination, I commanded rain to fall; and, by comparing the time of my 
command with that of the inundation, I found that the clouds had listened to my lips." 

" Might not some other cause," said I, "have produced this concurrence^ The Nile 
does not often rise on the same day." 

" Do not believe," said he, with impatience, "that such objections could escape me. I 
reasoned long against my own conviction, and laboured against truth with the utmost ob- 
stinacy, I sometimes suspected myself of madness; and should not have dared to impart 
this secret but to a man like you; — capable of distinguishing the wonderful from the impos- 
sible, and the incredible from the false." 

" Why, sir," said I, " do you call that incredible, which you know, or think you know, to 
be truer' 

" Because," said he, "I cannot prove it by any external evidence; and I know too well 
the laws of demonstration, to think that my conviction ought to influence another, who can- 
not (like me) be conscious of its force. I therefore shall not attempt credit by disputation. 
It is sufficient that I feel this power;— that I have long possessed, and every day exerted it. 
But the life of man is short. The infirmities of age increase upon me; and the time will 
soon come, when the regulator of the year must mingle with the dust. The care of ap- 



572 AFFECTIONS OF THE INTELLECT. 

produced the same thing. An instance is mentioned of a foreign surgeon having 
trephined a man, for a large wound of the temporal bone; and, when the wound 
was healed, the man could not refrain from stealing. He was an honest man be- 
fore; but after the wound he had an irresistible desire to steal. The surgeon was 
something of a philosopher. The people could not imagine how stealing was a 
disease; but the gendeman who had performed the operation, was convinced that 
it was; and, by representing the case scientifically to others, he procured the libe- 
ration of the individual. 

The Puerperal State. — The puerperal state is, no doubt, one cause of insanity. 
During labour, women are subject to such an irritation of the head, and probably 
of the spinal marrow, as to fall into insensibility and convulsions; and, in like man- 
ner, puerperal women frequently become insane. They become so, in general, 
from the third or fourth day after delivery, up to the fourteenth or fifteenth; and, 
now and then, they will become insane during suckling. Dr. Gall says, that he 
knew four women who, in pregnancy only, had a desire to steal. They had a 
local or partial insanity; and not, as we usually see in the puerperal slate, — a 
general insanity. 

Old Jige. — I think old age has a tendency to produce insanity; and there it is, 
in general, insanity o^ feeling. The intellectual faculties decline when we grow 
old; and the feelings frequenUy fall into a state of excitement. I have frequently 
seen^ old men, whose intellectual faculties have become much decayed, become 

pointing' a successor, has long disturbed me. The night and the day have been spent in. 
comparisons of all the characters which have come to my knowledge; and I have yet found 
none so worthy as thyself. Hear, therefore, what I shall impart, with attention such as the 
welfare of a world requires. If the task of a king be considered as difficult, — who has the 
care only of a few millions, to whom he cannot do much good or harm, — what must be the 
anxiety of him, on whom depends the action of the elements, and the great gifts of light and 
heal! Hear me, therefore, with attention. 

" I have diligently considered the position of the earth and sun; and formed innumerable 
schemes, in which I changed their situation. I have sometimes turned aside the axis of the 
earth, and sometimes varied the ecliptic of the sun; but I have found it impossible to make 
a disposition by which the world may be advantaged. What one region gains another 
loses, by any imaginable alteration; — even without considering the distant pans of the solar 
system, with which we are unacquainted. Do not, therefore, in thy administration of the 
year, indulge thy pride by innovation. Do not please thyself with thinking, that thou canst 
make thyself renowned to all future ages by disordering the seasons. The memory of mis- 
chief is no desirable fame. Much less will it become thee to let kindness or interest pre- 
vail. Never rob other countries of rain, to pour it upon thine own. For us [Egyptians] 
the Nile is sufficient." 

I promised that, when I possessed the power, I would use it with inflexible integrity; and 
he dismissed me, — pressing my hand. " My heart," said he, " will be now at rest; and my 
benevolence will no more destroy my quiet. I have found a man of wisdom and virtue, to 
whom I can cheerfully bequeath the inheritance of the sun." 

The sage confessed to Imlac, that since he had mingled in the gay tumults of life, and 
divided his hours by a succession of amusements, he found the conviction of his authority 
over the skies fade gradually from his mind; and began to trust less to an opinion that he 
never could prove to others, and which he now found subject to variation, from causes in 
which reason had no part. " If I am accidentally left alone, for a few hours," said he, " my 
inveterate persuasion rushes upon my soul, and my thoughts are chained down by some ir- 
resistible violence; but they are soon disentangled by the prince's conversation, and instan- 
taneously released at the entrance of Pekuah. I am like a man habitually afraid of spectres; 
who is set at ease by a lamp, and wonders at the dread which harassed him in the dark; 
yet, if his lamp be extinguished, feels again the terrors which he knows that when it is light 
he shall feel no more. But I am sometimes afraid, lest I indulge my quiet by criminal 
negligence; and voluntarily forget the great charge wiih which I am entrusted." 

" My reason," said the astronomer, " has been so long subjugated by an uncontrollable 
and overwhelming idea, that it durst not confide in its own decisions. I now see how 
fatally I betrayed my quiet, by suffering chimeras to prey upon me in secret; but melancholy 
shrinks from communication; and I never before found a man to whom I could have im- 
parted my troubles, though I had been certain of relief. I rejoice to find my own sentiments 
confirmed by yours; — who are not easily deceived, and can have no motive or purpose to 
deceive. I hope that time and variety will dissipate the gloom that has so long surrounded 
me; and that the latter part of my days will be spent in peace.'^—'^ Hislory of Rasselas, 
Prince of Abi/ssi7iia. Bi/ Samuel Jo/mson, LL. />." Chapters 40, 41, 42, 43, 46, and 47. 



AFFECTIONS OF THE INTELLECT. 



573 



exceedingly passionate, suspicious, and at last delirious; — totally unlike any thinff 
thev were before, and in such a state as I considered to be madness. 

Excesses of all Kinds. — Excess of all kinds will induce this disease. Sexual 
indulgence is always enumerated among the causes of insanity; but very frequently, 
I have no doubt, excessive sexual indulgence, as well as improper indulgence, is 
the result of a morbid state of the brain itself. I have no doubt that a great many 
who indulge in sexual pleasures, beyond what is intended, (thinking of nothing 

else, — running riot every day,) do so through a morbid excitement of ihe head; . 

a diseased state. They live in indolence; and, not having any thing else to do, 
they select this as a good occupation. I have no doubt that many persons indulge 
in this way, till they go mad; but I am quite satisfied that this is not always the 
case; but that the state which ends in insanity, has originally produced a violent 
excitement in that particular direction. 

Cessation of Discharges. — The cessation of discharges will have the same effect. 
Persons have gone mad from the drying up of an ulcer or an issue; and the dis- 
ease has sometimes arisen in the way of metastasis. When a disease to which a 
person has been long accustomed disappears, sometimes insanity will occur. I 
have seen it come on after gastrodynia; and it is said to have occurred, sometimes 
after itch, and other diseases. It is merely a disease of the brain; and therefore 
persons afflicted with it are subject to all other affections. Diseases of the liver 
and intestines will sometimes produce a sympathetic excitement of the head; so as 
to occasion insanity. Disease of other parts, on the other hand, will sometimes 
impede this disease. 

Agency of ihe Devil. — I need not say that the devil has nothing to do with this 
disease, any more than any other; but some physicians say, that the disease is 
caused by the devil, or demons. The devil is a particular individual, but demons 
are supposed to be the spirits of departed persons. Even sound writers give an 
account of insanity being produced by the devil. Sauvages, the first writer on 
nosology, says that he really cannot agree with those German physicians who, one 
and all, say that persons possessed by the devil do wonders. Hoffman and Sau- 
vages state, that signs are produced by demoniacal agency. One of these authors 
says, in the first place, that when a person is mad through demons, he has a de- 
moniacal manner. He has not only heard them vociferate unusually loud, and 
make most unusual gestures, but perform wonderful and unusual motions of the 
body. In the second place, he says that these motions of the body (convulsions) 
came on suddenly, without any preceding disease. Thirdly, that such patients are 
very blasphemous; and look very much like the devil. Fourthly, that thev have a 
knowledge of men; and reveal secret and particular objects faithfully. Fifthly, that 
they have a knowledge of unknown tongues; — uoi foreign tonofues. To be con- 
versant with unknown tongues, is much more clever than knowing foreio^ntonfrues. 
We should all be desirous to know the latter in this way; because it would save us 
the trouble of learning them. Sixthly, he says, that they have unusual stren^yth; 
and, seventhly, that they vomit singular things; — such as hairs, pieces of flint, pins 
and needles, and things of that description; and tliat they not only discharge them 
from the stomach, but even sometimes from the eyes. When this occurs, we may 
be quite sure a person is possessed of the devil. PJiysicians have now driven 
demons from the nosology; and Voltaire says, that the devil is always much mis- 
taken when he addresses himself to doctors; — that we are the men who drive him 
out. 

e. Diagnosis and Prognosis, 

Phrenifis. — As to the general diagnosis of insanity, we have to distinguish it 
from phrenitis, from fever, and from delirium tremens. There ran be no doubt 
that, in insanity, there frequently are signs of inflammation; — tliat there is pain 
and heat of the head; quickness of pulse; thirst; a dry and foul tongue; high 
coloured urine; and a throbbing of the temples;— just as' in delirium from inllam- 



574 AFFECTIONS OF THE INTELLECT. 

malion. But, in the first place, insanity is a chronic disease; whereas phrenitis 
and fever are not; and, in the next place, although there are these symptoms of 
inflammation of the brain in insanity, when it first begins, (so that we may be in 
doubt as to whether it is phrenitis — common inflammation — or not,) yet we have 
this criterion; — the insanity is out of all proportion to the signs of inflammation. 
I know of no other mode of discerning the true nature of the case, when signs of 
inflammation are present, than this. But in insanity, we may have no signs of 
inflammation at all; so that there can be no doubt as to its not being a case of in- 
flammation of the brain. The state of the brain may be much the same, and tliere 
may be something of quibbling in it; but the distinction is important: because, if 
there be decided inflammation of the brain, we may set to work according to the 
strength of the patient; and, by antiphlogistic measures, do great good; whereas, if 
the signs of insanity be out of all proportion to the signs of inflammation, and it be 
taken for a mere case of phrenitis, we shall in general do great harm. Antiphlo- 
gistic measures are, generally, very useful in the beginning of insanity, when 
there are more or less signs of inflammation; but if the signs of aberration of mind, 
be out of proportion to the signs of inflammation, they will do serious mischief. 
Indeed, if we go boldly to work, and think that it is a case of inflammation, anti- 
phlogistic measures will frequently cause the patient lo sink; or they will perpetuate 
the disease. It is of importance to consider, whether the signs of inflammation, 
and the signs of insanity, are in proportion to each other. If the latter be only in 
proportion to the former, the case may be treated as inflammation. Our diagnosis 
will be also assisted, by knowing whether the individual has ever been insane be- 
fore, and whether there is insanity in his family; because, if these circumstances 
do exist, and if we think that disturbance and inflammation are coexistent, and not 
one dependent upon the other, then we must not have recourse to antiphlogistic 
measures. 

Fever. — As to the delirium of fever, it is easily known (in general) by the pecu- 
liar hollowness of the eyes, the vomiting, the extreme loss of appetite, the pain of 
the loins, and so on. One cannot easily mistake a case of this description; and 
when delirium afterwards comes on, if it be violent, it is in proportion to the signs 
of inflammation; and if it be not violent, — if it be muttering delirium, then it is in 
proportion to the sinking of the patient, the fluttering state of the pulse, and the 
typhoid symptoms. 

Feigned Madness. — It is of importance to know whether the disease is real or 
feigned. If it be feigned madness, the impostor cannot keep himself awake; as 
madmen frequently do. Madmen frequently sleep regularly; but frequently they 
can do without sleep for a long time; but, where the disease is feigned, persons 
cannot hold out. Neither can they desist from eating and drinking, as madmen 
frequently can; and the pulse is frequently not affected; — at least if they are con- 
fined, so that they cannot gain access to stimuli. Madmen will rave for days and 
weeks, without stopping; whereas a person who is feigning madness, generally 
thinks it necessary to rage violently, because he considers it an important feature 
of insanity; and the consequence is, he cannot continue it. Supposing, however, 
that the patient does not aflfect mania (that is to say, general ms^miy, derangement 
on all points), but ^nonornania,^ he generally overdoes it. It is impossible to con- 
vey, by words, an accurate idea of what we mean; but generally there is some 
over-acting, or some sort of inconsistency. He does not support the character 
well. He is not aware of all which he ought to do; and he does more than he 
should. 

Concealed Madness. — There is no difficulty, therefore, in establishing the 
diagnosis; — as to whether it is phrenitis, or fever, or insanity; or whether it is a 
case of feigned insanity or not. The difficulty is to ascertain whether a patient 
is really mad, when he pretends not to be so. The difficulty is not to prove cases 
of " morbi simiilati;''^ but cases of " morbi dissimulati;^^^ — not where the disease 

* See Page 549. '' " Pretended diseases." 

« " Concealed diseases." 



AFFECTIONS OF THE INTELLECT. 575 

is pretended; but where the patient pretends not to have it. I formerly alhided to 
some cases, which showed how cunning madmen were;^ — how necessary it is to 
take them by surprise; — to ask circuitous questions; so that ihey may be led to the 
main question, without being aware of it. 

Prognosis. — If there be hereditary tendency to the disease, or if there have 
been an injury of the head, or if there be a peculiar organization of the head, or if 
there have been previous attacks of the disease, — recovery is not the less probable, 
but relapse is the more probable. Such persons do not less easily recover than 
others; but when they have recovered, they may easily fall into the disease again. 
I believe that the prognosis is rendered more favourable by the individual, in whom 
the disease occurs, being neither very young, nor in an advanced life; but in the 
middle period of life. The more violent the exciting cause, the more favourable 
will be our prognosis; because, if the exciting cause be very slight, — if a small 
spark have excited a great flame, it may be supposed that the person is strongly 
disposed to insaniiy; whereas, if the exciting cause be very violent, there was pro- 
bably but little disposition to the disease; but the violence of the cause was every 
thing. 

Mania, — general excitement of the brain, — general delirium, — general violence 
of feeling, affords a more favourable prognosis than monormnla. Mania is a gene- 
ral disturbance of the whole head; and it is more capable of correction than a fixed 
disturbance on one point. It appears to be more of the nature of the inflamma- 
tory state of the brain; and inflammation is more easily recovered from, than any 
thing locally fixed, — where the patient dwells upon some one particular point. 
Dementia, or that weakness of intellect which follows insanity, affords the least 
favourable prognosis; for the brain is generally in such a state of inexcilability, 
tiiat it seldom recovers its power. If a person have epilepsy, or other diseases of 
the nervous system, recovery is rare. The longer the disease has existed, the less 
chance is there of recovery; the more acute the disease, the more transient (in 
general) it is. With regard to those cases which occur in a puerperal state,* reco- 
very is more frequent than otherwise. The prognosis may generally be given 
favourably, when the patient has fallen into the disease after delivery, or during 
suckling. 

/. Treatment of Insanity. 

The treatment, like the causes of insanity, is generally divided into two kinds, 
— moral and physical^ and the physical, again, are divided into two kinds, — first, 
antiphlogistic measures; and, in the next place, soothing measures. 

1. Physical Treatment. 

Antiphlogistic Measures. — When the case is recent, and there are phrenitic 
symptoms, the remedies for inflammation within the head are to be adopted, w\\h 
more or less vigour; or when the case is not recent, but we have similar symptoms 
during any period of the disease, the same measures are to be more or less adopted. 
Generally speaking, however, antiphlogistic measures are not very admissible. 
When blood is taken away, it is found, in the greater number of cases, tliat it is 
neither buffy nor cupped; and the majority of cases treated actively, as phrenitis, 
do not turn out so well, as those in which such treatment is not adopted; or in 
which such treatment is adopted with very great moderation. 

I have before mentioned'' that, in insanity, there may be no signs of phrenitis at 
all; or that if there be, still the mental aberration, and the mental excitement, are 
out of all proportion to the signs of inflammation which exist. I staled'' that the 
disease is not inflammation of the brain; for, though there may be more or less of 
an inflammatory state, yet that does not explain the disease. It is a morbid state, 

» See Pages 552 and 559. ^ See Page 570. 

<= See Page 574. «i Ibid. 



576 AFFECTIONS OF THE INTELLECT. 

not necessarily of an inflammatory nature; and that morbid state, although frequent- 
ly connected with inflammation, is unquestionably not founded upon it. 

Blood-letting. — In the beginning of the disease, however, very frequently a 
certain extent of blood-letting is proper; together with a certain degree of purging 
and ptyalism. For example: — the exhibition of tartar emetic, in large doses, — so 
as to produce a state of nausea, and depression of the system, — may be service- 
able. But we must be guided, in the employment of these measures, by the state 
of the patient; by the recency of the occurrence; by the slate of the constitution 
at large; and by the strength and character of the pulse. We must remember that, 
whatever signs of inflammation there may be, the disease is not necessarily of an 
inflammatory character; and that it is much better to adopt moderate antiphlogistic 
measures, such as will not gready depress afterwards. 

Cold to the Head. — Among these, the application of cold to the head is one of 
the best. The application of ice is often much more effiective than bleeding; and 
it is not attended by such subsequent depressive effects as bleeding. I can lay 
down no rule for the adoption of antiphlogistic measures, except this; — that we 
must be very much on our guard, and not trust too much to bleeding. When the 
disease has existed for any considerable time, if a fit of violence come on, it is very 
rarely to be treated by blood-letting; but cold must be applied; and we must 
remove, as much as possible, all stimuli. 

Stimulants and Narcotics. — However, we have sometimes a very different 
state from that of inflammation. Frequently there is great aberration of mind; but, 
while the mind is in a state of high excitement, the pulse is of a weak character,—- 
perhaps very rapid; and it is clear, from the whole state of the patient, that we 
must not adopt depressing measures; but that, on the other hand, stimulants and 
narcotics are the most useful. Frequently, in this disease, there is a weakness of 
pulse; which easily proves, to an experienced person, that the case is one, not of 
inflammation, but of irritation. This is to be treated by cold; — in the form of ice, 
or cold water, or a shower-bath; and frequently by good nourishment, and narco- 
tics. Cold lessens the morbid irritability of every part of the body. 

Both Plans Conjoined. — Now and then, both plans may be very moderately 
conjoined; — ^just as in the treatment of inflammation. But frequently maniacal 
patients are in such a state of excitement, that they will not bear more than the 
application of ice to the head, and moderate purging; and we may find benefit by 
the administration of a certain portion of wine; or (what generally answers still 
better) a certain portion of porter, or good strong malt-liquor of some other kind; 
together with nutritious food. As to narcotics, morphia has been found of late to 
answer much better, in a great number of cases, than opium. I have seen persons 
soon sent to sleep, in this state, by a large dose of camphor; — a scruple of camphor 
given every three or four hours. 

It is necessarj'', not only at the beginning of the disease, but at its crisis, to 
prevent the patient from falling into an inflammatory state of the head; and, on the 
other hand, it is necessary to keep up the strength; — not to allow him to sink into 
a state of debility and irritation. Moderate antiphlogistic measures are the only 
ones to fulfil the former indication; and nutritious food, or even the moderate 
adnjinistration of stimuli, together with narcotics, are very serviceable for the latter. 

Jlttend to other Diseases, if present. — I need not to say it is necessary, in all 
cases, to remedy any other disease that may be present. If there is costiveness, 
vomiting, chronic hepatitis, or any other disease, get rid of it if possible; for, in 
most instances, it will only exhaust the patient so much the sooner; and in fact, 
irritation in o?ie organ, frequently keeps up irritation in another. Now and then 
cases occur, in which mania is suspended by the production of another disease; but 
these instances are comparatively rare. If the new disease were but slight, (sup- 
posing, for example, it were only the itch,) it might he well to let it run its course; 
but if there were any serious disease, I should consider it our duty to cure it; 
at any rate, to lessen it as much as possible; because the insanity itself could not 
do more mischief than it will. 



AFFECTIONS OF THE INTELLECT. 577 

Support the General Health. — Not only is it necessary to remedy any diseased 
state that may exist, — unless it be clearly beneficial to the mind, and at the same 
time clearly not injurious to the body, — but it is also necessary lo support the 
health as much as possible; — to have the patient, as much as possible, in the fresh 
air; to observe the most perfect cleanliness; and to take care that all his food shall 
be of the best quality. 

Warm and Cold Baths. — Warm and cold baths are found very useful; but it is 
in melancholia that warm baths answer best. The cold bath, in most cases of 
insanity, when patients glow after it, is an exceedingly useful measure; and in 
violent paroxysms, a cold shower-bath, continued till the patient is pretty nearly 
overpowered, has often a beneficial influence. As a means of remedy in chronic 
cases, also, the shower-bath is one of the best things that can be employed. 

A hot and a cold bath have been sometimes had recourse to together. If the 
patient be placed in a hot bath, and after a short time a stream of water be allowed 
to play on the head, — descending for about three feet, till the head be thoroughly 
cold, — it is said to be very beneficial. These are all various modes of effecting 
the same purpose. 

Means for subduing the violence of the Paroxysms. — Speaking of the reme- 
dies for the purpose of subduing great violence, I may mention tliat the most 
violent fits of insanity, — the greatest paroxysms of rage will, in general, cease for 
a time spontaneously. It was the custom of Pinel, the celebrated French physi- 
cian, to let patients exhaust themselves; — to let them rave away; being certain that, 
after a time, they would be quiet ajrain. Nature is exhausted after great excite- 
ment; for the latter cannot be carried on for a long time. But, for the purpose of 
suppressing this violence, when it is too long continued, some praetiiioners have 
recommended a rotary machine; in which the patient is set upright, and spun round 
as fast as possible; — till he is sick and giddy, and reduced to quietness. In that 
way a maniac, like any body else, will be rendered pretty calm. It has been 
recommended to lay the patient horizontally, with his head at the centre, and to 
spin him round in that position; so that the blood might be driven, from the head 
to the centre of the body, by the centrifugal force. I have seen. it put in practice 
in lunatic asylums abroad; where the patients spun round as fast as a tetotum; and, 
it is said, with the effect of quieting them. 

2. Moral Management. 

With regard to moral management, very great good may be eflfected. The jne- 
dicol treatment is, for the most part, adopted for the purpose of lessening any 
urgent symptoms at the time; and for the purpose of preventing mischief; but with 
regard to curing the disease, I believe physical treatment, in the greater number of 
cases, is not very efficacious. We may do great good by means of it; — we may 
prevent an inflammatory state of the head; we may support the constitution; we 
may do great good by cooling ihe patient, procuring sleep, maintaining the general 
health, removing diseases in other parts of the body, re-exciting a suppressed dis- 
charge, preventing additional mischief, and lessening urgent symptoms. The moral 
treatment, however, is of the very highest importance. 

Cidtivate the Healthy Faculties. — In the first place, it is right to cultivate any 
faculties that are still sound. If patients be not universally insane, but have any 
mental ficulties left in a state fit for occupation, it is exceedingly serviceable to 
employ them. If a patient have a taste for drawing, for music, for mechanical 
contrivances, or for any other employment, that faculty should be cultivated. He 
should be allowed to make the best exertion he can with his intellect. A pleasur- 
able occupation of this description, is exceedingly advantageous; — not only as c()n- 
tributing to the happiness and the comfort of the patient, but as witiulrawing him 
from insane ideas. By this means persons have frequendy had their insanity very 
easily subdued. 

Moderate Exercise. — It is also found, almost universally, of great service lo 
voT,, T.— :^7 



578 AFFECTIONS OF THE INTELLECT. 

enjoin moderate exercise. A large number of maniacs, who have no intellect left 
for any pleasurable mental occupation; and many who, even while in their senses, 
knew not what intellectual delight was, — may still derive great pleasure, as well 
as great improvement of health, from bodily exercise. Nothing is found more 
useful, in the treatment of lunatics, than to give them things to do, and, more espe- 
cially, to make them work in gardens; and occupy themselves continually, in the 
open air, with bodily exercise. 

Interest the Feelings. — It has also been found of great use, not only to maintain 
activity of body, and cultivate those faculties of the mind which are still entire;-— 
to make the most of what is left; but also to interest the feelings. This has been 
found particularly the case with females. We should give them animals to take 
care of; for the tender feelings are excited, and a constant interest is kept up by 
having animals under their care. This has been found, in many instances, of very 
great use. Whatever their station in life may be, by giving them bodily exercise, 
we maintain the general health; we withdraw their attention from madness to rea- 
son; and, in some degree, create a pleasant state of mind. This may be done by 
mental occupation, as well as by bodily exercise. One great point is, to produce 
a pleasurable state of excitement; and, in conformity with this, it is necessary to 
make them as happy, in all respects, as possible; — to treat them with the utmost 
kindness; — never to have recourse to severity, except in urgent cases; and never to 
have recourse to harsh punishments, or to any thing which can border on cruelty. 

Impropriety of Harsh Treatment. — Nothing should be done which is calcu- 
lated to irritate their mental or bodily feelings; — to inflict corporeal pain, or pro- 
duce vexation of mind; unless the latter be absolutely necessary. No stripes, or 
corporeal punishment, ought ever to be adopted. Formerly, straps and bars were 
had recourse to, as a proper mode of treatment. Till modern times, the chief 
treatment of insanity consisted in cruelty. Celsus gives direction for the employ- 
ment of the greatest severity towards lunatics."* Meibomius (after whom the tarsal 
glands are named) says that Rhazes, an Arabian physician, orders that when a 
person labours under "love-madness," and nothing else will do, he must be tied 
up, and then soundly thrashed, and beat well with the fists; and this again and 
ao-ain. " One swallow does not make a summer;" and therefore, if one thrashing 
does not do, give the patient another. Another writer agrees with him; and says — 
"If the patient be a young man, let his posteriors be well flogged; and, if he be 
not quiet then, put him into the bottom of a tower, with some bread and water, 
till he begs pardon for being mad, and becomes sane." Such were the ideas enter- 
tained, formerly, of the treatment of insanity.'' 

Restraint, tvhen Necessary, should be Mild. — There should be the mildest re- 
straint possible. Restraint is sometimes very necessary; because some patients 
are mischievous; and they will not only tear things to pieces, and do all the mis- 
chief they can; but they will murder themselves or others. But restraint, when 

a Celsus, however, is by no means an unqualified advocate of harshness; for (in Book 3, 
Chapter 18) he says — " Ssepius tamen assenliendum, quam repugnandum est; paulatimque, 
et nun evidenter, ab his quae stult6 dicentur, ad meliora mens adducenda. Interdum etiani 
elicicnda ipsius inlentio; ul fit in hominibus studiosis litterarum, quibus liber legitur, aut 
reci6, si delectantur, aut perperam, si id ipsum eos ofFendit; emendado enitn convertere 
animam incipiunt. Cluin eliam recitare, si qua meminerunt, cogendi sunt. Adcibura 
quoque quosdam non desiderantes reduxerunt hi, qui inter epulanles eos collocarunt." — 
" Yet we are oftener to agree with their opinions, than to oppose them; and by this means 
the mind is (by degrees, and insensibly) to be led from a foolish to a belter mode of disv^ern- 
ment. Sometimes, also, an effort of tiie mind is to be elicited; — a plan which is adopted 
with literary men; to whom a book is read, correctly if it please them, or incorrectly if 
such improper reading displeases them: for they then turn their attention to correcting it. 
Moreover, they should be urged to recapitulate whatever they may remember. Some, 
who had before no desire for it, have been induced to partake of food, by being seated with 
those engaged in eating." 

b This " love-madness" (observes Dr. Elliotson) is certainly the only case in which such 
treatment should be adopted;— if adopted at all, 



AFFECTIONS OF THE INTELLECT. 579 

necessary, should always be effected in the gentlest manner. At those lunatic 
asylums where the greatest attention is employed, there (I believe) the greatest 
gentleness is found admissible; for the more cruelly we behave to lunatics, the 
worse they are. It is in mismanaged lunatic asylums, that we have shouting and 
howling; and that every kind of trouble is experienced. Where the keepers of 
lunatic asylums are benevolent, — use no more restraint than is necessary; and 
especially use restraint in the least offensive manner; and where they take every 
admissible opportunity of being kind to the patients; — there we find the patients 
nearly all quiet; and a very small number indeed require corporeal restraint. 

If punishment be necessary for having done amiss, patients ought not to be 
flogged, but confined for a day; — as a child would be; and should be told that that 
is tiie punishment for having done amiss. It is certainly right to be firm in all this; 
— never to threaten punishment, and then not put it in execution. A maniac would 
soon find out this mistaken lenity, and take advantage of it. Whatever is threatened, 
should be put into execution; — provided we threaten nothing but what is right; so 
that maniacs may depend upon punishment, as a certain consequence of misconduct. 
But the utmost that is required in the way of punishment, is to deprive them, for a 
litde time, of any pleasure which they are accustomed to have, or to employ a lilde 
more restraint than usual. 

Removal of Knives, 4'^- — ^^ the next place, it is very necessary that there 
should be nothing dangerous allowed to be in the patient's reach; — knives, or any 
instrument of which the patient might make a bad use. There are various degrees 
of insanity; and many patients may be trusted with things that might do harm; but, 
as a general rule, every thing with which he could do mischief, should be removed 
from a patient's reach. The windows should be well secured; and the patient 
should have no opportunity whatever of doing mischief; for lunatics are very sly. 
Bars, however, should be so placed before the window, as to look ornamental, 
rather than otherwise; and so as not to give the idea of a prison-house. 

Separation from Friends. — There should be nothing about the individual, to 
remind him of the circumstances connected with his insanity. Hence, in most 
cases, it is found useful (as a general rule) that the patient should be removed from 
his friends; for the circumstances connected with his insanity will (of course) pre- 
sent themselves, if the patient see his friends frequently, or remain in his own 
house. It is, for the most part, advantageous to take the patient away from his 
friends, and his own premises; in order that all associations connected with his 
insanity may be removed. 

Intervieivs ivith Friends. — Still, although it is necessary to remove patients 
from their friends, yet when reason is returning, it has sometimes been found 
useful to gratify them with a sight of those they love the most. I know that ex- 
ceptions to the rule of not allowing them to see their friends are rare; but now and 
then that rule may be broken through, and great advantage be derived from such a 
breach of it. Dr. Gooch, in the "Transations of the College of Physicians, '"* and 
likewise in one of his posthumous volumes,'' gives an account of a lady with puer- 
peral insanity; in whom the gratification of seeing her husband, was apparently 
productive of good effects. It was an experiment; but Dr. Gooch satisfied himself 
that it was likely to be productive of benefit. It is a good general rule, not to be 
broken through without care; but the result, in Dr. Gooch's case, was very satis- 
factory.'' 

» Volume 6; Page 294. 

^ "Account of some of the Most Important Diseases peculiar to Women." 
« A lady, twenty-eight years of age, of good constitution, but susceptible mind, became 
affected with melancholia, a few months after her second lying-in. Toward the end of her 
pregnancy, a frightful incident had occurred to a near relation; and affected her so deeply, 
that she often spent the night sleepless, sitting up in bed, thinking of her misfortune, and 
dreading that she should lose her reason after her confinement. Having nursed her child 
without feeding it for three or four months, with much unnecessary anxiety and exertion- 
she grew thin and weak; complained of sinking at the stomach, and aching in the legs; and 
experienced so much confasion of mind, that she could not arrange her domestic accounts. 
She became low-spiriledj— she knew not why. She was advised to wean her child, look some 



580 AFFECTIONS OF THE INTELLECT. 

A similar case occurred to me, some years ago, in a g-entleman who had been 
deranged from moral causes. From great anxiety of mind, he was perfectly de- 
ranged; but his insanity subsided, and he told me that he should like to see his 

light tonic and gen'le laxative, and went down to the sea-side; but, at the end of a month, she 
returned home;— having derived little benefit from herabsence. Her spirits became gradually 
more depressed; and it was impossible to persuade her that she had not some fatal disease. One 
day it was a cancer; another, inflammation of the bowels; and to such a height did her appre- 
hensions rise, that her husband was often brought home, by some alarming message, and 
found her with a solemn air; and, in a low wliisper, giving direction to her servants whom 
she had assembled around her, what to say if she should expire before her master arrived. 
She now grew much worse; and there was no longer any doubt about the nature of her com- 
plaint. She was seen by a physician of extensive experience in these diseases, and sent 
into the country. Many weeks passed: sometimes she was better, sometimes worse;— now 
accusing herself of the deepest depravity, and meditating schemes of self-destruction; then, 
again, convinced of the absurdity of her notions, and struggling against the load which for 
a short time every day weighed on her heart. In this way many weeks passed. At length, 
the disease came upon her with more violence than ever; and, in her self-examination and 
condemnation, she became quite ferocious. 

She was now put under the care of an experienced attendant; separated entirely from her 
husband, children and friends; placed in a neat cottage, surrounded by an agreeable coun- 
try (it was the finest season of the year); and visited regularly by her physician. 

For several M^eeks she manifested no improvement. Sometimes she was occupied with 
one notion, sonnet imes with another; but they were always of the most gloomy description. 
At length it became her firm belief, that she was to be executed for her crimes, in the most 
public and disgraceful way. Every noise she heard, was that of the workmen erecting the 
scaffold; every carriage, the officers of justice assembUng at the execution; but what affected 
her most deeply was, that her infamy had occasioned the disgrace and death of her children 
and husband, whose spirit haunted her. As soon as the evening closed, she would station 
herself at a window at the back of the cottage, and fix her eyes on a white post that could 
be seen through the dusk. This was the ghost of her husband; who, day and night, was 
whistling in her ears. 

Several weeks passed in this way. The daily reports varied; but announced nothing 
happy. At length her husband became impatient; and begged to have an interview with 
her; — thinking that the best way to convince her he was not dead, was to show himself. 
This was, objected to. He was told the general fact, that patients are more likely to recover 
when completely separated from their friends; and that if she saw him, she would say it 
was not himself, but his ghost: but the husband was obstinate; and an interview was con- 
sented to. When he arrived at the cottage, he was told that she had had a k)lerable night, 
and was rather more tranquil; but that there was no abatement of her gloomy notions. " As 
soon as I entered the drawing room, where she usually spent the day," (I [Dr. Gooch] copy 
his own statment, and which he wrote down at the lirrie of the occurrence,) " she ran into a 
corner, hid her face in her handkerchief, then turned round, and looked me in the face; — 
one moment appeared delighted at the thought I was alive; but immediately afterwards 
assumed a hideous^expression of Countenance, and screamed out that I was dead, and come 
to haunt her. This was exactly what Dr. Gdoch had anticipated; and for some minutes I 
thought all was lost, 

" Finding that persuasion and argumen-t only irritated and confirmed her in her belief, I 
desisted; and tried to draw oflf her attention to other subjects. It was some time since she 
had seen me or her children. I put her arm under mine, took her into the garden, and began 
to relate what had occurred to me and them since we parted. This excited her attention: 
she soon became interested; and I entered, with the utmost minuteness and circumstantiality, 
into the affairs of the nursery, her home, and her friends. I now felt that I was gaining 
ground; and, when I thouglit I had complete possession of her mind, I ventured to ask her, 
in a joking manner, whether I was not very communicative for a ghost. She laughed; I 
drew her from the subject; and again engaged her attention with her children and friends. 
The plan succeeded beyond my hope. I dined; spent the evening with her; and left her, at 
night, perfectly herself again." 

He went the next morning, in a state of intense anxiety, to know whether his success had 
been permanent; but her appearance at the window, with a cheerful countenance, soon re- 
lieved his apprehensions. While he was there. Dr. Gooch came in. He went up stairs, 
without knowing the effect of the interview; and came down, saying — " It looks like magic!" 
With a view of confirming her recovery, she was ordered to the sea-side to bathe. As soon 
as the day of her departure was fixed, she began to droop again; the evening before it, she 
was very low; and, on the morning of her selting-oflf, was as bad as ever. This state conti- 
nued for several weeks, in spite of sea-air and bathing; and ceased as suddenly as it had 
.done before; — apparently in consequence of interviews wiih friends, calculated to remove 
the apprehensions by which her mind was haunted. She has since then continued perfectly 
well; and has had another child, without the slightest threatening of her former malady. — 
(Jooch, on the Diseases peculiar to Women; Chapter "^l. {Second Edition; Pages 163 to 168.) 



AFFECTIONS OF THE INTELLECT. 581 

wife; for that it was very hard to be kept from seeing his wife and family. I 
found him still deranged; but I stopped with him two hours, and satisfied myself 
that it would do him good. He wislied to leave his bed-room, and see diffeient 
parts of the house. I took off his jacket, and led him down stairs; and gratified 
him by letting him see, first one part of the house, and then another. I watclied 
the effects, and found it did not disturb him in the least. On the contrary, he 
seemed to gain intellect, and power over himself, as we proceeded. There were 
many litde gratifications which he wished for, and which I let him have. One 
curious thing was to kill ^bantam- cock, which he saw from a window; and which 
appeared to him as a spectre, or a fiend. The colours, he said, had been terrific 
to him; and he should not be happy till it was killed. I gratified him with it; and 
he was exceedingly thankful. He killed it himself. I watched him carefully, fur 
some time after this; and at last I satisfied myself, that the sight of his wife would 
not be dai)gerous. I might have been wrong; but it turned out that I was riglit. I 
brought her from a neighbour's house; and the interview was most affecting. From 
that moment he was perfecdy in his senses; except for a few days when he was 
violently excited, and then he was found to ramble. This rule of separating a 
patient from his friends, therefore, although a very proper one, may be now and 
then transgressed; but it should not be broken without extreme caution. For the 
most part, when patients are insane, if their friends be about them, it increases the 
general excitement; and there is no chance of doing any good, till they are with- 
drawn. 

The absence of all corporeal punishment, — of all cruelty or severity, — of every 
thing which is calculated to irritate the patient, and the adoption of every thing that 
is mild, and gende, and soothing, and calculated to excite their best feelings, and 
all their feelings in a pleasurable and satisfactory manner; — this will lead, very fre- 
quenUy, to the removal of the disease. But beyond this gradual operation on the 
disease, moral treatment cannot be expected to go. We cannot expect, by moral 
treatment, to cure a madman at once. 

Immediate Recovery by Moral Means. — A story, however, is related, of a per- 
son being cured in France, all at once, by moral means. A madman maintained 
the possibility of the miracle of St. Denis. The miracle was, that the saint kissed 
his own head. A madman was maintaining that this was a fact; and said it was 
possible, because he had done so himself. Another madman inquired how he did 
It; and whether he kissed it with his heel; — and then he laughed at him. From that 
moment the man never spoke of it again. Now it is quite clear that the man must 
have been almost in his senses, to have seen the validity of any such reasoning. 

Another is said to have believed himself the Holy Ghost; and he had a neigh- 
bour in the madhouse, who also believed that he was the Holy Ghost; and, as 
they were not far separated, they were brought to each other. The one inquired 
— " Can there be two Holy Ghosts ? You say you are the Holy Ghost; and / am 
the Holy Ghost;-^can there be two?" The man got up and said — "There cannot 
be two Holy Ghosts; — I must be wrong!" — and he never again called himself the 
Holy Ghost. But when such an effect as this is produced, the person must be 
almost well. 

There was another man who fancied himself dead,* and implored to be buried. 
He assured his attendants that he was quite dead; and he abstained from food, as 
a dead man ought to do; and was laid out, as dead men are. He was conveyed 
towards the church; — not enclosed in a cofiin, but carried in a bed. His friends 
took care that some merry fellows should meet the funeral, at a certain part of the 
road. They asked who it was that was going to be buried; and tlie men who 
carried him replied, that it was a very bad fellow, — that tlie world had happily got 
rid of him. This so provoked the man, that lie sat upright; and became so savage, 
that he jumped down to thrash them all. He was tlien taken home; sat down; ate 
a good dinner; and recovered from that lime. This is another instance of a man 

* Sea Pase 550. 



582 AFFECTIONS OF THE INTELLECT. 

who was all but well at the moment. It is not for such purposes as these, that 
moral treatment is to be adopted. We may do good in such cases as these; but, 
in general, such a result is not to be expected. 

Stratagem som^etimes Necessary. — It is very necessary to have recourse to 
stratagem in many cases. There was another instance of a man* who fancied 
himself dead, and would not eat; and, as there was a fear that he would die of 
starvation, the following stratagem was adopted. Some people'' dressed themselves 
in shrouds, like corpses; and went into his room, which had been previously dark- 
ened. These people carried food with them, and ate- of it freely; saying ihat they 
were dead, and the dead always ate well; and, as he wished to do every thing that 
became a gentleman who was dead, he thought he would eat too. It is said that he 
then fell asleep; and that when he awoke his fancy was gone,'' Another person would 
eat, but he would not be seen eating; and this is very common. Some madmen 
will not eat in the presence of any body; nor will they eat if they think any one 
will discover that they have been eating. A madman who had such a whim, had 
food given him; with a request that he would feed the cat with it. He was ex- 
tremely hungry, and ate it very readily; and afterwards declared that he had given 
it to the cat, who swallowed it down all at once. 

Regularity in the Performance of Daily Functions. — One point is very neces- 
sary to be attended to. If we make insane people do every thing with regularity, 
there is far less trouble with them, in the way of eating and drinking, sitting up, 
and going to stool. A certain hour should be fixed for all these purposes. Nothing 
is found more useful, in the treatment of insane persons, than to establish habits 
for every thing which we wish them to do. If a certain hour be established for 
going to the water-closet, they will go as a matter of course, without ever thinking 
of staying away, and retaining the contents of their bowels; whereas, if there be 
no fixed time for it, we may have the greatest difficulty. So with respect to food, 
and every thing else. 

« Henri-Jules de Bourbon; the first prince of the house of Conde. 

^ His valets, Girard and Richard. 

c During the last twenty years of his life, he was frequently subject to fits of hypochondria- 
sis. In these fits, he would utter the strangest things imaginable; and act, in every respect, 
like an insane person. In his last journey to Burgundy (of which he was governor), for 
instance, he fancied himself a hare; and ordered the bells not to be rung;— lest they should 
frighten him, and compel him to take refuge in the woods. He once fancied himself a 
plant; and, as such, ordered himself to be watered. For this purpose, he placed himself in 
ihe garden of the Hotel Conde; and insisted on being watered by M. de Piainville, one of 
his pages. This page, however, was unwilling to perform so strange an office; and, leaving 
the two watering-pots full of water, that he had. brought, made his escape, and hid himself. 
His royal highness was filled with indignation at the page's disobedience; and threatened 
worlds of mischief in retaliation. The threats, however, died away, as the fancy lost hold 
of his imagination. One of the most frequently occurring of his mental delusions, was the 
belief that he was a bat; and he actually caused a room to be hung withstufi^, and wadded; 
— for fear he shovdd fly against the boards in the day-time, and do himsel'f some injury. An 
hour before his dissoludon, he ordered a couple of stout sticks to be brought to him. At a 
loss to imagine what he could want sticks for at such an awful hour, they were tremblingly 
brought to him; when, having caused them to be placed on either side of him on the bed, he 
called for the princess, and Mademoiselle de Langeron. These ladies being apprised of his 
royal highness's wish to see them, (not, however, without being first warned to beware of the 
sticks,) with doubtful feelings made their appearance. When the prince saw them, he said 
that, considering the shameful way in which he had treated them during his lifetime, he 
deserved that they should retaliate upon him; and begged that they would make him die 
under the blows they would minister to him with the two sticks. The poor prince, how- 
ever, was saved such a death; for he died before he could persuade his wife to take one of 
the cudgels. — Extracted from the '■^ Memoires du Comte de Maurepas;'* in the ^^ Mirror of 
Literalurei' Volume 33, Pages 314 and 315. {No. 949; May 18, 1839.) 



AFFECTIONS OF THE SPINAL CORD. 583 



CHAPTER VII. 
AFFECTIONS OF THE SPINAL CORD. 

[Having, in preceding chapters, considered those affections, which are seated 
solely in the brain, and are characterized by a disturbance of the functions of sen- 
sation, judg-ment, and volition,** we will now proceed to another class of affections; 
mainly distinguished by the presence of spasm or convulsion on the one hand, or 
paralysis on the other. Recent investigations into the physiology of the spinal 
cord, have shown that these affections consist in the derangement of functions 
belongings exclusively, to a system of which the true spinal cord constitutes the 
centre. It is desirable, therefore, to point out the distinguishing features of the 
two systems. 

*'The functions of the cerebral system, — sensation, perception, judgment, voli- 
tion, and voluntary motion, — are gradually developed from infancy to adult age. 
It is the -i^vxri^ — the * animus,' — the ' soul,' enthroned on an organization, which 
gradually becomes more and more perfect. These functions are psychical. How 
different from those of the true spinal or mere excito-motory system! By the for- 
mer we feel external impressions, joerceii^e external objects, judge of their proper- 
ties, ivish and ivill to approach and avoid them, and actually move (by a voluntary 
effort) to or from them. By the latter, when an external object induces an appro- 
priate action in certain muscles, its ingestion into the animal frame is effected 
or prevented, without any cognizance of our mind or will; although sometimes 
with such concurrence shown by additional voluntary acts. Thus, the atmospheric 
air is inspired, while carbonic acid is excluded, without any voluntary, cerebral, or 
psychical act; the sphincters still act, when the organ through which the soul 
manifests its faculties is removed. 

" Cerebral diseases affect primarily the cerebral functions, and the true spinal 
functions consecutively. The diseases of the true spinal system induce changes 
in the excito-motory phenomena in the first place, and in the cerebral functions in 
the second. Cerebral diseases are generally more insidious in their progress, than 
the true spinal; because slight aberrations of the cerebral functions are less observa- 
ble than similar affections of the true spinal system; — pain, vertigo, watchfulness, 
&c., being less striking than the slightest degree of convulsive movement or para- 
lytic affection. It is on this account that \\-\q first symptom observed in cerebral 
disease, is frequently one belonging to the true spinal system; especially vomiting, 
perhaps strabismus. 

"The true spinal diseases, especially those of eccentric origin, affect in a re- 
markable manner the functions belonging to this system; — those of the eye and 
eyelid; those of the larynx and pharynx; the respiration; the action of the expul- 
sors and sphincters; and that state of the muscles designated by the term ' tone.'' 
We must revolve in our minds the symptoms of epilepsy, of hysteria, of tetanus, 
and of hydrophobia; the causes and phenomena of vomiting, of asthma, of abortion, 
of tenesmus, and of strangury; and we shall be forcibly struck with the justice of 
this remark. 

*' In many diseases the influence of the excito-motory power, and of the pas- 
sions, over acts of volition, is most obvious; as is also that of volition over excito- 
motory power. Let the patient in chorea be directed to move his hand in a given 
manner; we shall immediately observe the distorted movements produced by the 
disordered agency of the excito-motory power. Let the patient be agitated, and 

» Phrenilis (Page 481); Hydrocephalus (Page 500); Apoplexy (Page 51-2); Mental Shock 
(Page 530); Delirium Tremens (Page 531); Tumours in the Brain (Page 536); Alleciiuns 
ofihelniellect (Page 533). 



5S4 AFFECTIONS OF THE SPINAL CORD. 

his chorea is tenfold worse than before. The disordered action of chorea, are also 
aggravated by every act of the will; they subside, on the contrary, during sleep. 
On the other hand, every convulsive efTort affects the brain with congestion and its 
consequences; of which a fatal coma, or effusion, is not the least frequent.'"* 

We shall now proceed to consider the various affections of the cord itself; com- 
mencing with " Spinal Irritation."]] 



SECTION I.— SPINAL IRRITATION. 

Definition. — [This term has been used to designate an affection usually charac- 
terized by pain in the back; either induced or increased by pressure of the spinous 
processes of the vertebrae, accompanied by neuralgic and hysteric symptoms, of a 
nature so variable as to simulate almost every form of disease to wliich the body 
is liable. Spinal irritation ought to be considered rather as an effect of disease, 
than as a malady sui generis; but, as the subject is of the highest practical import- 
ance, it is proper to direct attention to it, by giving a detail of its phenomena in this 
place. 

Symptoms. — The phenomena this affection presents, differ according to the ex- 
tent, seat, and intensity of this irritation; and are so greatly diversified as to pre- 
vent the possibility of giving a description that would be applicable even to the 
majority. of cases. The only means we can think of for conveying a general idea 
of this disorder, is by referring to the different forms of hysteria, neuralgia, and 
chronic rheumatism. A combination of the symptoms occasionally presented by 
all three, constitutes spinal irritation. 

The only constant symptom, is more or less pain on pressing the spinous pro- 
cesses of the vertebrae. It may be confined to one spot, or be more or less diffused 
over the spinal column; — pointing out the extent of the spinal irritation. In many 
cas€s the patient is unconscious of any thing wrong in the back, often denies the 
existence of pain in that situation, and refers all the uneasiness to the ultimate dis- 
tribution of the nerves arising from the part. Sometimes there is a dull constant 
pain; which is overlooked, and thought to be wholly unconnected with the local 
complaint. When pressure is made on the affected part, however, the pain in the 
back is increased; and not unfrequently the patient starts as if an electric shock 
had been received, or falls into a state of syncope. Ttie seat of pain generally 
corresponds with the origin of the nerves ramifying on the organs, or portion of 
the surface complained of; although in some instances, as stated by Griffin, the 
morbid changes in the cord appear somev^^hat more extensive than the external 
tenderness. The local pain is often produced or increased by lifting heavy weights, 
or twisting the body; and has often been excited by jerks or slight concussions when 
"walking. 

In conjunction with the spinal tenderness, there may be neuralgic pains (more 
or less diffuse) over different parts of the surface, diminished sensibility, convul- 
sions, or paralysis; and, as the functions of the different viscera and organs of the 
body are often impaired, various diseases are simulated. Thus women suffer neu- 
ralgic pains sometimes in the right, but more commonly on the left side, beneath 
the mamma; sometimes, again, the breast itself is more especially affected; — con- 
stituting the '• irritable mamma" of Sir A. Cooper. In other cases there is a feel- 
ing of numbness, — as pointed out by Dr. Brown of Glasgow; or of constriction 
round the thorax; — as if a walnut, or other hard substance, were pressed within a 
light belt. Occasionally the affection commences with pain in the occiput, and 
rheumatic sensations in the neck and shotilders; several cases of u^hich are given 
by Mr. Teale of Leeds. At other times, instead of neuralgic pains, there is a sense 
of numbness in the hands or feet; extending more or less over the extremities. 

* "Diseases and Derangements of the Nervous System. By Marshal Hall, M. D." 
Chapter VI. 



AFFECTIONS OF THE SPINAL CORD. 585 

We have seen a case where the only symptom was excessive coldness in tlie hands 
and fingeis, that often amounted to actnal pain; and prevented the individual from 
sewing, and carrying on her usual employments. If the spinal irritation be more 
severe, the internal organs participate; and the symptoms produced vary according 
to the portion of the cord that is affected. 

When the spinal tenderness is confined to the cervical portion, there may be 
headache; loss of voice; neuralgic pains in the face and gums; trismu^J; various 
disorders of vision (as ocular spectra, muscse volantes, night-blindness, &;c.); more 
or less deafness, or confused sounds in the ears; diminished or perverted sensation 
of taste and smell; dysphagia; paralysis of the tongue; sickness; vomiting; loss of 
appetite; inordinate hunger or thirst; pain at the stomach; pyrosis; dilhcult breath- 
ing; cough; irregularity of the pulse; palpitations; disposition to syncope; paralysis 
of one or both arms (sometimes confined to the fingers, hands, arms, or shoulders); 
increased sensibility or numbness in those situations; pricking, formication, &c. 
Although these symptoms may have coincided at different times with cervical ten- 
derness, it is evident that many of them — more particularly such as affect the 
special senses — arise from irritation of the cranial portion of the cord. When 
vertigo or delirium is present in such cases, it is probable that the brain itself is 
more or less affected. When the irritation is in the dorsal region, the dyspnoea 
and palpitations of the heart are more marked; there is sometimes dry cougli; 
pleurodynia;^ pain under the clavicles, in the shoulders, and in the superior ex- 
tremities; sense of constriction in the thorax (often like a tight band); neuralgic 
pains in the side: diminished sensibility in the breast and epigastrium; more or 
less derangement in the digestive organs; &c. When it is situated in the lumbar 
portion, the symptoms are, — pain in the parietes of the abdomen, hypogastrium, 
loins, and genito-urinary apparatus; symptoms resembling gravel in the kidneys, 
ureters, or bladder; irritable uterus; cramps and increased sensibility, or palsy 
(more or less complete) in the inferior extremities. 

When the spinal irritation is more diffused, there is an admixture or combination 
of the above symptoms. Hence the occasional difficulty experienced in tracing 
the various undefined symptoms to their true source. Cases of angina pectoris, 
asthma, different form of neuralgia and hysteria, spasmodic croup, convulsions, 
hydrophobia, epilepsy, tetanus, chorea, paralysis, spasmodic cfilic, diarrhcpa, cho- 
lera, irritable bladder, &c., are recorded by Griffin; all of which have been con- 
nected with the spinal irritation, and disappeared on its departure. It often happens, 
that the spinal tenderness shifts its position; Vv^hen the other symptoms change also. 
Griffin details a remarkable case of a young lady, in whom the symptoms success- 
ively assumed the appearances of organic lesion of the lungs, heart, and abdominal 
viscera; together with an endless variety of other complaints of a neuralgic, asth- 
matic, epileptic, cataleptic, and paralytic nature. Indeed, the singular changes the 
disease undergoes, render it impossible to obtain a perfect knowledge of its nume- 
rous forms, without studying in detail the extraordmary cases which have been 
recorded of it. 

Causes. — Women are much more predisposed to this complaint than men; and 
young girls more than married women. Of one hundred and forty-eight cases 
given by Griffin, twenty-six were males, forty-nine married women, and seventy- 
three girls. In a table of one himdred and fifty-four cases (given in the same work), 
we have determined that one occurred at the age of four years, that there were seven 
between the age often and fifteen; eighteen between fifteen and twenty; thirty-one 
between twenty and twenty-five; fifteen between twenty-five and thiity; seventeen 
between thirty and thirty-five; eighteen between thirty-five and forty; fourteen 
between forty and forty-five; twelve between forty-five and fifty; seven between 
fifty and fifty-five; three between fifty-five and sixty; five between sixty and sixty- 
five; and six whose ages are not recorded. 

This disorder, therefore, is most frequent between the ages of fifteen and fifty; — 

a From TrXsufov, ike side; and oJyv>j, pain. 



5S6 AFFECTIONS OF THE SPINAL CORD. 

the menstrual period of women. Spinal irritation has been observed in every habit 
and constitution; — in the full and plethoric, as well as in those who are spare and 
delicate. In almost all who have been affected, however, somewhat of the nervous 
temperament has been remarked, or at all events a peculiar excitability of the 
system. The most common exciting causes are uterine disorder; exposure to 
cold and moisture; dyspepsia, worms, and other sources of irritation in the ali- 
mentary canal; affections of the liver; mental emotions; erysipelatous, rheumatic, 
and eruptive fevers; local injuries, &;c. 

Nature. — As spinal irritation, uncomplicated with other disease, rarely termi- 
nates fatally, the exact anatomical characters of this affection are unknown. There 
can be little doubt, however, that in the majority of cases the symptoms are refer- 
able to a state of congestion of the spinal cord or its investing membranes. Ludwig 
and J. P. Frank have alluded to the effects of spinal congestion, and the anatomical 
circumstances which favour its occurrence. The latter, in particular, has pointed 
out the absence of valves in the spinal vessels; together with their peculiar distri- 
bution on the surface of the cord. Their anatomical structure and arrangement 
render them peculiarly liable to congestion; as the venous blood must ascend in 
opposition to gravity. They are also equally pressed on by the cerebro-spinal 
fluid in a state of health; and any cause which tends to increase or diminish its 
normal quantity, may readily be conceived to produce venous congestion. Hence, 
derangements in the menstrual function, and the various causes which have just 
been mentioned, frequently occasion dorsal and lumbar pains; with other symptoms 
of spinal irritation. The vessels, being principally superficial, unless very much 
dilated, occasion only partial pressure; and consequently increased action, followed 
by the principal phenomena of this affection; namely, neuralgic pains. That motion 
is not so commonly increased or diminished, may be attributed to the relation of 
the cord with the osseous walls which surround it, — as pointed out by Ollivier; 
for the anterior columns are almost immediately applied to the bone, while the 
posterior are five or six lines distant from it. Independently of any positive evi- 
dence, therefore, it may be said that the theory of congestion is fully capable of 
explaining the phenomena, and is the morbid condition which of all others we 
should expect to follow the known causes of the disorder. On the other hand we 
cannot, with some authors, suppose it to be chronic inflammation; for the change-, 
able nature of the affection, and its sudden appearance and disappearance, are op- 
posed to such an opinion. With regard to the spinal tenderness, it has been well 
pointed out by Mr. Locock, (" Edinburgh Medical and Surgical Journal," No. 
136,) that "an inspection of the vertebral column, in an anatomical subject, will 
show at once how impossible it is to press the cord or the nerves going from it, in 
the slightest degree." We cannot think with him, however, that " tenderness of 
the spinal marrow is a sign of little value;" as numerous cases prove, that there is 
a connection between the situation of the local tenderness and other symptoms; 
while local treatment has dissipated the disorder, when remedies directed to the 
removal of its more remote effects have failed. No doubt the spinal irritation is in 
itself only a symptom, although one which indicates with tolerable certainty the 
origin of the malady; and, as our pathological knowledge improves, there is every 
reason to suppose that this view of its pathology will be generally admitted. 

Diagnosis. — It is remarked, by the Messrs. GrifUn, that there does not appear 
to be any complaint to which the human frame is liable, — whether inflammatory 
or otherwise, — which may not occasionally be imitated in disturbed states of the 
cord; and hence it is a prolific source of those complaints called " hysterical" or 
" nervous." The same authors have given the following diagnostic symptoms, by 
which it may be distinguished from organic disease: — 1. The pain or disorder of 
any particular organ being altogether out of proportion to the constitutional dis- 
turbance. 2. The complaints, whatever they may be, usually relieved by the re- 
cumbent position; always increased by lifting weights, bending, stooping, or twist- 
ing the spine; and, among the poorer classes, often consequent to the labour of 
carrying heavy loads; as in drawing water, manure, &c. 3. The existence of 



ArrECTioNs or the spinal cord. 587 

tenderness at that part of the spine whicli corresponds with the siifTerlng- organ. 
4. The disposition to a sudden transference of the diseased action from one organ 
or part to another, or the occurrence of hysterical symptoms in affections appa- 
rently acute. Attention to the four circumstances above enumerated, will gene- 
rally enable the practitioner to identify this disorder. It may readily be mistaken 
for disease of the vertebral bones; as there is not unfrequenUy an apparent promi- 
nence of the vertebrse, where the tenderness is felt. As such an error may lead to 
very distressing consequences, it will be well to enumerate the circumstances which 
distinguish the one from the other. In vertebral disease, the prominence is angu- 
lar, and depends on displacement of the bones, or curvature; in spinal irritation it 
is round, and is occasioned by slight swelling of the ligaments or coverings of the 
spine; in diseased vertebra there are seldom hysterical symptoms in young fe- 
males, whereas they are common in spinal irritation. Disease of the vertebra is 
most common in young persons of a strumous constitution; whereas spinal irrita- 
tion is most frequent in adults. Lastly; complete paralysis is common in vertebral 
disease, but rare in spinal irritation; and, in the latter, the general health is not so 
much affected. 

Prognosis. — The prognosis in spinal irritation is always favourable; as there is 
every reason to believe, that the mere state of irritation uncomplicated with a more 
serious morbid lesion, has never proved fatal. When there is any other coexisting 
disease, the prognosis (of course) is the same as that of the particular affection with 
which the spinal irritation is complicated. 

Duration. — The duration of the symptoms is very variable; — from a single day, 
to three or four years. A case is given by Griffin, where it continued four years 
and a half. According to his experience, a quick and irritable pulse, and furred 
tongue, are indications of an obstinate and troublesome attack. 

Treatment. — The various and often contradictory symptoms, induced by spinal 
irritation, render its diagnosis and treatment difficult and uncertain. Numerous 
facts, indeed, attest that individuals have long laboured under rheumatic, neuralgic, 
and hysterical complaints; during which they have suffered the greatest tortures; 
although they have been relieved in a few days, by treatment directed locally to 
the spine. Whatever difficulties, therefore, may exist in drawing a line of demar- 
cation between the effects of spinal irritation and numerous other disorders, and 
notwithstanding the obscurity that rests on the precise nature of the morbid change 
which produces it, the great practical utility to be derived from its study is unques- 
tioned. So fully are we impressed with its importance, that we consider that, in 
all cases of neuralgia, rheumatism, and hysteria, the spine should be examined; 
while, perhaps, there is scarcely a functional disorder to which the young female 
is liable, which may not occasionally be found connected with spinal irritation. 
We have often had an opportunity of observing the manner in which numerous 
disorders have been traced to this source; and feel assured that if practitioners in 
general would pay greater attention to this complication, many of the extraordinary 
and anomalous cases which are at present the cause of great embarrassment in prac- 
tice, might terminate in the speedy relief of the patient, and increased credit of the 
physician. 

It must not be supposed, however, that the difficulty terminates, even when the 
disease is found to be connected with spinal irritation; for experience has demon- 
strated, that this is in itself not unfrequenlly a secondary effect; — produced by the 
disordered functions of other organs. The first object of the medical attendant, 
therefore, should be to determine whether the affection is idiopathic or sympa- 
thetic, acute or chronic. 

When the disorder is idiopathic, our attention must be directed to the restora- 
tion of the general health of the patient; and an antiphlogistic or tonic line of treat- 
ment must be determined on, according to the circumstances of the case. Accord- 
ingly the application of leeches, or cupping over the spine where there is tender- 
ness, or stimulants and counter-irritants, should be employed; — according to the 
general strength of the patient, and the acute or chronic nature of the disease. la 



5S8 AFFECTIONS OF THE SPINAL CORD. 

many cases, the loss of blood by leeches has been sufficient to remove the symp- 
toms; hi others counter-h-ritation, as by bhsterhig or the tartar emetic ointment, lias 
succeeded. The tartar is particularly recommended by Mr. Tate; and may be 
used M'ith every hope of benefit. But when tiie affection is sympaihelic (as is 
generally the case), in addition to the above means the origin of the malady is to 
be anxiously sought after; and remedies calculated to remove it are to be adminis- 
tered. By far the most common cause in females, is derangement in the men- 
strual discharge; and, in such circumstances, the endeavours of the medical 
attendant should be directed to promote the due performance of this function. If 
there be irritation in, or improper action of, the digestive or biliary organs, the 
disordered state should be combated by appropriate remedies. Every medicine 
employed should have reference to the state of the system, and constitutional 
powers of the individual; and a low or a nourishing diet prescribetl accordingly. 
In persons of au irritable temperament, change of air, exercise, congenial society, 
and all methods of distraction, should be recommended. In chronic cases, the dis- 
ease is often very intractable; but if it have been previously treated in an inju- 
dicious manner, much may be effected by the above means. If there be much 
pain or watchfulness, anodynes are useful; hyoscyamus and belladonna should be 
preferred; — opium often increasing the irritability. In other respects the treatment 
should be conducted on the principles laid down under Hysteria and Neuralgia; 
with which disorders spinal irritation is almost inseparably connected."*] 



SECTION II.— INFLAMMATION WITHIN THE SPINE. 

I^This, like encephalitis, may be distinguished into: — 1. Inflammation of the 
7ne7nbranes, or spinal meningitis. 2. Inflammation of the substance, or spinal 
myelitis. The latter may be again distinguished into: — I. Inflammation of the 
cerebral, or sentient and voluntary tracts. 2. Inflammation of the true medidla. 
3. Inflammation of the principal divisions of the medulla. 

- Causes. — The causes of iiiflammation within the spine are (principally) blows 
or falls, violent muscular efl'orts, and exposure to damp or cold. One patient be- 
came aff'ected with acute spinal myelitis, from being long exposed to the rain and 
cold in an open boat. This afl'ection has frequenUy occurred from the pernicious 
custom of lying upon damp grass. Rheumatism seems occasionally to have led 
to this disease. The observations of M. Louis have distinctly shown the connec- 
tion between caries of the vertebrae and spinal myelitis. 

Symptoms. — It !s rare that meningitis of the spine exists without meningitis 
within the cranium. It is equally rare for the membranes to be inflamed, or one 
of the cerebral tracts, without affection of the substance, or of the other portions 
of the spinal marrow. The distinctions between these affections, therefore, are 
not easily defined. Happily they are not essential to the treatment. Those symp- 
toms which point to such distinctions will be noticed, however, as we proceed. A 
much more interesting distinction arises from the various locality of the inflamma- 
tion; — according as it affects the " medulla oblongata," or the cervical, dorsal, 
lumbar, and sacral portions of the spinal marrow. A knowledge of the anatomy 
and physiology of the part, frequently enables us to define the region of the spinal 
marrow which is the seat of the disease; and guides us at once in our prognosis, 
and in the local application of remedies; — the most important part of the treatment. 

Symptoms of Spinal Meningitis. — In general, the symptoms of meningitis are 
more those of irritation of the spinal marrow, or spasm; those of myelitis, more 
those of destruction of the organ, or paralysis. Both kinds of symptoms may 
exist, however, or follow each other, in both diseases. Diseases, especially those 
of the nervous system, are usually more complicated in individual patients, than 
as they are described in books. Hence a difliculty in the commencement of prac- 

» " Library of Medicine;" Vulume 2; Pages 184 to 189. 



AFFECTIONS OP THE SPINAL CORD. 5S9 

tice. We are led to expect impossibilities; — diseases well defined in their simple 
forms. It will be well for ns, in reference to our present subject especially, to 
become well acquainted with the anatomy and physioloory of the parts; and we 
shall then be able justly to interpret each symptom as it appears. 

Among the first symptoms of spinal meningitis, is local pain in some part of 
the spinal column; augmented by the movements of the patient, and by percussion; 
but rarely, if ever, by pressure along the spine. This pain sometimes extends 
along the back and limbs, in which there is then tenderness of pressure; — a symp- 
tom which may serve to distinguish meningitis from myelitis, in which there is 
usually loss of sensibility. 

The next important symptom is spasm, or various kinds of muscular contraction. 
The head, the neck, or the trunk is bent backwards; or there is trismus,'' torti- 
collis," partial or complete opisthotonos, *= or contraction of the limbs; — constant, 
or recurrent, or exacerbated, in paroxysms, on moving, on being moved, (fee; with 
extreme pain. Sometimes there are convulsions. The respiration is sometimes 
difficult. There is sometimes retention of urine and constipation. 

The symptoms will vary according as the meningitis exists principally at the base 
of the brain; or at the upper, or the lower, part of the spine. 

Symptoms of Spinal Myelitis. — The symptoms of spinal myelitis, are those 
of paralysis of sensation and voluntary motion. A sense of numbness (impaired 
sensibility), and a sense of feebleness (impaired muscular power), are first observed, 
singly or combined, in one or both of the inferior or superior extremities. In 
some cases, probably of complication with meningitis, there is augmented sensi- 
bility. In other cases there are spasmodic or convulsive affections. If the disease 
proceeds, the paralysis of sensation and voluntary motion gradually augments. 
Generally the paralysis affects first the inferior, and afterwards the superior extre- 
mities; far more rarely it pursues a contrary course: occasionally the motions alone, 
and very rarely the sensations alone, are paralyzed. If the disease occupy the 
tipper parts of the spinal marrow, the respiration, and even the action of the larynx 
and pharynx, become impaired; and we have difficulty or choking in swallowing, 
or asphyxia. There is sometimes the sensation of a cord-like tightness across the 
epigastrium. If the lower part of the spine be affected, the bladder, the rectum, 
and their sphincters, are variously paralyzed; and there may be retention of urine 
and constipation, or involuntary evacuations; or retention and involuntary flow 
of urine may be combined. The condition of the bladder and the condition of 
the rectum should be ascertained, by proper examinations, in every case. In some 
instances there is perfect impotence, or inertia of the uterus: in others tlie patient 
has become a father, or the uterus has been excited to expel the foetus. These 
differences, doubtless, admit of explanation by a reference to the kind of affection, 
— irritation, or destruction, and its locality, — in the cervical, dorsal, or lumbar 
portions of the spinal marrow. 

AJorbid .appearances. — The morbid anatomy is, in everv respect, similar to that 
of cerebral meningitis and myelitis.*^ It is rare, indeed, that spinal meningitis 
occurs without a similar affection of the membranes of the brain. We have 
injection of the " pia mater," and of the spinal vessels in general; effusion of 
serum, lymph, pus, and blood, under the arachnoid, diffused or in portions, and 
perhaps softening of the adjacent medulla. The arachnoid itself is free from 
blood-vessels; the morbid changes supposed to take place in this membrane, have 
their seat in the subjacent cehular membrane, or in the " pia mater." In chronic 
meningitis, there are sometimes membranous adhesions and effusion, of a cartila- 
ginous hanhiess. 

The principal morbid change in myelitis, is softening; which mav occupy the 
whole, or any portion, either side, or the anterior or posterior part of ihc spinal 

* From T^»!;<», fo gnash. 

^ From "lorqneo," to twist; and ''collnm," the neck'. 

•5 From oTTK^Qev. backward; and t£i»<w, to draw. 

d See Page 48G. 



590 AFFECTIONS OF THE SPINAL CORD. 

marrow; it most frequently affects the cervical or lumbar portions. Tliere is, as 
in the same affection of the brain, a degree of tumefaction. Induration is the fre- 
quent result o( chronic myelitis. 

Treatment. — The most efficacious treatment of inflammation within the spine, 
consists (I believe) in the application of cupping in acute cases, and of issues and 
setons in the chronic. Cupping may be applied so as to involve the two princi- 
ples of local depletion and counter-irritation. For this purpose, the scarification 
should be deep, and crossed; and little blood should be drawn; — the operation 
being repeated, according to the violence of the disease and the powers of the pa- 
tient. In reference to the use of issues, M. Louis makes a very apposite remark: 
—"Experience has demonstrated the utility of issues in Pott's disease; when that 
affection is of long standing, and voluntary movement more or less injured. A 
necessary consequence of the foregoing is, that the same means ought to be em- 
ployed in the simple or primitive softening of the spinal marrow." The adminis- 
tration of mercury in the acute cases, and in the chronic cases when these are 
uncomplicated with a tuberculous diathesis, is an important measure. 

The most moderate diet should be enjoined; the bowels should be kept free; 
and the recumbent posture, with the utmost quiet, should be preserved. 



SECTION III.— SPINAL APOPLEXY. 

Little, I believe, can be said of this form of spinal disease. If it can ever be 
suspected during life, it can only be from the suddenness of the accession or attack 
of the symptoms; and the treatment must be the same as in acute inflammation 
within the spine. 

In a very interesting case, (for which I am indebted to Mr. Kiernan,) the '< me- 
dulla oblongata" being suddenly compressed, the respiration ceased, and the 
patient expired instantly. An organic change, which would have produced irrita- 
tion rather than pressure, would have induced a very different effect.*] 



SECTION IV.— SPINA BIFIDA. 

Definition. — There is sometimes a collection of water low down in the spine; 
and a tumour is formed externally. From the bone being generally deficient and 
the spine gaping, the disease is called " spina bifida." This, like the accumulation 
within the head, is sometimes congenital, — born with the child; and sometimes it 
is not. Sometimes a collection of water will exist with a sound spine; and some- 
times the spine is bifid. 

Appearances of the Parts. — A tumour is produced, — sometimes more than one; 
and generally the tumour is situated at the lower part of the spine; — in the loins. 
The higher the tumour is situated, the more rare is the case. These tumours are 
of all sizes; — from merely a little elevation of the skin, to the size of a child's head. 
Sometimes the tumour is diffused; sometimes it is very prominent; and sometimes 
it is both diffused and prominent. It is also of all shades. The skin externally 
is seen in all conditions. Sometimes it is healthy; sometimes it is very thick; 
sometimes it is inflamed; sometimes it is gangrenous, ulcerated, and fistulous; and 
sometimes I have seen it very hairy. The subjacent membranes are likewise 
found in all sorts of slates. Sometimes the membranes are diseased, while the 
skin remains healthy. 

Characters and Seat of the Fluid. — The fluid which is contained in these tu- 
mours, is exactly like the fluid of hydrocephalus; — for the most part, exceedingly 
limpid, like rock-water; and its quantity varies, from a few ounces, to six or seven 

*" Diseases and Derang'ements of the Nervous System. By Marshall Hall, M. D." 
Chapter 7; Pages 315 to 319. 



CONVULSIONS. 591 

pounds. It will exist sometimes in the arachnoid, sometimes between the arach- 
noid and "dura mater," and sometimes between the arachnoid and the " pia ma- 
ter;" — that is to say, it will exist in the arachnoid on either side; and it will be 
found between the " dura mater" and the bones. It has even been found in the 
canal which runs along the " medulla spinalis." 

AVhen there is a deficiency of bone, there is sometimes a fissure all the way 
through; — from the cervical vertebrae, down to the os coccygis. That, however, 
is very rare. Sometimes it runs from the last cervical vertebra, down to the be- 
ginning of the sacrum; or it exists only in the loins. The latter is a common 
occurrence. The deficiency is sometimes a mere slit; sometimes there is an im- 
perfect evolution of the lateral arches of the bones; and sometimes there is even 
separation of the body of the vertebrae also. 

Varieties in the Position of the Cord. — Besides this variety as to the state of 
the integuments, as to the state of the membranes, as to the situation of the water, 
and as to the condition of the bones, there is a great variety also as to the situation 
of the spinal marrow. Sometimes it is precisely in its natural place; sometimes it 
runs outside the tumour; sometimes it is distributed upon the sac; and sometimes 
it has been seen deficient in the aff'ected piirt. 

Freqimit Coexistence of Club-Foot.—li has been noticed by some, that club- 
foot frequently coexists with this affection. It is well known, that when there is 
a species of monstrosity in one part of the body, it is very common to find a de- 
fect in another: if an important part (such as the heart or brain) be deficient, it is 
very common for other parts to be malformed. In this disease, then, club-feet 
often coexist; but very frequently they do not; because they are only minor devia- 
tions from the natural structure of the body. I recollect an instance of a child 
having this disease, where the tumour was situated on the loins, and was sur- 
rounded by a considerable quantity of hair; and there were club-feet; but the tu- 
mour ceased spontaneously. No measures were resorted to, for the best part of a 
twelvemonth; although, when the child was first born, there was the appearance of 
ulceration, and even gangrene. The disease, however, entirely disappeared; the 
surface became flat; hydrocephalus commenced; and ultimately destroyed the child. 

Treatment. — With regard to the treatment of spina bifida, I need not make any 
remarks. Medicine is of no avail; but cases have been much relieved, if not 
cured, by puncturing, and by the careful application of a bandage; — exactly the 
same treatment that has succeeded in hydrocephalus.* The part is frequently in a 
state of gangrene, and then no treatment can be borne; but when the employment 
of remedial measures is admissible, they are entirely mechanical, and therefore de- 
volve on the surgeon. 



CHAPTER VIII. 
CONVULSIONS. 



Definition.— \J&y the term ''convulsion,'" is meant a diseased state of the mus- 
cular tissues; characterized by violent involuntary contractions, with alternate re- 
laxations. This diseased action is common to the muscles both of voluntary and 
involuntary motion; but occurs much more frequently in the former. The term 
''spasm'' has been applied, by some, to the inordinate action of the invoJmitary 
muscles; — the term "convulsion" being more particularly reserved to designate tiie 
irregular contraction of the voluntary muscles. When the contractions have been 



"^ See PageSU. 



592 CONVULSIONS. 

of some duration, and are not quickly succeeded by alternate relaxations, they have 
been called ''tonic convulsions;" — exemplified in tetanus; whilst involuntary alter- 
nate motions of contraction and relaxation have been termed '^clonic convulsion;" 
of which hysteria affords an example. The term '^ convulsion^ ^ has sometimes 
been exclusively appropriated to clonic convulsion; but as the principal difference 
between clonic and tonic convulsions consists in degree, and they both originate in 
the same causes, it is more convenient for practical purposes to include them under' 
the same head. Very slight and quick alternations of contraction and relaxation, 
constitute what is called "tremor."* 

Convulsions manifest themselves in various degrees, and under various forms. 
They occur as a symptom in the course of many diseases; and they sometimes 
assume such regular and well-defined characters, as to constitute distinct and sepa- 
rate diseases; as, for instance, in the case of tetanus and hysteria. There are, how- 
ever, attacks of simple convulsion, partial and general, that cannot be referred to 
hysteria, epilepsy, or any of the well-defined convulsive afTeclions which have re- 
ceived generic names.''] 

In Infants. — Children are very liable to epileptic fits and regular convulsions; 
from irritation of the bowels, teething, and other circumstances. These will some- 
times depend upon the mere circumstance of teething; and cease if the gums be 
lanced. Sometimes they arise from the intestines, and are cured by purging; so 
that other antiphlogistic measures are not required; but sometimes they depend on, 
and are connected with an inflammatory state of the head; and after death we find 
the same appearance as in hydrocephalus;'' — at least, the Iming membrane of the 
ventricles is as red as a piece of scarlet cloth. 

Treatment. — The treatment of convulsions (if we cannot discover in the gums 
or intestines an exciting cause, which it is in our power to remove) should be, if 
the pulse will justify it, the same as for hydrocephalus.** We must take blood 
away freely, give mercury, and put ice on the head. But it is necessary here to 
make the same diagnosis that we do in hydrocephalus.® These convulsions may 
be connected with debility, with a weak pulse, with paleness of the face, or with 
only a transient flushing of it; and, in such cases as these, assafcEtida,or a small quan- 
tity of laudanum, or ammonia, may answer a good purpose.^ In these cases of con- 
vulsions, cold affusion has frequently been attended with very good effect. In the work 
of Dr. Currie on Cold Affusion,^ — a sort of classical work in medicine, and well worth 
reading, — he mentions several cases of convulsions in children, where they ceased 
immediately on the sudden application of cold water. Now if these convulsions 
had arisen from an inflammatory state, the effect would not have been of this kind. 
We cannot cure inflammation by merely throwing cold water on a patient. It is 
clear that the convulsions of children may frequendy arise from irritation, not 
within the head, but connected with a distant part; but if there be an over-fulness 
of the head in particular, or of the system at large, without marks of inflammation, 
or still more ivith marks of inflammation, it is not right to trust to any thing but 
the common antiphlogistic remedies vigorously applied. 

Chronic Convulsions. — The chronic convulsions of children are allied to epi- 
lepsy; and must be treated in the same way. 

° ''Spasm" is morbidly increased action; "paralysis" Is morbidly diminished action; 
"convulsion" is irregular action. " Tremor" is a loss of balance from diminished action, — 
approaching to paAsy, "convulsion" is a loss of balance from increased action,— ap- 
proaching to spasm. A ''clonic spasm" is a convulsion. Palpitation of the heart is an ex- 
ample. — Dr. Fletcher. 

^ "Cyclopgedia of Practical Medicine;" Volume 1; Page 466, 

«= See Page .504. ^ See Page 505. « See Page 528. 

f See Page 529. s See Note to Page 321. 



I 



EPILEPSY. 593 



CHAPTER IX. 

EPILEPSY. 

Synonyraes. — The disease next to be spoken of is epilepsy. The name of the 
disease is given to it from the suddenness of the seizure; — from £Tti7.aixj3avco, to 
seize upon. It is also called, in Latin, " morbus comitialis;^^ because if a person 
in the '* comitia," or popular assemblies, of the Romans was seized with the dis- 
ease, it was considered a bad omen, and the comitia were dissolved. It is also 
called " morbus sputa-,''' — " the spitting disease;" from the custom of spitting 
into the bosom, to avert the unfavourable omen. The Romans were remarkably 
superstitious; and fancied it was a sign of ill luck to be seized with a fit; and 
therefore they spit into their bosoms, to save themselves from something perni- 
cious, or to do good to the patient. In common language it is called " the falling 
sickness;" and, now that the lower orders have got hold of fine names, they call 
it by various appellations. The Jews ascribed it to the influence of demons; it 
is also indicated in the New Testament; where persons are said to have been sud- 
denly seized by an evil spirit, and to have fallen into the water or fire;* because a 
patient who is liable to the disease may be near fire or water, and he will fall into 
the one or the other. 



SECTION L— PROGRESS AND VARIETIES. 

Definition. — In epilepsy, there is a sudden loss of sense, with convulsions of 
the voluntary muscles; and the loss of sense continues after the convulsions have 
ceased; — so that a person is said to " go to sleep" after the fit. 

Symptoms of the Attack. — In the fit, the countenance is ghastly and pale, or 
perhaps of a bluish red; it is sometimes sallow. The lips are livid; the neck and 
the cheeks are much swollen; and, perhaps, the whole body is bedewed with 
sweat; but especially the head and cheeks. There is foaming at the mouth; and 
generally the tongue is bitten. There are universal violent convulsions, horrid 
grimaces, a rolling of the eyes, and dilatation of the pupils. Sometimes it hap- 
pens that the urine and faeces are discharged involuntarily; — the urine most fre- 
quently; and occasionally there is a discharge even of semen, with or without an 
erection; — I do not know which. The hands are generally clenched, in the fit; 
and the heart palpitates strongly. The pulse is quick; and the respiration is short, 
deep, and irregular. 

Not attended by suffering. — When the patient wakes from the state of sopor, 
he has generally no recollection of what has passed; and perhaps, therefore, there 
is no suffering. The want of recollection of suffering, however, is no proof that 
there has been no suffering; for we have all suffered enough in cutting our teeth, 
and yet we know nothing of it now. So it may happen respecting more recent 
events. The fit may be attended with more or less suffering; but I should think 
there was none, for persons do not suffer, in general, when they are hung; — 
although they may struggle, and hang so long as to be insensible, and almost dead. 
There is an account, in Lord Bacon's works, of a person who was hung, and all 
but killed; and yet he did not suffer. From a short account written by Cowper, 

* " There came to Him a certain man, kneeling down to Him, and saying—' Lord, have 
mercy on my son; for he is lunatic and sore vexed! For ofttimes he falleih into the tirej 
and oft into the water.' And Jesus rebuked the devil; and he departed out of him; and the 
child was cured from that very hour." — " The Gospel according to Matthew;'" Chapter 17; 
Verse 15. 

VOL. I.— 38 



594 EPILEPSY. 

the poet, it appears that he three times attempted to commit suicide; and one of 
these attempts was by suspension. The account was v/ritten by himself; and was 
found among his manuscripts. It is very scarce; — on account of its having been 
bought up. He there mentions, that he suspended himself over his chamber- 
door, in the Temple; and became perfectly insensible. He only recollected a 
flash of light appearing before his eyes. His weight at last caused him to drop 
on the floor, where he was found; and, after a time, he recovered.^ He says that, 

* One evening in November, 1763, as soon as it was dark, — affecting as cheerful and 
unconcerned an air as possible,— I [Covvper] went into an apothecary's sliop, and asked for 
a halt-ounce phial of laudanum. The man seemed to observe me narrowly; but if he did, I 
managed my voice and countenance, so as to deceive him. The day that required my at- 
tendance at the bar of the House [of Commons] being not yet come, and about a week dis- 
tant, I kept my bottle close in my side-pocket; — resolved to use it when I should be convinced 
there was no other way of escaping. — Not knowing where to poison myself, — for I was 
liable to continual interruption in my chambers [in the Temple] from my laundress and her 
husband, — I laid aside that intention, and resolved upon drowning. For that purpose, I 
immediately took a coach; and ordered the man to drive to Tower- Wharf; — intending to 
throw myself into the river from the Custom-House-Gluay. I left the coach upon the 
Tower-Wharf; — intending never to return to it: but, upon coming to the quay, I found the 
water low, and a porter seated upon some goods there; — as if on purpose to prevent me. 
This passage to the bottomless pit being mercifully shut against me, I returned to the 
coach, and ordered it to the Temple. I drew up the shutters [of the coach], and once more 
had recourse to the laudanum, and determined to drink it off directly; but God had other- 
wise ordained. A conflict, that shook me to pieces, suddenly took place; not properly a 
trembling; but a convulsive agitation, which deprived me (in a manner) of the use of my 
limbs; and my mind was as much shaken as my body. Distracted between the desire of 
death, and the dread of it, twenty times I had the phial to my mouth, and as often received 
an irresistible check; and, even at the time, it seemed to me that an invisible hand swayed 
the bottle downwards, as often as I set it against my lips. I well remember, that I took no- 
tice of this circumstance with some surprise; — though it effected no change in my purpose. 
Panting for breath, and in horrible agony, I flung myself back into the corner of the coach. 
A few drops of laudanum which had touched my lips, besides the fumes of it, began to have 
a stupifying effect upon me. Regretting the loss of so fair an opportunity, yet utterly unable 
to avail myself of it, I determined not to live; and, already half-dead with anguish, I once 
more returned to the Temple. Instantly I repaired to my rooms; and, having shut both the 
outer and inner door, prepared myself for the last scene of the tragedy. I poured the lauda- 
num into a small basin, set it on a chair by the bed-side, half undressed myself, and laid 
down between the blankets; — shuddering with horror at what I was about to perpetrate. I 
reproached myself bitterly with folly and rank cowardice, for having suffered the fear of 
death to influence me, as it had done; and was filled with disdain at my own pitiful timidity: 
but still something seemed to overrule me, and to say — " Think what you are doing! Con- 
sider, and live!" At length, however, with the most confirmed resolution, I reached forth 
my hand towards the basin; when the fingers of both hands were as closely contracted as if 
bound with a cord, and became entirely useless. Still, indeed, I could have made shift with 
both hands, — dead and lifeless as they were, — to raise the basin to my mouth; for my arms 
were not at all affected: but this new difficulty struck me with wonder; — it had the air of a 
divine interposition. 1 lay down in bed again, to muse upon it; and, while thus employed, 
heard the key turn in the outer door, and my laundress's husband came in [to the outer 
room]. By this time, the use of my fingers was restored to me. I started up hastily; dressed 
myself; hid the basin; and, affecting as composed an air as I could, walked out into the 
dining-room. In a few minutes I was left alone; and now, unless God had evidently inter- 
posed for my preservation, I should certainly have done execution upon myself; — having a 
whole afternoon before me. Both the man and his wife having gone out, outward obstruc- 
tions were no sooner removed, than new ones arose within. The man had just shut the 
door behind him, when the convincing spirit came upon me, and a total alteration in my 
sentiments took place. The horror of the crime was immediately exhibited to me in so 
strong a light, that— being seized with a kind of furious indignation— I snatched up the 
basin, poured away the laudanum into a vesssl of foul water, and — not content with that — 
flung the phial out of the window. This impulse, having served the present purpose, was 
withdrawn. I spent the rest of the day in a kind of stupid insensibility; — undetermined as 
to the manner of dying, but still bent on self-murder, as the only possible deliverance. 

I went to bed, to take (as I thought) my last sleep in this world. The next morning was 
to place me at the bar of the House; and I determined not to see it. I slept as usual, and 
awoke about three o'clock. Immediately I arose, and (by the help of a rush-light) found 
my i^enknife, took it into bed with me, and lay with it (for some hours) directly pointed 
against my heart. Tvvice or thrice I placed it upright under my left breast;— -leaning all 
my weight upon it; but the point was broken off square, and it would not penetrate. In 
this manner the time passed, till the day began to break. I heard the clock strike sevenj 



EPILEPSY. 595 

although he was thus in the jaws of death, and had become perfectly insensible, 
yet he had no previous suffering; and therefore, as there was no suffering in that 
state, it is probable that there is no suffering in epilepsy; — that there is such a 
state of insensibility that nothing is experienced. I should suppose that in drown- 
ing there is no suffering, if it occur at once. Shakspeare's expression is — 

" Oh Lord! methought what pain it was to drown!"* 

but there is no reason to suppose there is pain, if the individual go down and do 
not come up again; but if he come out of the water, the suffering is dreadful. 

Duration of the Attack. — The convulsions of epilepsy may last from a mo- 
ment, to fifteen minutes or more; and sometimes they recur after they have ceased, 
before the sopor is over. The sopor, or coma, is generally complete, both during 
the convulsions, and for some time subsequently; but not always. This, there- 
fore, is the character of epilepsy; — a sudden attack of convulsions of the voluntary 
muscles, together with insensibility; — the insensibility continuing after the convul- 
sions have ceased.^ 

Most frequeMly attacks One Side. — Frequently, like all diseases of the ner- 
vous system, it occurs more on one side than on the other. Paralysis frequently 

and instantly it occurred to me, that there was no time to be lost: the chambers would soon 
be opened; and my friend would call upon me, to take me with him to Westminster. " Now 
is the time!" — thought I. " This is the crisis! No more dallying with the love of life!" I 
arose; and, as I thought, bolted the inner door of my chambers; but was mistaken: my touch 
deceived me, and I left it as I found it. My preservation, indeed, as it will appear, did not 
depend upon that incident; but I mention it, to show that the good providence of God watched 
over me, to keep open every way of deliverance; — that nothing might be left to hazard. 

Not one hesitating thought now remained: I fell greedily to the execution of my purpose. 
My garter was made of a broad piece of scarlet binding, with a sliding buckle; — being sewn 
together at the ends. By the help of the buckle, I formed a noose, and fixed it about my 
neck; straining it so tight, that I hardly left a passage for my breath or for the blood to cir- 
culate: the tongue of the buckle held it fast. At each corner of the bed, was placed a 
wreath of carved work, fastened by an iron pin, which passed up through the midst cif it; 
the other part of the garter, which made a loop, I slipped over one of these; and hung by it 
some seconds: — drawing up my feet under me, that they might not touch the floor. But the 
iron bent; and the carved work slipped off, and the garter with it. I then fastened it to the 
frame of the tester; — winding it round, and tying it in a strong knot. The frame broke short, 
and let me down again. The third effort was more likely to succeed. I set open the door, 
w^hich reached within a foot of the ceiling. By the help of a chair, I could command the 
top of it; and the loop, being large enough to admit a large angle of the door, was easily 
fixed so as not to slip off again. I pushed away the chair with my feet, and hung at my 
whole length. While I hung there, I distinctly heard a voice say, three times, — " 'Tis 
over!" Though I am sure of the fact, and was so at the time, yet it did not at all alarm me, 
or affect my resolution. 

I hung so long that I lost all sense. — all consciousness of existence. When I came to 
myself again, I thought myself in hell.' The sound of my own dreadful groans was all that 
I heard; and a feeling like that produced by a flash of lightning just beginning to seize upon 
me, passed over my whole body. In a few seconds, I found myself fallen on my face to the 
floor. In about half a minute, I recovered my feet; and, reeling and staggering, stumbled 
into bed again. By the blessed providence of God, the garter which had held me till the 
bitterness o^ temporal death was passed, broke just heiore eternal death had taken place upon 
me. The stagnation of the blood under one eye (in a broad crimson spot), and a red circle 
round my neck, showed plainly that I had been on the brink of eternity. Soon after I got 
into bed, I was surprised to hear a noise in the dining-room; where the laundress was light- 
ing a fire. She had found the door unbolted, notwithstanding my design to fasten it; and 
must have passed the bed-chamber door, while I was hanging on it; and yet never perceived 
me. She heard me fall, and presently came to ask me if I was well;— adding, that she feared 
1 had been in a fit. I sent her to a friend, to whom I related the whole affair; and despatched 
him to my kinsman, at the coffee-house. As soon as the latter arrived, I pointcil to the 
broken garter, which lay in the middle of the room; and apprised him, also, of ihe attempt 
I had been making. His words were:— " My dear Mr. Cowper, you terrify me! To be 
sure you cannot hold the office at this rate. "Where is the deputation'?" I gave him (he 
key of the drawer where it was deposited; and, his business requiring his immediate attend- 
ance, he look it away with him; and thus ended all my connection with the parlinmcnl- 
office. — Cowper's Works; edited by Dr. Southey; Volume 1; Chapter 5; Pages l'2-2 to 131. 

" " Richard the Third;" Act 1; Scene 4. " See Page 593. 



596 EPILEPSY. 

does so; St. Vitus's dance affects one side more than the other; hysteria does the 
same; and we find that epilepsy likewise has the same tendency. 

Occurs most frequently during Sleep. — The fits of the disease most frequently 
occur during sleep, or in the state intermediate between sleeping and waking; when 
we all experience a little delirium. If we fall asleep in a moment from a waking 
slate, there is no delirium; but if v^e fall asleep gradually, the mind wanders. 
If we wake suddenly there is nothing of the kind: but if we wake very sloivly^ 
then again a little delirium is experienced. We are more accustomed, however, 
to go to sleep gradually, than to ivake so; and therefore the delirium is observed 
far more commonly in going to sleep, than in waking. Now it is at the instant 
when a person is neither in full action nor at complete rest, that epilepsy particu- 
larly attacks him. A great number of persons have a fit, just when they are going 
to sleep, or when they awake; — many have it when they are asleep; and, again, 
some only have it either when they are going to sleep, or when they are about to 
awake. 

Warning of Us Occurrence. — Occasionally the patient has no warning what- 
ever; and has no knowledge of the fit. I have seen many persons who are not at 
all aware that they have fits. These have been persons in the decline of life, who 
are in the habit of sitting in the house; — not going about so as to run the chance 
of being injured; and who have been watched by the rest of the family. I have 
known them have fits for years; and yet they have not been aware of it; — at least 
they pretended they were not. The individual has been seized in a moment; and 
has afterwards wondered what has been the matter. But some persons have good 
warning. Some, previously to the attack, have vertigo and headache, sufficient to 
show that they are going to have it. Sometimes there is just vertigo enough, and 
no more, to enable them to escape from danger. Some have headache, a day or 
two before the vertigo; but some have vertigo only just in sufiicient time to make 
them get out of the dangerous situation in which they are placed. Occasionally, 
a spectre has been seen at the moment of the fit; — an image has passed before 
the mind, before the fit took place. I recollect that Dr. Gregory" used to mention, 
in his lectures, that he knew a patient who, before the fit, saw a little old woman 
come out of the corner with a stick; and when she approached and struck him, 
down he fell in a paroxysm. It is a mental delusion of the moment, produced by 
an excitement of the brain. The fact is mentioned by Sir Walter Scott, in his 
*' Letters on Demonology and Witchcraft;" — certainly not one of his best books."" 

a See Note to Page 239. 

^ A patient of Dr. Gregory, a person (it is understood) of some rank, having requested 
the doctor's advice, made the following extraordinary statement of his complaint: — " I am 
in the habit of dining at tive; and, exactly as the hour of six arrives, I am subject to the 
following painful visitation. The door of the room, even when I have been weak enough 
to bolt it (which I have sometimes done), flies wide open; an old hag, like one of those who 
haunted the heath of Forres [alluding to the witches in "Macbeth"], enters with a frown- 
ing and incensed countenance, comes up to me with every demonstration of spite and in- 
dignation which could characterize her who haunted the merchant Abudah in the Oriental 
tale; she rushes upon me, says something, but so hastily that I cannot discover the purport; 
and then strikes me a severe blow with her staff. I fall from my chair in a swoon; which 
is of longer or shorter endurance. To the recurrence of this apparition I am daily sub- 
jected;— such is my new and singular complaint." The doctor immediately asked, whether 
his patient had invited any one to sit with him, when he expected such a visitation. He 
was answered in the negative. The nature of the complaint, he said, was so singular, it 
was so likely to be imputed to fancy, or even to mental derangement, that he had shrunk 
from communicating the circumstance to any one. " Then," said the doctor, " I will dine 
with you to-day, tete-^i-tele; and we will see if your malignant old woman will venture to 
join our company." The patient accepted the proposal, with hope and gratitude; for he 
had expected ridicule rather than sympathy. They met at dinner; and Dr. Gregory, who 
suspecifd some nervous disorder, exerted his powers of conversation, (well known to be of 
the most varied and most brilliant character,) to keep the attention of his host engaged, and 
prevent him from thinking on the approach of the fatal hour, to which he was accustomed to 
look forward with so much terror. He succeeded in his purpose better than he had expected. 
The hour of six came almost unnoticed; and, it was hoped, might pass away without any 
evil consequence; but it was scarce a moment struck, when the owner of the house exclaim- 



EPILEPSY. 597 

Sometimes, before the fit, the patient utters a loud scream. He is not aware of 
any suffering- that occasions him to do it; but only says that he cannot help scream- 
ing. Sometimes the patient has a warning during the first fits; but when he has 
been long subject to the disease, no warning takes place. Sometimes, after a fit, 
not only will a patient forget it, but no symptom remains; on the other hand, 
people will occasionally be subject, for some days, to headache and sleepiness. 
Sometimes these symptoms only remain a few hours; but in other cases they will 
remain a few days. 

*^ura Epileptica. — Sometimes, before the fit, there is a warning; occasioned by 
a sensation of tickling, or crawling, along the surface of the body. There is a 
sensation as if fluid were creeping from the fingers, or from the thighs, towards 
the trunk; and sometimes as though a spider or flea were creeping over the skin. 
When it appears like fluid, it is generally like cold fluid. This has been ascribed 
to a sort of rush of air or wind, and has been called "aura;" and, being connected 
with the epilepsy, it is called " aura epileptica^ It does not follow the course of 
particular nerves. It appears to reside in the skin; and there is certainly no con- 
nection between it and the neurilema of the part. I have seen several instances of 
this afTection; and I made a note of one case, in 1826. A boy had a sensation of 
two auirae; which ran along the dorsum of the foot, up the front of the legs and 
thighs. Each stream ran up the trunk, and they met at the epigastrium; and then 
it seemed as if there were five streams, running from the two up the trunk. As 
soon as the aurae. got to the epigastrium, down he fell. He compared the sensation, 
which was very rapid, to that of the creeping of a spider. I had another case of 
the same kind, in May, 1826. 

Frequency of the Fits. — Occasionally, the fits are very numerous at first; but 
gradually become less so. While, however, they become less numerous, they 
generally become more severe, and last longer. I think, in the majority of cases, 
the fits are most frequent at first; so that a person will have a dozen or twenty in 
a day; but as they become fewer, I have generally observed them last longer, and 
the severity is greater. Occasionally I know the reverse takes place; — they are 
not so numerous at first. Some have but one fit for many years; — an interval of 
many years occurring before another takes place; and, so far as I know, some 
have but one fit during life. It has proceeded from some temporary cause; and 
the disease has never recurred. 

The Mind becomes Impaired. — If the disease have continued long, and the fits 
have not been very infrequent, the mind generally becomes impaired; but if the dis- 
ease have continued long, and yet the fits have not recurred except at long inter- 
vals, then the mind is not impaired. The reason is simply this; — the disease of 
the brain, which gives rise to these fits, at last disturbs other functions. It is not 
the epilepsy that causes it; but the cause of the epilepsy impresses other parts of 
the brain. That the disease, however, does not necessarily impair the mind, is 
shown by the example of Julius Caesar, and Napoleon; both of whom, we are told, 
were subject to it."" 

Complicated with other Diseases. — It is very common for one, two, or more 

ed, in an alarmed voice, — "The hag comes again!" — and dropped back in his chair in a 
swoon; — in the way he had himself described. The physician caused him to be lei blood; 
and satisfied himself that the periodical shocks of which his patient complained, arose from 
a tendency to apoplexy.— " Z,e;;ters on Demonology and Witchcraft. By Sir Walter Scott." 
Letter 1; Pages 23 to 25. 

* Cassius. Did Coesar swoon ? 

Casca. He fell down in the market-place, and foamed at the mouth, and was speechless. 

Brutus. 'Tis very like! He hath the "falling sickness." 

^"Julius Ccesar;'' Act 1; Scene 2. 

It is reported that afterwards, he [Coesar] imputed it [his conduct to the Senate] to his 
disease; — saying that their wits are not perfect which have this disease of the "falling <^^''.''' ' 
when, standing on their feet, they speak to the common people; but are soon troubled with 
a trembling of their body, and a sudden dimness and giddiness. — ''Pictorial Edition of 
ShaJcspeare;'' Part 35 {''Julius Cossar")- Tragedies, Vohme2; Page 23G. {Quoted from 
North's Tromslation of ^'Plutarch's Lives.") 



598 EPILEPSY. 

diseases of the nervous system to be united; and we find, in illustration of this 
observation, that epilepsy frequently occurs in chorea, in hysteria, in insanity, in 
idiotism,'' and not unfrequently in palsy; — that is to say, the pathological state of 
the brain or spinal marrow, or both, will produce sometimes one symptom, and 
sometimes another. The disease may be such, as to extend from one portion to 
another, and to affect various parts. This union of different diseases of the nervous 
system, is almost always seen. In St. Vitus's dance, there is a peculiar constitu- 
tion of the mind, — a little fatuity. Apoplexy and palsy we see united every day; 
and apoplexy is the common termination of many diseases of the nervous system; 
—of insanity, for example. These different nervous diseases may coexist or suc- 
ceed each other. 

Variety of Epilepsy. — There is a great variety in epilepsy. That which I have 
just described is the most common form; but there are very great varieties; — so 
that persons may quarrel about the deiinition, if they choose; and say that such 
and such forms are not epilepsy. If we define epilepsy to be " a complete loss of 
sense, with general convulsions," then an incomplete loss of sense, ov partial con- 
vulsions, is not to be considered epilepsy. But it is not wise to quarrel about 
terms, in this way, so long as we understand what is meant by them. 

It will sometimes happen that there is decided insensibility before the convul- 
sions take place; and that during the convulsions, the person becomes more or 
less sensible. This is one form in which the disease appears. Occasionally pa- 
tients have no convulsions at all; — they will simply fall down in a state of insensi- 
bility, and rise up again without knowing what is the matter with them. Occasion- 
ally, instead of these convulsions occurring throughout the body, they are confined 
to one side; and sometimes they are still more partial; — being confined to one 
extremity. Sometimes, instead of convulsions, there is mere tremor of the body; 
or a part of the body will shake violently. Occasionally, during the fit, there is 
delirium. The person shows that he is not insensible; but, instead of being insen- 
sible, he is in a state of violent delirium; — apparently in an alarming condition; 
although in general, I believe there is no danger at all. Sometimes patients have 
this delirium on recovering from a comatose state. Occasionally the disease as- 
sumes the form of partial tetanus; one-half of the body being in a state of the most 
intense spasmodic rigidity. I have seen two cases, where the person was seized, 
at the moment of the convulsions, with a spasm of one-half of the body, attended 
with the most excruciating pain. One arm and one leg have been drawn up; yet 
there has been no danger; and the nature of the case has been shown very plainly, 
by the next paroxysm being epileptic. 

Ecslasis. — Sometimes there is a variety in what occurs in this respect; — a per- 
son is insensible to all around him; and yet has, before the fit, no internal uncon- 
sciousness. I have seen several instances where, before the fit, the patient became 
unconscious of external objects; — that is to say, the comatose state came on before 
the convulsions; but, in that apparently comatose state (a state of sopor in which 
there was no perception of any thing around) the patient was internally in a state 
of activity; and that condition is called " ecstasis;'"* — whether it be united with 
epilepsy or not. In this state, people sometimes walk, dress themselves, and even 
compose poetry; and yet they have no knowledge of it. If they be awakened in 
this condition, they are alarmed; or, at least, they are surprised at the situation in 
"which they are placed. Sometimes they recollect it all; — ^just as we recollect a 
dream. Sometimes we may remember a dream, but sometimes we have no know- 
ledge of it; while those near us see that we have been dreaming. So it is in this 
state of ecstasy, which consists in the mind being internally active. Sometimes 
the paroxysms are not quite complete; so that a person is half aware of what is 
going on about him. If the patients be in a situation where they have frequently 
been before, and have become habituated to it, they have been known to walk over 

" See Pas:e 543. 

b From (*(erTa|Wai) to be mentally deranged. 



EPILEPSY. 599 

difficult places, where there was the greatest clanger, with impunity. These 
places, however, were well known to them; so that habit influenced their motions. 
Sometimes, however, the activity of the mind is so imperfect, that tiiey know 
where the window is, and how to open it, yet they forget that there is the street 
beyond the window; and they step out, and are dashed to pieces. This all arises 
from an imperfect activity of mind. This state of ecstasis is nothing more than 
active dreaming. In dreaming we are often active, reason correctly, and even 
compose poetry; but in this state of ecstasis, more tlian that is done; — persons will 
compose to a great extent, reason accurately, and perform voluntary motion, — so 
as to go from one place to another, and do many tilings; and yet, for the most part, 
they will be ignorant of it. A patient of mine had this ecstasis before the paroxysm 
of epilepsy. She was a girl, and subject to epilepsy; and, before she fell down, 
she was insensible to all around her; but, in the state of insensibility, she used to 
liiim "Robin Adair," and "Home, sweet home," so correctly, that none could 
find fault with her; but she was quite unconscious of it. After this, the activity of 
the mind ceased; she became unconscious internally as well as externally; and the 
convulsions then came on. I had another patient, more religiously and devoutly 
disposed; and she ahvays sung hymris, and in good time. 

Dr. Darwin considered this somnambulism, or " w-alking in the sleep,"* (which 
is only an imperfect degree of sleep,) to be an epileptic disease. Whether it is 
true epilepsy or not, is another thing; but he considered it to belong to the family 
of epileptic affections. Dr. Prichard, of Bristol, (whose work on nervous diseases'" 
is well worth reading,) considers walking in the sleep and ecstasis to be both of an 
epileptic character. If a person be asleep, and be seized with a partial conscious- 
ness, and partial voluntary power, it is called "somnambulism;" but if he be seized 
in a waking state, tlien it is called " ecstasis." It is the same state; only it may 
begin when we are asleep, by a degree of activity; or when we are awake, by a 
degree o( insensihilily. They come exacdy to the same thing. They frequently 
occur without epilepsy; but they are frequently united with it. 

jSight-jMare. — The night-mare is considered by some as allied to epilepsy. In 
the night-mare, which is technically called " incubus, "•" there is a degree of sense, 
but a deceptive feeling;— generally some unpleasant dreams, and more or less loss 
of volition. There is a strong, but ineffectual desire to make a muscular effort. It 
is only a variety of somnambulism; and when the paroxysm ceases, we can make 
a voluntary effort: whence it is imagined, we get rid of the night-mare by making 
the effort; whereas the effort is made because the diseased state ceases. I think it 
is a siigiu degree of epileptic affection. There can be no doubt that it is a cere- 
bral affection; and it may arise from eating suppers, and from other causes. It is 
singular that there is one house in the country, where I always have the night- 
mare; and in my own case the spectre has taken the shape of a devil, with a co- 
lour like that of oil-skin. The house is that of a friend of mine. I repeatedly 
changed ni}' bed-room; and at last I did not go to bed at all, but slept in the draw- 
ing-room. Still, however, I had the night-mare. I do not know the reason. 
Possibly it was goinsf from London, partaking of a late dinner, eating more than I 
should, being cheerful from seeing my friends, and then going to bed. Certain it 
is that in that house, for four or five years, I regularly had the night-mare. 

Coma without Convulsions. — The state of ecstasis I have described, precedes 
the commencement of the fit; and I believe it sometimes takes place after the fit; 
but other varieties take place in the fit itself. I mentioned that, sometimes, the 
coma ceases when the convulsions come on;'* and some people have coma without 
convulsions at all;*^ and that is a kind of epilepsy which is frequenUy mistaken for 
apoplexy. Many persons are said to have twenty fits of apoplexy, when they 
have never had one. Old people will fall down senseless; and will get up again, 
just as if nothing had happened; and if a practitioner be near, he bleeds them; and 

* From " somnus," sleep; and " ambnlo," to u-alk. 

^ " Treatise on Diseases of the Nervous System; bv J. C. Prichard, M. D." 

« From " incubo," to Bit upon. <i See Page 598. 



I 



600 EPILEPSY. 

a cure of apoplexy is thought to be effected; but there is no reason to suppose that 
it is any such thing. It appears to be only imperfect epilepsy, — epilepsy without 
convulsions; for there is no stertorous breathing; no harm arises from it; and such 
persons very frequently, sooner or later, have regular epilepsy. A slight degree of 
this is sometimes seen; — so that persons will not lose themselves entirely. They 
feel that they are going; they catch hold of something; and they are right again. 
It is, no doubt, an imperfect form of epilepsy. The coma is not fully formed; last- 
ing only a few moments. I have known this occur; and then the coma to last 
longer, and be more perfect; till, after some years, the coma has been joined with 
convulsions; so that I have no doubt elderly persons (and sometimes it happens to 
young ones) fall down senseless, and come to, without suffering any consequences 
whatever; and have frequent attacks of it. Occasionally, mere faintness is pro- 
duced; — not enough to make the person take hold of any thing. 

Partial Convulsion. — The convulsions, I mentioned,* are sometimes very 
local. Sometimes it is only an arm or a leg that is convulsed. I had a case 
occurring in a boy, in 1828, whose muscles at the back of his head were affected; 
and likewise the muscles of his eyes. He was frequently seized with a fit; which 
made him hold up his head, and begin winking his eyes. During this state of 
partial convulsions, his head was drawn back, and he was perfectly insensible; but 
he never dropped down. His father once fired a pistol close to his ear; but the 
boy took not the least notice of it. He would heave a deep sigh, stir about, and 
be himself again. I have seen him, repeatedly, in a paroxysm of this description. 
He would have thirty fits in a day; stand still all the time; and be perfectly uncon- 
scious of them. There was a boy in St. Thomas's Hospital, who was nearly in 
the same state. When he was attacked he held his forehead, and said he was un- 
conscious. I never saw him in a fit; but I have frequently seen the other boy in 
one. So imperfect is the fit, that if the patient be eating his dinner at the time, he 
continues to masticate as though the fit were not on him; but he is quite unaware 
of what he is doing. I had another patient, in whom the head was drawn down; 
and, w^hen sitting at a table, down his head would come upon it; till his nose was 
beat flat, like a kidney. Before he had epilepsy, his mother said, he sat "nod, 
nodding;" till his nose was almost as fiat as the rest of his face. I have seen cases 
affecting one part of the body only. I had under my care an old lady who had 
had hemiplegia of one side; and this side became subject to epilepsy, and was con- 
vulsed from time to time. It is useful to know these things; because we might 
think that a patient, in these anomalous forms of epilepsy, was suffering under some 
structural disease that might prove dangerous. If it be merely epilepsy, we may 
give a much more favourable prognosis, so far as life and death are concerned; 
though the prognosis in epilepsy is generally unfavourable, because it is rarely 
curable. 

More frequent in Youth. — This is a disease, which is very common in infants 
and young children; and it will sometimes continue till puberty, and then cease; 
but it will sometimes occur again, after the sexual period of life is over. I had a 
patient (an old lady) who informed me that she had epilepsy, when a child, every 
few weeks; and that the fits gradually grew rarer, till puberty. During the men- 
struating period they ceased, and she had no fit for thirty years; but when men- 
struation ceased, then she had a fit every year or two; — sometimes not so often. 
She had pain in the occiput, for five years, before the disease returned; and, one 
day, she suddenly fell down dead. Here was an instance, within my own know- 
ledge, of a person having the disease when a child; of its ceasing at puberty, and 
during the menstruating period; and of its beginning again, when she relapsed into 
her former state. Generally, when the disease lasts through life, it begins just 
before puberty, or about that time. Dr. Heberden not only observed this, but also 
states that there was no mitigation from puberty, so fiir as he could judge from his 
experience.^ It is generally imagined, that puberty mitigates the disease or destroys 

« See Pa^e 598. 

»> See his " Commentaries;" Chapter 33. (First Edition; Page 1G3.) 



EPILEPSY. 601 

it altogether; but I believe that the hopes of parents, on that point, are usually 
false; and that puberty does not influence it. Either so many young persons die 
of the (hsease, and do not grow old, or it ends in other nervous diseases, — particu- 
larly insanity; so that, at last, the individual is put in the class of insane persons. 
Whatever maybe the reason, we certainly see it more frequently in young, tlian 
in old people; and I suppose it arises from a variety of causes. Persons become 
fatuous; and then the epilepsy is considered only a secondary matter; and now and 
then it ceases altogether. Old people are most subject to that form of epilepsy, 
which is characterized by coma without convulsions;'' and which, I stated, '' is often 
mistaken for apoplexy. 

Most frequent in Males. — Males are more subject to the disease, than females; 
except when it occurs in young children and inhmts. In infants, the proportion 
is just the same; because there is not the individual difference of constitution; 
but as the period of puberty arrives, and there is the distinction between the sexes, 
then it is more common among males than females. I once made a calculation of 
the number of patients I had had with this disease. In 1829, I found that I had 
had in the hospital thirty-seven patients; twenty-seven of whom were males, and 
only ten females. They were nearly all boys and girls; so that it is much more 
commonly seen in young persons, than in old ones. 

SECTION II.— CAUSES. 

Hereditary Predisposition. — With regard to the causes of the disease, we may 
first mention a certain hereditary predisposition. This is shown, perhaps, — not 
by brothers and sisters, and predecessors (uncles and aunts, fathers and mothers, 
grandfathers and grandmothers) having had this disease, — but by their having had 
other affections of the nervous system. The same state of the nervous system 
will frequently not produce the same disease; — one may have epilepsy, and another 
some other nervous affection. When, however, these things occur in different gene- 
rations, we may class them together, and consider them as the development of an 
hereditary predisposition. We continually see, in females, something wrong in 
the nervous system; but it does not produce the same effect in all. Some will 
have one disease, and some another. 

The Form of the Head. — Epilepsy is frequently conjoined with a curious form 
of the head: it is very often united wnth a deficiency of brain; and (of course) 
with fatuity, or idiocy. Epilepsy is frequently united with that form of idiocy 
which depends, not upon disease of the brain, but upon a deficiency of brain. 
Many people have a narrow forehead; — a low forehead, sloping back; and they 
have epilepsy. This is not universal, nor indeed general; for any derangement 
of the nervous system may produce epilepsy. Many persons are idiots, not from 
there being a deficiency of brain, but from the brain being of bad quality; but 
there is one kind which depends entirely upon a deficiency of the anterior part of 
the brain; that no one now can deny. Where such is the case, it is common for 
epilepsy to be united with it. It is very common to find a sugar-loaf form of the 
head in epileptic patients. Epilepsy is sometimes united with a large head. I 
mentioned that the hydrocephalic man,'' who had ten pints of water in his head, 
was epileptic* Sometimes it arises from a preternaturally thick skull; and, on the 
other hand, epilepsy may accompany the most beautifully formed head: simply 
from some accidental disease in the head. However, one circumstance connected 
with the predisposition to epilepsy, is an idiotic form of the head;— a shallowness 
of brain. Not that I conceive the shape of the head has any thing to do with the 
production of the disease; but where the brain is more or less deficient in deve- 
lopment, very frequently the patient is likewise epileptic. 

Cerebral Disease, — Epilepsy sometimes exists in chronic hydrocephalus, and 

« See Page 598. b See Page 590. 

" Cardinal. a See Pages 509 and 510. 



602 EPILEPSY. 

various other diseases of the head; but we frequently see it in the best formed head. 
There is a predisposition to it, indeed, from any cerebral disease whatever. What- 
ever disease may exist in the brain, the person so affected is very liable to have 
epilepsy. Tlie same state which produces one disease of the brain, may (either 
by its intensity, or by extending to other parts) produce epilepsy. Very often, 
however, the predisposition to this disease is inexplicable. A person is seized 
with an epileptic tit, from some circumstance which will not produce it in another; 
and yet we may be able to discover no difference between the two individuals. 
It is the same with all other diseases. We see a predisposition, or an indisposition, 
to them, unconnected with external circumstances. We cannot tell why, for ex- 
ample, one person will take a contagious disease, or become affected the moment 
he is exposed to it, while anolher equally exposed escapes; and so it is, frequently, 
with regard to epilepsy. 

Exciting Causes, — If the predisposition be very strong indeed, then the slightest 
exciting cause will produce it; — such as will scarcely more than quicken the pulse 
in another person. It lias followed tremor; — we find many cases of epilepsy, evidently 
ascribable to extreme dread. Injuries of the head (not in one part merely, but any 
part) will produce it. The suppression of habitual discharges, whether natural or 
artiiicial, has the same effect; and so also has tiie suppression of irritation. It will 
arise in females from a suppression of the menses; and, in males, from the suppres- 
sion of an haemorrhoidal discharge which has become habitual. It arises from the 
cessation of a mere irritation; — for example, from the cessation of an accustomed 
cutaneous disease without discharge. The cessation of gout will produce it; and also 
tumours, especially if situated on the head. These causes, I mentioned, will 
sometimes give rise to phrenilis.^ The presence of the tumour produces inflam- 
mation of some particular part, so that epilepsy occurs; or the removal of the tumor 
causes a greater quantity of blood to be thrown on the brain; and thus the disease 
is induced. It occasionally takes place in violent fever. In fever, the brain is 
frequently in a state of great excitement; and epilepsy occurs. Sometimes, among 
other causes, it has been excited by worms in the intestines or stomach, by teeth- 
ing, and even by a stone in the bladder. Irritation of any part of the body what- 
ever, if it amount to a certain point, and the person be predisposed to the disease, 
may produce epilepsy. In the " Edinburgh Medical Essays," there is mentioned 
an instance of the disease being produced by a small hard body in a nerve, at the 
lower end of the "gastrocnemius externus" muscle. The disease had existed twelve 
years; but on this body being removed, it entirely ceased.'' It is also produced by 
inflammation of the membranes of the brain: when speaking of arachnitis, or the 
acute hydrocephalus of children, I mentioned that convulsions were very common. ° 
Poison will produce it; mineral poisons (lead, for example,) and all the tribe of 

■^ See Pages 492 and 493. 

^ In July, 1720, a woman about thirty-eight years of age, was brought to me [Dr. Short]. 
She had laboured twelve years under an epilepsy; which, from one fit a month, was come 
to four or five violent ones every day (each continuing an hour, or an hour a half); by 
which she was rendered mopish and silly, and incapable to take care of her house and 
family. Her husband was reduced in his circumstances, from his affection and care for 
her;— having got and followed all the advice he could. Evacuations of all kinds had been 
tried; the epHeptic and cephalic tribes of medicines had been ransacked; and many other 
medicines had been used in vain; — the disease growing more severe. Her fit always began 
in her leg, toward the lower end of the gastrocnemii muscles; and (in a moment) reached 
her head, and threw her down;— foaming at the mouth; with distortions of the mouth, neck, 
and joints. While I talked with her, she fell down in a fit. I examined the leg; and found 
no swelling, hardness, laxness, or redness, different in that place from what was in the other 
leg; but — suspecting (from her fit beginning always at that part) that the cause of her dis- 
ease lay there — I immediately plunged a scalpel about two inches into it; where I found a 
small indurated body, which I separated from the muscles, and then took up with a forceps. 
It proved to be a hard cartilaginous substance or ganglion, about the size of a very large 
pea, sealed on a nerve; which I cut asunder, and took out the tumour. She instantly came 
out of the fit, cried out she was well, and never after had a fit; but recovered her former 
vigour, both of bodv and mind. — ^' Msd leal Essays and Observations. Published by a So' 
clety in E,linbur^hr Volume 4i {VlZ^o)-^ Article 21. {Fifth Edition; Pages Z'^i and Z'db.) 
See Page 503. 



EPILEPSY. 603 

vegetable poisons, will give rise to it.* Sinall-pox will also produce it; it is com- 
mon for children, at tha period of the eruption of small-pox, to have epileptic fits. 
Dangerous haemorrhages may produce it. When a person is almost expiring from 
haemorrhage, the collapsed state of the brain, from the want of blood, excites con- 
vulsions. In some persons, sexual intercourse will produce it. It is said that 
Napoleon had epileptic fits on such occasions; — not on every occasion of the kind; 
but at periods of particular excitement. Imitation will produce it, especially in 
females. If they see it in others, they are prone to fall into the same slate. 

SECTION III.— MORBID APPEARANCES. 

Thus we have just seen, that any violent irritation, whether mental or corporeal, 
in whatever part of the body it is situated, may produce this disease. Mere in- 
flammation of the brain, or injury of any part of the head, may cause it, when 
there has been no disposition to the disease before; and it may entirely cease on 
the cessation of inflammation within the head, or the cessation of any cause of ex- 
citement there. On this account, we may frequently expect to find no morbid ap- 
pearance in the head. As any irritation of any part of the body may produce it, it 
is not reasonable to suppose that we must in all cases find disease in the head. It 
may, however, arise from inflammation and irritation of various kinds in the head 
itself; and, in such circumstances, we may expect to find disease in that part. 
Now this is just what really occurs. Sometimes, on opening epileptic persons, 
we find nothing wrong in the brain; even when there has been no evident ex- 
citing cause at a distance. When there is an exciting cause at a distance, we 
cannot expect to find any thing morbid in tlie brain; but where we can discover no 
exciting cause at a distance, — no stone in the bladder, — no tumour, — no worms in 
the intestines; but where the cause has been supposed to exist solely in the head, 
— even in this case the disease has sometimes, and not unfrequendy, disclosed 
nothing after death. It has appeared to be a disease of mere function; and has not 
produced any structural change. It is always to be taken into account, however, 
that a great number of persons who open heads, are not qualified to do so; — that is, 
although qualified to perform the mechanical operation, they are not able to say that 
every part is perfectly sound. It requires a man to be a good morbid anatomist, and 
to take great pains, before he examines the head, and declares that there is nothing 
morbid in it. 

But after this disease we find, occasionally, an abscess in the brain, softening of 
the brain, induration of the brain, or tumours in and upon it. We also find exos- 
tosis,^ thickening, and effusioii; — not that the thickening and effusion have been the 
cause of the disease; but the irritation which produced the epilepsy, likewise pro- 
duced effusion and thickening. Every disease that is found in the brain, we may- 
find in persons who have been epileptic; because any organic affection of the part 
may produce the disease. Dr. Prichard (to whose work on Nervous Diseases I 
referred,'' as being an excellent production) says that he witnessed two dissections, 
M-here nothing wrong was seen in the brain. There was a man in St. Thomas's 
Hospital, who had been there from a boy (having been engaged as surgery boy); 
and who used to tumble about. I have heard that he was tipsy; but I do not wish 
to discredit his reputation. W^hen he died, his brain was examined; and, although 
he was idiotic as well as epileptic, it was said that nothing morbid was discovered. 
W^enzel, a German anatomist, and others, formed a society for tlie investigation of 
cases of this disease, — so far as regarded the post-mortem appearances; and they 
say, that in fifteen cases out of twenty the cerebrum was sound; but the pineal'^ 

* The most complete table we have seen of these poisons, and of all others, (whether 
animal, vegetable, or mineral,) and of the diseases which they produce, is that constructed 
bv the late Dr. Fletcher. It is published, as a Chart, by Builer, Medical Bookseller, St. 
Thomas's street, Southwark. 

* From £^, out of; and oa-Tsav, a bone. 
«i From TTjvsa, a pine-apple;— d\\\xCiiv\^ to its shape. 



604 EPILEPSY. 

gland was tliseased, and also the cerebellum; which was altered in consistence, 
colour, and size; but I have opened persons who have died of epilepsy, and no 
morbid appearance has been found in the cerebellum, or anywhere else; and, again, 
the cerebellum is often found diseased, without epilepsy. I believe the truth is, 
that any irritation whatever will produce this disease; which is nothing more than 
a great excitement of those parts of the brain connected with the voluntary muscles. 
It is stated in Dr. Carter's account of a lunatic hospital in France, that one of the 
physicians there, among the number of lunatics under his care, examined about 
thirty adult persons, who had been labouring under the disease; and he found no 
disease of the brain, but only of the "medulla spinalis." These observations 
were too limited. If sixty had been examined instead of thirty, I have no doubt 
that the inference would have been different. 

Seat of the. Disease. — Although this disease so frequently arises from a mere 
functional affection, or a temporary source of irritation, yet it is an infinitely more 
permanent disease than St. Vitus's Dance, or hysteria; and much more frequently 
does it arise from organic causes. It arises less frequently from structural change 
than palsy does, but more frequently from that source than does either chorea or 
hysteria. Whatever spot in the whole body is the source of irritation, — whatever 
spot even of the brain itself (the cerebrum or the cerebellum), it is probably the 
" medulla oblongata" which is the chief seat of excitement. My reason for arriving 
at this conclusion is, that pressure on the " medulla oblongata" always causes 
sleep. This has been ascertained experimentally, in individuals where no other 
part of the brain existed than the "medulla oblongata;" — the cerebrum and the 
cerebellum having been deficient. It is said that, in the case of certain foetuses, if 
the "medulla oblongata" be slightly compressed, we have convulsions; but if it 
be more compressed, we have sleep; and it is also ascertained, that if a sharp in- 
strument be passed into the brain, there is no sensation felt; but as soon as it 
reaches the " medulla oblongata," or the origin of the nerves (as people sometimes 
say), we have epilepsy. I think these circumstances make it probable that, what- 
ever the cause of irritation may be, it acts there. However, this is only a probabi- 
lity. It may be the chief seat of chorea, tetanus, and hysteria, as well as of epi- 
lepsy.* 

SECTION IV.— DIAGNOSIS AND PROGNOSIS. 

Feigned Epilepsy. — We have first to ascertain whether the disease is really in 
existence, or whether it is only feigned. This necessity arises from the fact, that 
impostors frequently pretend to labour under this complaint; because it looks so 
frightful, and so much excites the attention of bystanders. In ihe feigned disease, 
the pupils are not dilated; the nails and the face are not livid; and if their hands be 
forced open, they are instantly clenched again. In reed epilepsy, if we force open 
the hands, they remain so; but if a person be feigning the disease, and we open 
them, he will close them; — to show that it is real! Some imitate the foaming of 
the mouth, by. putting a little soap under the tongue. Again: in the feigned dis- 
ease, there cannot be such palpitation and rapidity of the pulse, as in the genuine 
affection. The impostor, by tossing about, may quicken the pulse; but he will 
not produce that thumping of the heart against the ribs, which occurs in the real 

» This opinion is confirmed, in a remarkable degree, by the researches of Dr. Marshall 
Hall and others, as to the fanclions of the true spinal cord. These authors have shown, that 
the closure of the larynx, the distorted vision, and general convulsions, are really a disturb- 
ance of the " true spinal" functions; while the coma, and other cerebral symptoms, are really 
effects consequent upon this disturbance of the spinal functions. Dr. Marshall Hall has 
divided epilepsy into two principal varieties: the first, arising from direct irritation of the 
cord itself, he has named ^^ centric epilepsy," the second, arising from irritation of remote 
organs acting through the medium of the " cxcitor" nerves, has on that account received 
the name of ''eccentric, or centHpebaV epilepsy. A knowledge of these distinctions enables 
us to reconcile the contradictory results of different observers, as to its morbid pathology; 
and to form a more accurate prognosis in each case. 



EPILEPSY. 605 

fit; and in the feigned disease, he does not very well bear putting the edge of our 
thumb-nail under his, so as to make an attempt to tear the cutis from the nail. A 
very horrid sensation is produced by this method; — perhaps as sharp an agony as 
the human body can experience. It is borne in real epilepsy; but in the feigned 
disease it is found very unpleasant; and impostors take the hand away, or strike 
the person attempting it. In the feigned disease, they generally take pains to fall 
down in a comfortable place; they do not fall against the fire or hot bars, or against 
the edge of a table; and so run the chance of getting a black eye, or lacerating their 
face. They generally fall down in some convenient place; and, like a cow, lie down 
steadily and quietly. One other mode of ascertaining the deception, is to propose, 
in the hearing of the person, some terrible means; such as the actual cautery. If 
he hears that, and especially if we bring a red-hot poker, he will get up instantly. 
Many have been detected by talking of some severe means; for the pulse, in con- 
sequence of the emotion, will then become quickened, in spite of their efforts to 
be tranquil. 

Hysteria. — We may distinguish epilepsy from hysteria, by there being, in most 
cases, a complete loss of sense; by the absence of globus hystericus, laughing, cry- 
ing, sobbing, or shaking during the convulsions; and the absence of delirium. 
Occasionally, hysteria is combined with epilepsy, and then globus hystericus is 
present; but if it do exist, it is only in a slight degree; and if it exist in no more 
than a slight degree, we are justified in considering it a case of hysteria, rather 
than epilepsy. If there be globus hystericus, all the other symptoms of hysteria 
will be present as well; — laughing, crying, sobbing, and perhaps a copious dis- 
charge of very limpid urine. The best mode of making the distinction, is not to 
depend upon one system, but to take a general survey; — to remember that, in epi- 
lepsy, there is usually a complete loss of sense; and that, in hysteria, there is only 
an incomplete loss of sense; and, above all, that the fits do not come on regularly 
before convulsions. Patients will become sensible; and then, in the midst of their 
sensibility, the disease begins again; whereas epilepsy generally goes on in a pretty 
regular manner. 

Prognosis. — If the cause be evident, and is of a temporary and removeable nature, 
our prognosis would be favourable; but if we cannot discover a cause for it, but 
see (at the same time) that the cause is not of a temporary nature, or within our 
power to remove it, then our prognosis should be unfavourable. If we discover 
the cause, and find it cannot be removed, still of course our prognosis must be bad. 
The disease, altogether, is one of the most intractable we can have to treat. It is 
a disease which, in a large majority of cases, cannot be cured; though, in most 
cases, we may lessen it. 



SECTION v.— TREATMENT. 

Treatment of the Attach. — If there be aura epileptica, we may frequently stop 
the disease by putting a ligature between the part from whence it arises, and the 
centre of the body. In a case of this nature, to which I have already alluded, 
where there were two aurae,"* a ligature was placed on each side; and when the 
patient complained of the sensation, some one tightened them. At last the fits 
ceased so long, that he went out of the hospital;'' but I heard, after a still further 
lapse of time, that they had returned. In the fit itself, there is nothing to do but 
to place the patient's head high; to put him out of danger, so that he may not knock 
himself; to loosen his neckerchief; and put a cork or piece of wood into his mouth, 
to prevent his biting himself. If there be any danger of apoplexy, of course we 
,may bleed;" but this is not usually the case. I stated that, in the convulsions of 
infants, cold aflusion had been found to do good;'' and I do not know that ii would 
do harm. Some persons say they have recovered patients from these fits, by put- 

^See Page 597. ^ St. Thomas's. "" See Page 592. 



606 EPILEPSY. 

ting salt into the mouth. I know that we may frequently recover hysterical women 
by this means. I have seen them shake their heads, splutter, and open their 
mouth; but epilepsy is not so soon got rid of. Still, however, it may do some 
good. 

Removal of the Exciting Causes. — To speak, however, of the treatment at 
large, and not of the particular fit. If the exciting cause be evident, we must re- 
move it, if possible. If it be ascertained that there are worms, it is impossible to 
say whether they are the exciting cause; but it is right to remove them. If 
there be a stone in the bladder, the operation of lithotomy^ should be performed. 
There was a case (rather a celebrated one, I believe) of a man, many years ago, 
who had received an injury of the head, and in whom epilepsy ensued. A sur- 
geon, at St. Thomas's Hospital, imagined that the removal of the piece of bone 
might cure the disease; — that a spicula of bone was most probably proceeding from 
the inner table. A circular piece of bone was removed, by means of the trephine; 
and there, luckily, was the spicula; and he never had a fit afterwards. The spicula 
is preserved in the museum at St. Thomas's. I should imagine that a large num- 
ber of the people who are epileptic, have received an injury of the head; but we 
might employ the trephine many times, without such a fortunate result. Mr. 
Wardrop cured a case of epilepsy, beginning with aura in one finger, by ampu- 
tating the small joint of the finger. Of course, if any other organ than the brain 
or spinal marrow, be diseased, we should remove it if possible. 

When produced hy Imitation.^-The disease frequently arises from mental 
causes; and there physic can be of no use. We must administer to the state of 
mind,'' if it be in our power to do so. The disease once pervaded a whole school, 
in Holland, in consequence of imitation. One of the boys had epilepsy; and the 
whole school became epileptic. It was cured there by making an impression on 
the mind. The boys were all arranged round the room; and were told that the 
boy who fell in a fit, should be flogged. This put a stop to the disease. I have 
no doubt that, many times, we might cure ague in the same way. 

When succeeding another Disease. — If the disease have appeared on the cessa- 
tion of another, we should (if possible) re-excite the original disease. If it occurred 
after gout and rheumatism, we should apply strong mustard poultices to the joints; 
but we should also endeavour to lessen an inflammatory state of the head; — not- 
withstanding we are endeavouring to re-excite the disease at a distance. 

Antiphlogistics. — Supposing there is no exciting cause to be found, then we 
may almost always do good, by adopting antiphlogistic treatment. In the first 
place, it is (generally) useful to insist upon complete abstinence from distilled and 
fermented liquors; — wine, spirits, and beer of all kinds; and gradually from meat. 
Persons cannot bear an abstinence from meat well, at first. If any one make the 
experiment to abstain from it all at once, he will find himself grow weak; but if 
he abstain from it gradually, no inconvenience is felt: and a great number of per- 
sons can live very well without it. We should also persevere in keeping an open 
state of the bowels. There should not only be one motion a day, but two. The 
head should be kept constantly cold, by the use of a shower-bath, and frequent 
washing of the head. In addition to all this, if the patient be plethoric, venesec- 
tion, bleeding, and leeches, will be found very useful. Of course, the degree in 
which all this is done, must be varied in different people; and some persons are 
too weak to admit of any thing of the kind; but if their state of body will admit 
of some part of this antiphlogistic treatment, and more especially if it will admit 
of a great deal, we shall find great alleviation. I know that most persons who go 
to St. Thomas's Hospital, are relieved; but I believe none are cured; and I have 
little doubt that the benefit they derive there, is simply from antiphlogistic treatment. 
Many are belter, before there is time for medicine to have any effect; because they 
are instantly put on milk-diet, or gruel, or slops. It is to be remembered, how- 

a Or lithotripsy. 

*» Canst thou not minister to a mind diseased^— " Macbeth;'^ Act 5; Scene 3. 



EPILEPSY. 607 

ever, that this is not to be borne in every case;--that there may be debility; and 
that a patient may be made worse by a plan of this kind; and even where such 
treatment is proper, we may make the patient worse by carrying it too far. I have 
seen many cases, where patients were better to a certain point; and beyond that, 
by lowering them, they became worse; and then, by going back to that point, they 
were better again. But even if patients be weak, and we cannot push antiphlo- 
gistic regimen to any extent, it is still necessary to avoid stimulants, and those 
thino-s which cause a flow of blood to the head, and great excitement of that organ. 
Setons, ^^c. — Setons, issues, and moxce, are sometimes useful; but occasionally 
I have found them useless. The application of tartar emetic ointment at the back 
of the head and scalp, is a very severe mode of treatment; and I have not found 
much benefit from it; but, by antiphlogistic treatment, and keeping the bowels open, 
I have almost always seen great benefit produced. 

Iodine and Mercury. — There can be no harm in trying mercury and iodine; 
because there may be some organic disease in the head, which these will remove. 
There may be irritation; there may be mere chronic inflammation; there may be 
something to be absorbed; and mercury may do good in such cases. Iodine may 
likewise do good, as a part of the treatment; but I should not advise one to try it 
very far. As a part (1 may say) of antiphlogistic regimen, mercury and iodine are 
serviceable. They act by causing absorption; but I am not aware that they do 
good, except in removing the eflects of chronic inflammation. 

Specific Remedies. — But besides all these things, which may be (\eemeA rational 
treatment, tliere are certain specific remedies in this disease, which we employ 
empirically; — that is to say, remedies which are found to do good without our 
knowing why. They will not cure the disease, once in many times; but when 
they do act beneficially, we know not their mode of operation. 

Nitrate of Silver. — The nitrate of silver is .one of these; and no doubt it has 
done great good. We may begin with the eighth, or the sixth of a grain for a 
child; but to an adult we may give a quarter, or half of a grain, and increase it to 
six or seven grains. I think Dr. Fowler says (in a case published in the " Trans- 
actions of the College of Physicians") that he once gave fourteen grains, every 
six hours. I know that when we get to a few grains, it frequently purges too 
much; — so that we cannot push it farther. It is a remedy which has a tendency 
to excite gastritis. The salt, or muriatic acid, that may be in the stomach, is de- 
composed by it; and that is the reason why some people bear a great deal. It has 
a tendency to act on the mucous membrane of the stomach; and tlierefore, during 
its exhibition, we should press on the stomach, to see if there be tenderness. 
There is no rule for the dose; some will have unpleasant effecls from one or two 
grains, and some will bear five or six with impunity. 

Discoloration of the Skin. — But, besides these immediate eflfects, there is 
another, of a chronic nature. It has a tendency, if it be given for a length of time, 
to make the skin blue. The decom[)osed salt is deposited on the surface of the 
cutis; more and more decomposition takes place; and the cutis becomes black at last; 
— as though a lead pencil had been rubbed on the surface. We see some persons 
almost as dark as mulberries; and may fancy that they are going to fall down, from 
congestion of the head; but they are merely stained by this medicine. It will 
cause the sclerotica to be blue; but not to the same intensity as the cutis. I have fre- 
quently seen the sclerotica nearly of the colour of" preservers" (as they are called), 
which some people wear to preserve their eyes. The nitrate will also blacken the 
tongue or fauces. It is to be remembered, that a large dose is not requn-ed, in 
order to induce this effect; but that a small dose, if it be continued tor some time, 
will lead to the same unpleasant results. If administered even in minute dose?, lor 
so short a time as three months, I believe there is a chance of the skin bring blue. 
It does not so much depend on the quantity, as on the time that the medirine is 
given; and, on this account, I think we should he cautious of givifig it, in |>rivate 
practice, lonsrer than a month; and, as I do not think a month sutficient to proiluce 
any beneficial eflects, I seldom use it. If it be ?io/ given for a long lime, it will do 



608 EPILEPSY. 

good; and if it he given for a long time, we run the chance of blackening the patient. 
In the case of young ladies, it should never be given.* 

CupriJimmonio- Sulphas. — The preparations of copper, (cupri ammonio-sulphas, 
and sulphate of copper,) will be found, I think, more useful than the nitrate of silver; 
— little use as any of tliem are. I have seen benefit result from them. Respecting 
the dose of these, it is best to give the fraction of a grain; and to increase it gradu- 
ally. In cases where a large quantity is borne, it may exceed one, two, or three 
grains a day; and very frequently by no means so much. An over-dose occasions 
sickness and gastrodynia.'' 

Iron. — Iron has been proposed in this disease; but I cannot say that I ever saw 
it do good. I have no doubt, when a person has been lowered improperly, that it 
will do a certain amount of good as a tonic; but as to a specific power in the dis- 
ease, I believe it has none. I had under my care a patient, who had been bled and 
starved; who had had issues, setons, moxae, and every other remedy that could be 
imagined; and who was, in consequence, much debilitated. He then went to some 
gentleman, who gave him iron; and he told me that it cured him. I have no doubt 
that he had been reduced too low; and that iron did him good as a tonic; but, six 
months afterwards, he applied to me again, as bad as ever. 

Acetate of Lead. — Dr. Rush, of America, states that acetate of lead has very 
great power over the disease. It is a fact that, in large quantities, it will sometimes 
cause the disease. Where persons have been poisoned by lead, from taking a quan- 
tity into the stomach, or have been much exposed to its exhalations, epilepsy has 
been produced. Of course that is no argument against its moderate use; but I can- 
not say that I ever saw any good arise from it. 

Zinc, Jlrsenic, ^c. — The sulphate of zinc has been much praised, as well as 
the oxide.*" I have given it in St. Vitus's dance. It may be exhibited in large 
quantities; — sometimes twenty or twenty-four grains; but I never saw it do good 
in epilepsy. The oxide of tin has been much praised; and so has arsenic; but I 
have seen persons from taking the latter, become epileptic. I do not believe these 
things are to be depended upon. Narcotics have been praised; — especially stra- 
monium;'^ but I am not aware that they deserve any great recommendation. 

Cold Affusion. — Cold affusion is certainly of use as a tonic; because it does not 
excite the patient. There are many tonics which excite the patient, at the same 
time that they increase his strength; but cold aff'usion does not. A cold shower- 
bath is useful in the disease; for it strengthens the constitution, without excitement; 
and it may knock down excitement by its antiphlogistic effects. It "braces" the 
body. 

Oil of Turpentine. — The oil of turpentine is occasionally useful; but far less so 
than in hysteria. In hysteria, it is an excellent remedy; and if there be worms, in 
epilepsy, we cannot use a better medicine than oil of turpentine. Dr. Prichard 
thinks, that if the intestinal canal be diseased, it may do good. In amenorrhoea it 
may be serviceable; not by exciting the menses, but by removing the state which 
induces the affection; and so in the case of worms. If it remove intestinal affec- 
tion, then we cannot say that it is good in epilepsy in general; but it removes the 
cause in those particular cases. Some contend that it is useful in epilepsy com- 
bined with insanity. I believe it has a particular effect on the nervous system; and 
where it has been said to be beneficial in epilepsy, I should suppose it was where 
there was some other disease. It has been given in two ways; — in small and re- 
peated doses; and in large and less repeated doses. Twenty drops have been given, 
two or three times a day; or an ounce every two or three days. Some have given 

» To obviate this inconvenience, attendant on the use of nitrate of silver, Mr. Lane has 
recently proposed the substitution of oxide of silver; — under the belief that discoloration 
of the skin will not follow its use. For fuller information on this subject, the reader is re- 
ferred to the "Medico-Chirurgical Review," for July, 1840 (Volume 33, Page 289); or to 
Braithwaile's " Retrospect," Volume 1, Page 224. 

^ The usual dose is half-a-grain, in a pill, night and morning. — Dr. Fletcher. 

« The dose of the sulphate is two grains; that of the oxide, ten. — Dr. Fletcher. 

<« From " stramen," 5^ra«7;— alluding to its fibrous roots. 



HYSTERIA. 609 

a drachm, once or twice a day; but I do not think that, in general, much good is to 
be expected from it. 

Conditions Favouring the Action of these Bemedies. — All the remedies just 
mentioned may fail, entirely through our not attending to antiphlogistic regimen. 
It is possible that cases happen, now and then, that would yield to some of these 
remedies; but we neglect to lower the patient. I am quite sure that remedies are 
frequently prevented from doing good, because we do not remove a plethoric state 
of the system. In some local inflammations, and in many cases of various dis- 
eases, it is necessary to lower the system to a certin point; and then remedies, 
which would not otherwise be useful, become so. The reason that the disease is 
so generally intractable, — that so many remedies are so uncertain, and so unsatis- 
factory, — is very evident. This is a disease which arises from every kind of irri- 
tation, in every part of the body; and the irritation may be structured, — may be 
slow inflammation, or something we cannot remove. If it always arose from one 
cause, it v/ould be a difl'erent thing; but it will arise from any cause whatever; — 
physical or mental, organic or inorganic; and situated in any part of the body. 
Not only, therefore, must it usually be an incurable disease, but there can be no one 
remedy for it. As to any one medicine being a remedy for epilepsy, I should think 
a little reflection would show, that it is quite impossible.^ 



CHAPTER X. 
HYSTERIA. 



Definition. — In this disease there are fits of general convulsions and insensi- 
bility, like epilepsy; but not a continuance of the insensibility after the convulsions 
are over.'' For the most part, the convulsions are renewed in the midst of the 
insensibility. There are also sobbing, crying, laughing, and shrieking in the fit; 
but particularly before and after it. Sometimes, though not always, there is a 
mixture of sobbing, crying, laughing, and shrieking, in the midst of the convul- 
sions. The insensibility is, generally, incomplete; the patient having some know- 
ledge of what is going on around, if not all the time, yet during more or less of it. 
Tliere is also experienced a sense of choking; — as if there were a ball in the 
throat, which could neither be got down nor brought up; together with irregular 
breathing; so that there is panting, and the chest heaves up and down. Frequently 
there is hiccup. Sometimes there is a rumbling noise in the abdomen; and a sen- 
Epilepsy is attended by clonic spasms; takes place chiefly in boys; and generally before 
puberty. The puerperal form of it is the worst; the lightest is that which occurs in small- 
pox. It begins with "aura epileptica;" the patient falls into convulsions; the hands are 
clenched; the urine and faeces discharged; the tongue is apt to be bitten, and there is froth 
from the moulh. These symptoms are followed by sopor. The pulse is not affected till the 
end of it; and is then accelerated from the violent motions of the patient. In a pretended fit, 
if you close the eye and open it suddenly, the pupil contracts; and if ammonia be put to the 
nostrils, it is felt. When called to a person in a real fit, lay him where he cannot hurt him- 
self or others; bleed if you can get an intermission sufficient; dash cold water on him; loosen 
all the bandages; put cork between the teeth; inject assafoetida into the rectum; put am- 
monia to the nostrils; and fill the mouth with salt. Cullen thinks it arises from plethora 
and debility; therefore, after a fit, diminish plethora, and increase the strength. Give 
mineral tonics, &c. It sometimes ceases at puberty; before that period, therefore, the prog- 
nosis is favourable. It is incurable if it arise from a spicula of bone or a tumour pressing 
on the brain. It is worse if accompanied by aura. A paroxysm is often kept off by fear. 
Hence horrible remedies were used;— such as drinking blood hot from gladiators.— Z?r. 
Fletcher. 

^ Hysteria is also distinguished from epilepsy by the patient's being able to sit on a chair, 
by the pupils not being affected, by the mind's not" being lost (for the patient can understand 
what is said), and by the absence of frothing.— Dr. Fletcher. 
VOL. I.— 39 



610 HYSTERIA. 

sation is experienced as if a ball were rolling to and fro; till at last it comes (o the 
epigastrium, and thence rises to the throat, where it sticks; and then the convul- 
sions begin, and the patient falls down. The abdomen seems to swell; and no 
doubt it does so. In a few minutes, sometimes, the abdomen will be distended 
with flatus. There is frequently, also, a great secretion of limpid urine; and this, 
unfortunately, is sometimes discharged. There is also violent palpitation; just as 
in epilepsy. 

Frequency of the Fits. — These fits will come and go in rapid succession. 
There is not merely one systematic fit, and then all is over; but there is a succes- 
sion of these fits; and (as I have frequently observed with regard to nervous dis- 
eases) one side is often more convulsed than the other. 

Tenderness of the General 6'Mr/«ce.— Occasionally there is extreme tenderness, 
not during the fit simply, but during the time that women are subject to these fits; 
and this extends over the whole of the surface. If we press ever so lightly on the 
chest and abdomen, we find them complain; and the same is felt more or less in 
the extremities; but it is particularly the case with the trunk; and this has often 
been mistaken, and no doubt still is, for inflammation. 

This morbid sensibility is a very remarkable circumstance; and we may fre- 
quently be deceived by it. I confess, I knew nothing about it for many years. 
Females, with some slight hysterical symptoms, will say they are so tender, that 
they cannot bear pressure; and such appears to be the fact. The least pressure or 
friction of the skin gives them agony. Sometimes it extends over the whole body, 
even to the extremities; and sometimes it is confined to the abdomen. 

I am quite satisfied that there is no pretence in all this. I saw one young woman 
who had been in bed three months in this state. She had been blistered, and 
leeched; but without any benefit whatever. I saw one young lady, about nine- 
teen, who was lying in bad in this condition. The uterus, I understand, was dis- 
turbed; so that she menstruated scantily; and there was fluor albus. Her bowels 
were habitually costive; — so as to require medicine. There was constant pain of 
the head, and much tenderness of the abdomen; so that any one would, without 
care, have thought it was inflammatory. She could not bear the least pressure; 
and yet there could be no inflammation; for the pulse was only 58, and the tongue 
clean; and, although there was much pain in the head and eyes, there was no 
drowsiness, and no intolerance of light. I had hesitation in considering it a variety 
of hysteria. Some years ago I had, in the hospital, a woman, forty years of age; 
who, when I touched her, cried out as if I had been going to murder her. 

Delirmm. — Patients, when they are seized with hysteria, are sometimes vio- 
lently delirious; so that a stranger would imagine there was phrenitis, which re- 
quired active treatment. It comes on suddenly, however, and there are other hys- 
terical symptoms present. We may generally satisfy ourselves that it is merely 
hysterical. 

Tetanus, Clavus, ^c— Sometimes patients have locked jaw; — the mouth being 
closed; and sometimes they have other tetanic symptoms; but that is the general 
one. Sometimes, from the violent afl'ection of the voluntary muscles, they have a 
sensation of extreme pain fixed in some part, called "clavus hystericus;'* — a sen- 
sation as if a nail ("clavus") were driven in; and I have no doubt that it is the 
same as the generally difl*used morbid sensibility of the surface; only that it is col- 
lected in one spot, and is therefore more acute than when diffused. Sometimes 
there is catalepsy; which I shall presently notice. There are all kinds of move- 
ments of the body, and all kinds of noises made. Sometimes patients will bark 
like dogs, or innlale various animals. 

Jiffeclions of the Joints. — It is a curious circumstance, mentioned by Sir Benja- 
min Brodie, that hysterical women, when the paroxysm is over, sometimes have 
an evanescent stiffness of the joints, attended with heat and pain." In the case of 

^ Sir Benjamin Brodie has published a work specially devoted to hysterical diseases. The 
title is — "Lectures illustrative of certain Local Nervous Affections." He says, that "at 
least four-fifths of the female patients who are commonly supposed to labour under diseases 



HYSTERIA. 611 

a young woman, who was seized at church with hysteria, wliich ended in hemi- 
plesria after siie got rid of the fits,^ one knee was stiff, although applications were 
resorted to for a month. Sir Benjamin, in one of his lectures published in the 
" Medical Gazette," mentions the occurrence in the wrist;" but, in my practice, I 
have seen it in various parts of the body. It is usually an evanescent state; but 
still it is sufficient to prevent the patient from using the parts. 

Mostly occurs in Females. — This is a disease which occurs much more fre- 
quently in females, than males; and in females particularly during their sexual 
period, — if I may so call it; that is to say, during the thirty years in which they 
are in their prime; namely, in this country, from about fifteen to forty-five. It 
must vary in different countries; but in England women menstruate from fifteen to 
forty-five. If the disease appear at other periods, it is more frequently earlier than 
later. We more frequently see hysteria in girls who have not menstruated, than 
in old women who have done menstruating."' 

Occasionally in Men. — But, although this disease is usually seen in females, it 
is certainly not altogether confined to them; for it will sometimes be observed in 
boys, and in men under very violent emotions. There is a passage in " King 
Lear," which refers to this: — 

" O how this mother^ swells up towards my heart! 
Hysterica passio, down, thou climbing sorrow! 
Tliy element's below. "^ 

It has been said that this disease can never occur in men, because it is hysteria; 
but we must not attend so much to the etymology of a word, as to its meaning. 
The name was given to the disease, from its having been supposed to arise from 

of the joints, labour under hysteria, and nothing else." (Page 37.) These Lectures were 
reported in the " London Medical Gazette;" Volume 19; Pages 197, 246, and 279. (Nos. 466, 
467, and 468; November 5, 12, and 19, 1836.) 

^ See Page 614. 

^ Females of nervous and irritable temperament, especially those who have suffered 
from mental anxiety, are liable to a peculiar affection of the wrist; and, unlike the gene- 
rality of hysterical complaints, the married and unmarried are subject to it in nearly a 
similar proportion. The patient complains of a pain in the wrist; which pain, after con- 
tinuing a certain space of time, is followed by a kind of puffy swelling, extending up the 
fore-arm, and down to the fingers. This swelling has many of the characters of that pro- 
duced by synovial inflammation; but differs from it in being more diffused. Sometimes the 
swelling is extensive; sometimes so slight as barely to be seen. Having lasted some days 
or weeks, it subsides; while the pain remains, constant in its character, aggravated by every 
motion, and rendered worse by the patient's attention being drawn to it. To prevent that 
motion which she dreads so much, the patient keeps her hand in one position; in conse- 
quence of which the joint grows stiff and rigid, and the parts assume a very characteristic 
appearance; — the skin being tense and glossy, and appearing to adhere pretty closely to the 
textures underneath. The pain may continue for three months, six months, or one or two 
years; at the end of which time it generally subsides;— leaving behind it a stiffness of the 
hand and fingers, from which the patient will gradually recover. In one case, however, the 
pain continued for three or four years; when the hand was left shrunk and withered; — the 
fingers being contracted and drawn into the palm. The nails had grown lank, scabrous, 
and rough. 

As the health is in general weak, remedies calculated to improve it, are of service to this 
local complaint; and, in two instances, bark was decidedly of use. From a scruple to half 
a drachm of the carbonate of ammonia, in the course of the day, — paying at the same time 
attention to the bowels, — is often a powerful remedy. If the menstruation be irregular, that 
irregularity is to be corrected by suitable remedies, — as the Vinum Aloes, steel, and simi- 
lar means. As a local application, the following embrocation will frequen'ly lull the pain: 
— Misturae Camphoree ^viss; Spiritus Rosmarini .^iss. M. This should be applied tepid, on 
a rag. A plaster, composed of equal parts of the Emplastrum Saponis, and Einpla-trum 
Bellad.innce, is frequently useful; at any rate, even when it does no good, it can do no harm. 
The vapour-bath, especially in the advanced state of the complaint, is also a ."serviceable 
remedy. At the same time that local or general means are employed, the surgeon should 
bear in mind one important caution: — never to draw the attention of the patient to her dis- 
order, more than is absolutely necessary. — ''London Medical Gazettei" Volume 2; Page 755. 
{Nn. 50; November 15, 1823.) 

= It occurs most frequently in young widows, and next in virgins. — Dr. Fletcher. 
d See Page 613. « Act 2; Scene 4. 



1512 HYSTERIA. 

the womb; but the collection of symptoms called " hysteria," will sometimes occur 
in males; — in boys and young men whose constitution approaches to that of 
females, and who are susceptible of violent mental emotion. 

Causes: Emotion. — Any woman may have hysteria, if she can but have emo- 
tion of mind strong enough. Epilepsy is a disease which only occurs in certain 
individuals, as it would appear, from a certain degree of predisposition;* but men- 
tal emotion will cause more or less hysteria in almost any woman. Anger or grief, 
especially grief from ungratified desire, or (to use a more elegant expression) "dis- 
appointed love," is the most common cause. I presume it is quite as frequent 
from disappointed lust, — in which desire is the only ingredient; as from pure, 
-simple, unrequited love. 

Most Common during the Menstrual Period. — It occurs particularly during 
the uterine period of life, on several accounts. First, because derangements of the 
uterus are a very common source of the disease; and (of course) the uterus is not 
deranged particularly, except during that period. Women do not suffer much in 
the uterus, till it performs its functions; and very little after those functions have 
ceased, except in cases of organic disease. It is during the period of its activity, 
that it suffers particular derangement; and, therefore, during that period, it will 
suffer particular sensations. Secondly, it is during the period of menstruation, that 
women fall in love, and have their attachments strongest. Sorrows of all sorts, 
whether real or imaginary, take place with the greatest severity during that par- 
ticular period. Thirdly, it is during that period of life, that all the feelings of 
women are most active. A woman's character becomes altogether developed, 
when she begins to menstruate: and after the period of menstruation has ceased, 
all her feelings become more or less obtuse. All our feelings dry up in the decline 
of life, and we are less susceptible of all emotion. I should suppose there is 
scarcely a woman who has not had hysteria in some slight degree; such as a 
choking in the throat; but it is generally a temporary disease, and by no means 
dangerous. Sometimes it is dangerous, but very rarely so; and, for the most part, 
il is only temporary. Epilepsy is so obstinate a disease, as to be an " op{)robium 
rnedicorum;" but hysteria generally ceases at last, although it may continue for a 
long time. When we consider that a slight cause is sufficient to produce hysteria 
in women, we shall see that it must be a temporary affection, and cannot be dan- 
gerous. Emotion of mind, cosliveness, plethora of the head, suppression of men- 
struation, or any thing of that kind, will excite it. 

Pathology of Hysteria. — There can be no doubt, I should suppose, that regular 
hysteria is situated in the head. The cause maybe anywhere; but the disease 
niust be in the head. If a patient is partially convulsed, it may arise from an 
affection of the spinal marrow; but, in hysteria, muscles that arise «&oi?e the spinal 
marrow are affected; in addition to which there is insensibility; which, I should 
suppose, shows that the seat is in the head. We see patients laughing, sobbing, 
and crying; and then they are suddenly in high spirits again; — so that it certainly 
must be an affection of the head; only that it arises from a variety of causes, situated 
in a variety of parts. It very rarely arises from an organic affection in the head, 
as epilepsy does. As to the other affections, — the palpitation, the faintness, and 
similar phenomena, — they only show the extent of the affection. 

Treatment. — The treatment of this disease is for the most part very successful; 
because there is scarcely a predisposition required for it; and the slightest exciting 
cause is sufllcient to produce it. This is not an " opprobium medicorum;" but, on 
the contrary, medical men gain the greatest credit in treating it. Although it would 
cease spontaneously, you may expedite the cure. 

Treatment in the Seizure. — The treatment during the fit, should be the same as 
that for epilepsy.** We must set the patient up, and loosen any thing tight about 
the bosom and neck; and if we find plethora, — so that there is danger of apoplexy, 
— we should bleed her. The best thing, however, and one that does not answer 

» See Pases GOO and GOl. b See Page 605. 



bYSTERIA. 613 

SO good a purpose in apoplexy, is to get a pail of water, or a large wash-hand 
basin full, and throw it strongly upon the patient. She is almost sure to come to. 
The water requires to be thrown with considerable force; and should not be spared. 
It is in hysteria that filling the mouth with salt,'' answers the best purpose. If 
this be done, the patient generally comes round. 

General Treatment. — In treating the disease at large, however, we should fol- 
low exactly the same plan as in epilepsy.'' We must, in the first place, look out 
for any exciting cause; and, if we can find it, remove it (if possible). In the next 
place, we must adopt antiphlogistic treatment; — provided there be signs of conges- 
tion of the head. Many cases of hysteria are cured rapidly by bleeding and 
purging. There is so frequently mere fulness of the head in this disease, and so 
frequently does costiveness produce it, that bleeding and pur2:ing very speedily (in 
general) get rid of the disease, or mitigate it considerably. Women are much more 
subject to costiveness, than men. They are not so particular in tliese matters; and 
their pelvis, being large, will hold a great deal; and therefore we continually hear 
women confess, that they have not had a motion for a week. At charitable insti- 
tutions, particularly dispensaries, — where patients attend in great numbers, — we 
find costiveness occurs far more frequently among women than men; and the hys- 
teria will cease on unloading the bowels. 

Ascertain the state of the Uterus. — It is necessary, in the treatment of this dis- 
ease, always to inquire into the state of the womb. It was supposed, formerly, 
always to arise from the condition of the womb; and the name of the disease 
(" hysteria") comes from utfr-f^a, the ivomb. Hippocrates says, that it occurs 
only in females; and the idea of its dependence on the womb, is shown by the 
name which common people give it;-:-" the fits of the mother.'''"^ The swelling 
of the abdomen, and the rumbling noise ascending the throat, were thought to be 
occasioned by the rising of the womb; and therefore attacks of hysteria were 
formerly called by the name I have just mentioned. The doctors formerly endea- 
voured to get rid of the fit, by attracting the womb, and by driving it downwards. 
They put assafoetida, garlic, and all sorts of disagreeable things into the mouth, 
to warn the womb to descend out of the way; and put "roses and posies" below, 
to coax it downwards."** 

Although the disease frequently does arise from the state of the womb, yet very 
frequently it does not; and therefore, in all cases, we should examine into the 
state of the womb. If we find amenorrhoea, we should endeavour to remove it 
by cupping the loins; and when we have done that, — provided the state of the 
patient will allow it, — we should stimulate the womb by oil of turpentine, and in- 
jections of ammonia thrown into the vagina; and, if possible, we should recom- 
mend marriage; which is by far the most effectual-mode of curing amenorrhoea, 
in many ladies. 

When arising from Sexual Desire. — But I believe that where it arises from 
something connected with sexual desire, the cause is, for the most part, situated in 
the head. It is astonishing how many young women, with good full bodies, have 
pain in the head and cerebellum. We have only to ask the question, and we find that 
the pain is situated there; and I know that by cupping that part well, and purging 
thoroughly, we may frequently get rid of hysteria, without attending to the womb. 
The state of the womb is only one cause among a number of others. 

Tonics and Antispasmodics. — Besides removing any exciting cause that may 
be present, and removing a plethoric state of the whole body (by bleeding, low 
diet, and purging,) we find it necessary, in other cases, to do just tlie reverse; — 
precisely as I mentioned in epilepsy.^ These, however, form only a very small 

«See Page GOG. b See Pa^e G05. c See Page Gil. 

d Borborygmus was once thought to arise from gas generated by semen piUretying in 
the womb. Burnt leathers, and other substances, were applied to the nostrils, to repel the 
uterus; and aromatics were iatroduced into the vagina, to tempt the womb.— i?r. Fletcher. 

e See Page G07. 



614 HYSTERIA. 

number of cases. It may be necessary to give tonics, (and I think iron is the 
best,) together with cold affusion and cold bathing. I think the cold bath answers 
better than any thing else. Occupation is essentially necessary; and, if possible, 
a good regulation of the mind. For certain symptoms various remedies are useful. 
For faintness and choking, the fetid gums (although they have been given on a 
strange hypothesis") are very useful. Assafcetida, by the mouth and anus, is very 
proper. Camphor and musk are more or less serviceable for the wind following 
the spasms. Stimulants of various descriptions are often required. For the ex- 
treme languor the patient feels, and the extreme sinking of which she complains 
at the epigastrium, stimulants are absolutely proper; particularly that preparation 
of iron called " ferri ammonio-chloridum." Some patients complain of experi- 
encing a sensation as if they had no inside. All the tonic medicines that I recom- 
mended in epilepsy,'' are useful; and they will frequently cure the disease. I am 
sure that the best way of treating hysteria, is to remove any exciting cause that 
may exist; to get the womb into good order; to prevent all fulness; and, if there 
be debility, to remove it. Let the patient be in the open air, and occupied; attend 
to regular exercise; and use the shower-bath frequently. 

Oil of Turpentine. — To speak of particular symptoms which sometimes attend 
it. The trismus may in general be got the better of, by a good dose of oil of 
turpentine. We may throw up two or three ounces by the rectum, or give it the 
patient to swallow; but the latter is not an easy matter. The jaw generally opens, 
as soon as the turpentine reaches the intestines; and I have never seen it fail in 
effecting a cure. Sometimes it has instantly removed the affection, but, in other 
esses, not for a few hours. 

The disease sometimes produces paralysis. I have seen paralysis of the whole 
of one side (hemiplegia); but it disappeared. I recollect particularly one case of 
a young girl, who was seized at church. It is very common for patients to be 
seized at church. I suppose they get excited by the discourse, and by the heat; 
and sometimes they see persons whom they like very much; but true it is that 
young ladies are very fond of going into hysterics at church; and they shriek out, 
disturb the congregation, and put a stop to the service for a time. Now this young 
woman did so; but there was no pretence in it; and afterwards she was in a com- 
plete state of hemiplegia. By dosing her well with oil of turpentine, and bleeding 
her copiously, she got completely well very speedily. I have seen several of. 
these cases; and they have all done very well. The paralysis is not of a perma- 
nent nature, but depends on a temporary state. 

I do not know a better remedy for a great number of cases of hysteria, than oil 
of turpentine;" and, to illustrate its efficacy, I may mention the case of a kitchen 
maid, who was seized with violent convulsions (supposed to be hysterical) and 
comparative insensibility. She had continued in that state all the day in which 
she was seized, all the night, and the following morning. I took thirty ounces of 
blood from her, and purged her with salts and senna; but she still remained insen- 
sible, and I then had her brought to St. Thomas's Hospital. — I ordered two ounces 
of the oil of turpentine; and in half an hour she was perfectly well. It had no 
purgative effect whatever; but — after she had been insensible for two days and one 
night, and had been freely bled and purged — a full dose of oil of turpentine restored 
her completely. The symptoms of insensibility, of trismus, and of paralysis, 
"will give way to this, much better than to any thing else; but it is right to bleed, in 
many cases, in consequence of the state of the head. The turpentine took no 
purgative effect, till a dose of castor oil was given; and then it went to work 
directly. After this she had an attack of paraplegia; but from that she perfectly 
recovered. I believe, therefore, that in trismus, in hemiplegia, in delirium, and 
in continual stupor, — provided we have proper recourse to bleeding and purging, — 
the best remedy is oil of turpentine. In the same class of medicines are the fetid 

» See the last paragraph but tvro. 

^ See Page 608. «^ Ibid. 



HYSTERIA. 615 

gums; anil, wherever we think proper to employ them, we may employ the oil of 
turpentine to the same advantage. It has the property of a strong purgative; though 
it requires to be set off by something else. We may give one ounce fiisi, — to see 
if that will do; and then follow it up by castor oil.'' 

Hysterical Irrifabi/ify. — Frequently nervous women are in a state of what they 
call "the fidgets." They cannot sit still a minute; and the slate is exceedingly 
distressing. Sometimes this is removed by the warm-bath; but it is best combated 
by mild narcotics. Sometimes I have given opium; and, now and then, I have 
known prussic acid tranquillize them, when nctliing else would; but, in other 
cases, we find other things do good. The shower-bath, if we can get them to use 
it, is of great service. Besides this slate of morbid irritability of mind and body, 
they are very perverse, and get great discredit by their bad temper; but I am satis- 
fied it is a morbid state. They are very sulky. I have frequently known them 
correct the medical attendant, scold, and even swear, and do all sorts of malicious 
things;— pretending to be worse than they were. I have no doubt all this is a 
morbid state of mind. Some of these attacks will come on periodically, particu- 
larly at the menstrual period; and, when they fall into this extraordinary state, it 
can only be treated on the same general principles as common hysteria; — removing 
fulness if there be any, anil enjoining the use of the shower-balh. 

I have treated those cases of morbid sensibility of the surface, which have fallen 
under my notice, on the same principle as neuralgia; — supposing them to be an 
affection of the nerves; — namely, with iron; and they have all done well. I have 
not found it so in that particular state called " clavus hystericus,'"' where the pain 
is all felt in one spot; but where the pain is diffused, it is one of the best medicines 
that can be employed. As to hysteria at large, I do not believe that iron has any 
power over it. It is only in those cases where there is debility, that it is of use; 
and then, I presume, it is not serviceable from any specific power over the disease; 
but as being the best tonic we have.*" 



SECTION I.— CATALEPSY. 

There is a disease which is spoken of separately; but which, I cannot help 
thinking, is merely a variety of hysteria;— it is called " catalepsy."*^ 

Symptoms.— In this form of the affection, the voluntary muscles will take on 
any state that we think proper to give them; and so they will remain. We may 
mould the body into any form we choose. Consciousness and perception are 
sometimes entirely destroyed; and sometimes only partially so. Frequendy the 
person is not aware of her existence, or of what is going on around; — conscious- 
ness and perception being both absent. Dr. Gregory*' used to speak of the case of 
a lady, who had undergone great mental anguish. Her history, he said, was like 
that of Isabella, in the tragedy of the " Fatal Marriage;" and she was seized with 
catalepsy. If her child \vas presented to her, she gave signs of knowing it; but 
that was the only proof she exhibited of the least consciousness.'' 

More Frequent in Women than Men. — It is a disease which occurs more fre- 
quently in women than men; — just as hysteria does;^ but, like hysteria, it some- 
times occurs in males. ^ There is a case mentioned by Bonet, of a deserter who 
was captured, and when taken shrieked violently; and who then entirely lost his 
voice, from the violent mental emotion. He was a man of no great courage. He 
became immovable and unconscious, and then fell into catalepsy; — so that they 
could mould him into any thing. This man neither ate nor drank, nor did he dis- 
charge his faeces or urine for twenty days; at the end of which time he sank. 

» Hysteria may be kept off by affections of the mind, particularly ridicule.— £)/-.i^/t7c/it'r. 

b See Page 611. «= See Page G08. 

<J From Kcira,\etfxQa.vj}, to seize. « See Note to Pag:e 230. 

f " Walking catalepsy" is somnambulism coming on in the day.— Dr. Fletcher. 



616 HYSTERIA. 

Sometimes Periodical. — Ocr^asionally the affection has been periodical. Dr. 
Heberden mentions, in his " Commentaries," that he once saw at St. Thomas's 
Hospital a case, which he visited from curiosity. The woman was thirty-six years 
of age; and had a paroxysm of catalepsy morning and evening. It usually con- 
tinued from one to three hours; but, on one occasion, it lasted twelve hours. The 
fits came on without any warning; and during them, he says, the pulse and the 
breathing were natural; the eye was fixed, as if she were looking attentively on 
some object; the arm continued as it was placed, for twenty minuies together, and 
once for a whole hour; and he was told that it would sustain a weight of seven 
pounds, in any posture in which it was placed. The jaws were closed; but if the 
nostrils were closed, then the mouth opened for the purpose of breathing. A slight 
winking was noticed, on approaching the finger to the eye; and a little contraction 
of the iris.* There was a case in St. Thomas's Hospital a few years ago. It 
came on in paroxysms at one certain period; but it was not under my care. It 
occurred (as hysteria so often does^) in a girl. The symptoms of the disease are 
not always regular. It is sometimes impossible to mould patients. They are 
perfectly rigid; and we can lay them out like corpses. 

Prognosis. — This disease is not necessarily dangerous, — any more than hys- 
teria;° but it appears, now and then, to have proved fatal; or, at least, that state of 
the system in which it occurred, has proved fatal. Such a case is mentioned by 
Dr. Gooch; and has been published in the " Transactions of the College of Phy- 



> On the twenty-sixth of June, 1764, in St, Thomas's Hospital, I saw a woman six-and- 
Ihirty years of age, motionless, with a fit of the catalepsy. Her pulse was quite natural; 
her breathing easy, tier eyes were fixed, — as by attentive contemplation; — not like those 
of a person who is either dying, or sick, or under any pain or uneasiness. Her limbs 
always retained the situation m which they were placed by the bystanders, — however incon- 
venient, I extended her arm, and saw it remain stretched out for twenty minutes; and I 
was told it continued so, on a former trial, above an hour; which scarcely any body in 
healih could support. I heard even that it would remain extended with a weight of seven 
pounds in the hand. If the patient was placed upright, she continued upright; and was not 
very easily thrown down. While she was sitting down, both the legs were extended, and 
raised from the ground; and they remained in that uneasy posture; as if they had been 
made of clay or wax. Her mouth was closed; and I was unable by any means, to open it. 
The eyelids were constantly open; or, if forcibly closed, they opened again as soon as the 
force was removed. She winked, but in a very slight manner, upon moving the finger quick 
towards the eye; at other times the eyelids did not move. At the approach of a candle the 
pupil contracted. If the nostrils were compressed, after a little effort, and apparent struggle, 
the lips opened for the purpose of breathing. I heard that she had been in this state some 
months. The fit returned morning and evening, almost every day; and continued some- 
times an hour, at other times three hours. The nurse reported, that one fit had lasted 
twelve hours. She used to be suddenly seized, without any previous notice. — " Comment- 
aries on the History and Cure of Diseases. By William Heberden, M. Z)." Chapter 69. 
{Page 361 of the First Edition.) 

t See Page 611, « See Page 612. 

d Mrs. is twenty-nine years of age; and has long been unusually subject to the com- 
mon forms of hysteria. I [Dr. Gooch] have seen her, after being strongly excited in con- 
versation, sink down insensible; and, a few minutes afterwards, recover with choking and 
sobbing. Her husband tells me, that he has often seen her, while silting at the dinner-table, 
become apparently insensible, with her eyes open, and still sitting up; — continuing in this 
stale several minutes, and then coming to herself again; but totally unconscious of what 
had taken place in the interval. She married nine years ago; has been pregnant many 
times, but has only borne one living child: every other time, she has either miscarried dur- 
ing the early months, or (what was more common) the child has died, without any obvious 
cause, about the sixth or seventh month, and premature labour has come on about a week or 
iwo afterwards. A few days after her last delivery (of a dead child at the seventh month), 
— a circumstance attributed to some domestic agitation, — she M^as seized with a violent 
aching of the head and face, — confined to the left side, and subsiding under the use of 
hemlock; but she continued to suffer flatulence of the stomach, had a quick weak pulse, and 
was much depressed in spirits. One evening, she told her husband, that she had never dis- 
charged the duties of a wife as she ought to do; and that her death would be a happy release, 
both to him and her; the next morning, she made an unsuccessful attempt to cut her throat. 
I now saw her, in consultation with a physician of extensive experience in these diseases. 
She was put under the care of a regular altendantj and was at limes so violent, that it was 



HYSTERIA. 617 

Diagnosis. — It is necessary in this disease, just as in hysteria and epilepsy, to 
ascertain whether the case is real. We are told tliat John Hunter discovered that 
a case of this disease was feigned, by putting a string round the wrist of a patient, 
after the arm was extended, and appending a weight to it. The string was sud- 
denly cut; and, as the man had then no weight to support, the arm was immedi- 
ately raised. It appeared to John Hunter, that the man had sustained the weight 
by the exertion of his muscles; and the throwing up of the hand after tlie string 
was cut proved the correctness of that opinion.^ Another device has been, to 
throw the patient into a cistern of cold water. If the disease be genuine, it is 
supposed that the patient will go to the bottom; but that if not, she will make an 
effort not to be drowned, and will struggle about. I should not, however, consider 
this any proof; because nothing is so good in hysteria, as throwing a woman into 
cold water. Therefore, in catalepsy, plunging the party in cold water, is likely 
to stop the paroxysm; and, if the paroxysm be stopped, then the person may 
struggle about, and yet not be an impostor. 

It is said, however, that a very ingenious mode of discovering whether the dis- 
ease was feigned or not, was put in practice by a physician (or at least by a prac- 
titioner) in the East. Pocock mentions, in his travels, that a case of this disease 
occurred in one of the favourites of a celebrated caliph; or, at least, that one of his 
favourite damsels pretended she was in this condition. Pocock says there was 
general sorrow throughout the palace; the women all sobbed; the eunuchs all 
groaned; and the Dey was distracted. He sent for all the royal physicians, ordinary 
and extraordinary. They used stimulants and warm fomentations to soften the 

necessary to confine her with a waistcoat. A few days after our first visit, we were sum- 
moned to observe a remarkable change in her symptoms. The attendants said she was 
either dying, or in a trance. She was lying in bed, motionless, and apparently senseless. 
It had been said, that the pupils were dilated, and ihe iris without motion; and some appre- 
hensions of efFasion on the brain had been eniertained; but, on coming to examine them 
closely, it was found that they readily contracted, when the light fell upon them. Her eyes 
were open; bat no rising of the chest, no movement of the nostrils, no appearance of re- 
spiration could be seen; the only signs of life were her warmth and pulse. The latter was 
(as we had hitherto observed it to be) weak, and about 120: her feeces and urine were voided 
in bed. The trunk of the body was now lifted, — so as to form rather an obtuse angle with 
the limbs (a most uncomfortable posture), and there left with nothing to support it. There 
she continued sitting, while we were asking questions, and conversing; — so that many minutes 
must have passed. One arm was now raised, then the other; and where they were left, there 
they remained. It was now a curious sight to see her sitting up in bed, her eyes open, star- 
ing lifelessly, and her arms outstretched; yet without any visible sign of animation: she 
was very thin and pallid; and looked like a corpse that had been propped up, and had stif- 
fened in that attitude. We now took her out of bed, placed her upright, and endeavoured 
to rouse her by calling loudly in her ears; — but in vain. She stood up; but as inanimate as 
a statue. The slightest push put her otf her balance; no exertion was made to regain it; 
and she would have fallen, if I had not caught her. 

She went into this state three several times. The first time, it lasted fourteen hours; the 
second time, twelve hours; and the third time, nine hours; — with waking intervals of two 
days after the first fit, and one day after the second. After this the disease resumed the 
ordinary form of melancholia; and, three months from the time of her delivery, she w^as 
well enough to resume her domestic duties. — ^'Medical Transactions, published by the Col- 
lege of Phijsicians in Londoii.'' Volume 6; Pag;es 266 to 270. 

* A patient in the hospital [St. Bartholomew's] feigned to be afflicted with catalepsy; in 
which disorder, it is said, a person loses all consciousness and volition; yet remains in the 
very attitude in which he was suddenly seized with this temporary suspension of the intel- 
lectual functions. Mr. Hunter began to comment, before the surrounding students, on the 
strangeness of the latter circumstance; and, as the man stood with his hand a little extended 
and elevated, he said — " You see, gentlemen, that the hand is supported, merely in conse- 
quence of the muscles persevering in that action to which volition had excited ihem, prior 
to the cataleptic seizure. I wonder," continued he, "what additional weight they would 
support!" So saying, he slipped the noose of a cord round the wrist, and hung to the other 
end a small weight; which produced no alteration in the position of the hand. Then, after 
a short time, with a pair of scissors, he imperceptibly snipped the cord. The weight fell to 
the ground; and the hand was as suddenly raised in the air, by the increased eifort which 
volition had excited for the support of the additional w^eight. Thus was it manifested, that 
the man possessed both consciousness and volition; and the impostor stood revealed. — 
" Hunterian Oration for ihe Year 1810. By John Abernethy, F. R. S." Pages 58 and 59. 



618 HYSTERIA. 

limbs, but all in vain; when a man, who had cured the grand vizier (the prime 
minister) of some secret disease, was recommended to the Dey. This man was 
named Gabriel; and he obtained a promise, that no offence should be taken at 
whatever plan he adopted to cure the lady. Being thus himself secure, the lady 
was brought into the presence of the court, with all the women around her, and 
covered with a fine muslin robe, flowing down to her feet. Gabriel ran up to the 
lady boldly; seized the hem of her garment; and endeavoured to raise it, — so as to 
expose her person. The lady modesdy put down her hand to prevent the insult; 
when he immediately turned roun<l to the caliph, and said — " O defender of the 
faithful, so and so is cured." Here was a case of complete deception, from the 
beginning to the end; and the poor man devised this ingenious means for detecting 
the cheat. 

Treatment. — With regard to the treatment of the disease when it is real, 1 be- 
lieve the best mode is to adopt exacUy the same plan as in common hysteria.'"* la 
the paroxysm we should dash c<jld water on the patient; and give her oil of tur- 
pentine, either by the mouth or the rectum. We should purge the patient well; 
and, if possible, remove any source of irritation that may be present. There are 
cases which, 1 have no doubt, will be best remedied by antiphlogistic measures, and 
the removal of plethora. On the other hand, there are cases which will be best 
treated by tonics. I have never had to treat a case; but, from what I have seen in 
other instances bordering upon it, I have no doubt that the same treatment as that 
employed in common hysteria, would answer very well. 



SECTION II.—TRANCE. 

Symptoms. — One of the curious forms of hysteria is long-continued insensi- 
bility, which is called " a trance.'''' Sometimes there is continued insensibility for 
a few days or weeks; and sometimes for many weeks. Sometimes patients will 
eat, if food be put into their mouths; and sometimes not. Sometimes they will 
wake for a few hours, or perform certain actions, show some power over volition, 
and then fall into the same state again. Some will open their eyes, and then fall 
asleep again. Some, in this state, are perfectly conscious of \vhat is going on 
around them; but cannot make the least effort. 

There is an instance mentioned of a female (for these strange things generally 
occur in females) who was presumed to be dead. Her pulse could not be felt, and 
she was put into a coffin; and, as the coffin lid was being closed, they observed a 
sweat break out, and thus saw she was alive. She recovered perfecdy; and then 
stated, that she had been unable to give any signs of life whatever; that she was 
conscious of all that was going on around her; that she heard every thing; and that 
when she found the coffin-lid about to be put on, the agony was dreadful beyond 
all description; — ^so that it produced the sweat seen by the attendants. I have 
seen a case of this extraordinary insensibility, where the patient continued for two 
or three weeks (with the exception of short intervals) in a state of insensibility, 
though not without signs of life; for the heart was still beating; and sometimes she 
performed, in this state, certain voluntary actions, and would afterwards be con- 
scious of having done so. Sometimes she would be unable to do any thing, and 
yet retain her consciousness; — so as to mention it afterwards. 

[There is another state of stupor or coma, in which the mind is entirely cut off 
from intercourse with the external world. This occurs in the worst states of fever, 
and in various diseases of the brain and irijuries of the head; and the same condi- 
tion takes place, from a very different cause, in the state of fainting. In such cases, 
there is seldom any recollection of mental impressions; yet there are facts which 
tend to show, that the patient is not in such a state of total insensibility to external 
things, as his appearance would indicate. Facts are wanting on this curious subject; 

"■ See Page 613. 



HYSTERIA. 619 

but there can be little doubt, that many of the stories related of things seen by per- 
sons in a state of trance, are referable to this liead; and that their visions consisted 
of the conceptions of the mind itself, believed for the time to be real, in a manner 
analogous to dreaming. That such impressions should not be more frequently 
remembered, in ordinary cases of stupor, probably arises from the higher degree and 
greater permanence of the affection, than of that which occurs in sleep. For we 
have reason to believe, that dreams which are remembered occur only in imperfect 
sleep; and that after very profound sleep, we do not remember any mental impres- 
sions, though we have satisfactory proof that they exist. Thus, a person will talk 
in his sleep, — so as to be distinctly understood by another; but wiiJiout having the 
least recollection of the mental impression which led to what he said.^J 

Sometimes Fatal. — Hysteria, in these irregular forms, although for tho most 
part a disease without danger, may become fatal. Two sisters were affected iii 
the same way; one of whom died before I saw her; and I went to see the other. 
Although she was well supported every hour, as she lay apparently a corpse; yet 
I believe she sank at last. The other was a case of regular hysteria; and I con- 
cluded the patient would do well under ordinary treatment; but all at once she 
sank. Swelling of the hands came on, the pulse became weak, and she died; but 
why, I cannot tell; for I could not obtain leave to open the body. 



SECTION III— LETHARGY. 

When consciousness and voluntary motion only are suspended, and a state re- 
sembling sleep is produced, — differing from it in being more prolonged, — the affec- 
tion is termed "lethargy," and (by some writers) " cataphora." This is only 
another form of catalepsy; but it is not necessarily, though it is occasionally, com- 
plicated with hysteria. A case is mentioned in the " Philosophical Transactions" 
for 1694, of a man, twenty-five years old, residing near Bath, who slept nearly a 
month in a state of lethargy. In two years, he again fell into an inordinate sleep. 
At first, he ate, drank, and discharged his urine and fasces; but at length his jaws 
set; and he ate nothing more, and did not awake for seventeen weeks. It so hap- 
pened that the barley was being sowed when he fell asleep, and when he awoke it 
was being reaped. In August he fell asleep again; and was bled, stimulated, and 
treated secundem artem; but did not wake till November. The termination of the 
case is not given. 

It is recorded, in Plott's " Natural History of Staffordshire," that a woman slept 
forty days. In the " Medical Observations and Inquiries," there is an account of 
a woman who slept seventeen or eighteen hours, every day, for fifteen years. Dr. 
Good mentions seeing a lady, who was only in the habit of waking for one or two 
hours, two or three times a week, during the summer.^ I believe an affection of 
this description is not dangerous. I have heard (but I do not know the particulars 
of the case) that there has lately been an extraordinary person of this description, 
who was in the habit of sleeping for weeks together. The only cases of the kind 
that I have seen, have been trances; — those affections of an hysterical nature, which 
I have already mentioned. ° 

Sometimes Fatal. — Although this disease is usually not of a dangerous cha- 

* " Inquiries concerning the Intellectual Powers, By John Abercrombie, M. D." Part 3; 
Section 1; Sub-section 5, Head 5. (Ninth Edition; Pages 144 and 145.) 

b I was some years ago acquainted with a very singular example, that continued for five 
years. The patient was a young lady of delicate constitution, in her eighteenth year at the 
time of the attack; her mind had been previously in a stale of great anxiety. The remissions 
occurred irregularly, twice or three times a "week; and rarely exceeded an hour or two. 
During these periods she sighed, ate reluctanily what was offered to her, had occasional 
egestions, and instantly relapsed into sleep. Her recovery was sudden; for she seemed to 
awake as from a night's rest, by a more perfect termination of the paroxysm, not followed 
\iy 2i rQ\^])se.—'' Study of Medicine-" Class ^\ Order i: Getius 8; Sjjccics i; Varicly 2. 

«= See Page 618. 



620 DISEASES OF MOTION. 

racter, Dr. Willan mentions, in his " Reports of the Diseases in London," that 
lethargy is very common among the Jews of this town; and that it frequently ends 
in fatal apoplexy. "* Occasionally, after fever, persons will sleep for a very consi- 
derahle time. Willis mentions a case of putrid fever, which terminated in a perfect 
sleep of four days; and, at the end of that time, the man was imbecile for two 
months. Mr. Jolm Bell (the surgeon) saw a man who, in consequence of a fall, 
lay a great length of time in a sleep of this description; and when he awoke he was 
incoherent; but he finally recovered. 



CHAPTER XL 

DISEASES OF MOTION. 

SECTION I.— PARALYSIS AGITANS. 

Definltlon.—'The first disease of this description which I shall notice, consists in 
a very slight tremulous motion; and is called " paralysis agitans,^^ or (in common 
language) " shaking palsy." It is defined to be an involuntary, chronic, tremu- 
lous motion of more or less of those parts of the body which are subject to volition, 
together with lessened muscular power; occuring in parts when they are not in 
action, and even when supported; together with a tendency to bend the trunk for- 
wards, and to pass from a walking to a running pace; the senses and the intellect 
being uninjured. Tetanus affects the voluntary muscles; but palsy does not 
affect them, like tetanus, with spasms; but with minute convulsions called " tre- 
mors;" alternating perhaps with relaxation, and quite involuntary. Not only are 
the motions involuntary; but the patient has not the same power in producing 
voluntary motion, that he has in tetanus. It is not the tremor which a person who 
has been intoxicated the night before, or has taken a cup of strong coffee or tea, 
shows when going to put the glass to his head; — shaking it till he spills the con- 
tents; but there is a tremor when the parts are still; and even supported. Of course, 
when we run, we make a much greater voluntary effort, than when we walk. The 
faster we run, the greater is the effort we make, and the more powerful and steady 
is the motion. We can therefore conceive, that, by a strong effort, the patient is 
more likely to overcome involuntary motion, than if he be only exerting half the 
volition; so that persons in this disease are not to be interrupted, and are con- 
stantly on the trot (as it were). 

Progress of the Disease. — The muscular weakness and tremors begin, gene- 
rally, in some one part of the body only; — for instance, in the head; but most fre- 
quently they begin in the hand or in the arm; and perhaps it is not till after some 
months, or even some years, that another part is affected. But the disease fre- 
quently increases both in degreee and in extent; more parts become affected; and 
parts affected before become more aflected; till, at last, the whole body shakes. 
Like St. Vitus's dance,'' it may be checked for a moment, or a few moments, or 
even to the extent of a minute, by a violently strong voluntary effort; but it soon 
returns. The patient becomes less upright, bends forwards, walks upon his toes, 
and steps quick and short; till at last he comes (as I stated in the definition'') 
almost to a running pace. If the disease remit in one part, it generally increases 
in another; so that if both arms tremble, and one is improved, the other will im- 

^ Lethargy is not a frequent disease among our own countrymen [the English]. I have 
seen it mosily in Jews, and other aliens of a dark, swarthy comy)lexion; who sometimes lie 
six or eight weeks, in a torpid insensible state. — '^Miscellaneous Works of the late Robert Wil- 
lan, M. D. Edited by Ashby Sf/iitk, M. Z)." Page 339. 

^ See Page 622. ^ See the previous paragraph. 



DISEASES OF MOTION. 621 

mediately shake in a twofold degree. This?, we shall see, is also the case in St. 
Vitus's dance.* A change of posture will sometimes disturb the action that is going 
on. This tremulous motion ceases during sleep; — the same as in St. Vitus's 
dance; unless the case be very severe, and has continued for a long time; for then 
the tremors will continue even during sleep. At length the muscles of articulation, 
mastication, and deglutition, become affected; and, finally, the urine and faeces are 
discharged involuntarily. Such is the loss of muscular power; and, in the midst 
of all this misery, the patient becomes emaciated, and death generally supervenes. 

However, sometimes the disease does not extend at all. Many persons have 
shaking palsy of the head, for several years, without any other part shaking, and 
without any increase in degree. This is a disease which frequently attacks per- 
sons in the decline of life. There is a curious instance mentioned by Mr. Parkin- 
son, in which hemiplegia occurred, and the paralyzed parts ceased to shake; but 
when the hemiplegia ceased, then the shaking returned. 

Diagnosis. — We have to make a diagnosis between this disease, and the tremor 
induced by drunkenness, or violent passion, or that which occurs in delirium tre- 
mens. The tremor, in these cases, occurs particularly when an effort is made, and 
is not lessened by an effort. It is not lessened by support; and generally the cause 
is obvious. Many old writers have made this distinction; — Galen, Sauvages, and 
others; yet I believe paralysis agitans was not well characterized, until Mr. Park- 
inson wrote his pamphlet on it, in 1817.^ 

Pathology. — Mr. Parkinson gives only one post-mortem examination; and that 
was a very severe case, where the disease was universal; where there was great 
muscular debility, impediment of speech, "^ and (at last) impairment of intellect. He 
found, in that case, the lingual and brachial nerves tendinous; — that is to say, greatly 
indurated; the " medulla oblongata" and " pons varolii" were very compact and 
large; and the " medulla cervicalis" (the cervical part of the spinal marrow) was 
hardened. 

Treatment.— T\\\s is a very obstinate disease; and I have no doubt its obstinacy 
arises, generally, from there being an organic affection. Mr. Parkinson imagines 
the disease to exist in the superior part of the cervical " medulla spinalis," extend- 
ing upwards to the " medulla oblongata;" and he suggests antiphlogistic measures, 
directed particularly to this part. I have not been, by any means, successful in the 
treatment of this disease. When it occurs in old people, (where the head, or one 
hand shakes,) I have never known good to be done. Where it has occurred gene- 
rally, I have never been able to cure more than one case; and, in that instance, the 
patient was not more than nve-and-thirty years of age, and I am satisfied there was 
no organic disease; whereas in old persons, I should think, there is organic dis- 
ease; — probably induration; or, at least, a process going on which leads to indura- 
tion. This man, who was in the middle period of life, was not likely to suffer 
from structural change, unless induced by inflammation. There was pain and heat 
of the head, and giddiness; and, therefore, I treated him antiphlogistically. I bled 
him well, blistered, mercurialized, and starved him; and he had setons introduced: 
but all without any benefit. Finding, after a long trial, that the plan did no good, 
1 gave him zinc: which is a very useful remedy in St. Vitus's dance. He took a 
considerable quantity, three times a day; but without any benefit; and I then ex- 
hibited sesquioxide of iron, under the employment of which he became perfectly 
well; and remained so for some time afterwards. I have since had four or five 
cases of the disease under my care, and have exhibited the same medicine; but it 

a See Page 622. 

»> " An Essay on the Shaking PaIs3^ By James Parkinson." It is the best work that has 
been written on the subject, 

<= Palsy of the tongue is often a local disease, arising from an affection of the ninth pair of 
nerves ("" lingual"); — causing stammering, &c. It may be caused by a stroke of lightning, 
and might be cured by another; and the same observation applies to galvanism; which, 
together with strong gargles (as of cayenne-pepper), is the best remedy. The general affec- 
tion occurs chiefly in old persons who have laboured much with poor diet. The best plan is 
to give tonics, and apply blisters to the spine. — Dr. Fletcher. 



622 DISEASES OF MOTION. 

has not produced the least benefit. Most of the cases remained unaffected by the 
remedy. One or two were certainly a little improved, for a time; but nothing 
farther. 

In Young Persons. — Now and then, the disease occurs in young persons in a 
transient slight form, not connected with any organic affection; but appearing to 
be in females an hysterical affection, and in males to depend on congestion of the 
head. I have seen several young adults, who have had a shaking of one arm or 
hand; which has been cured by purging them frequently, and using antiphlogistic 
remedies directed particularly to the head. We may cure that form of the disease 
very well; but when it occurs in the decline of life, I have hitherto found it in- 
curable. 



SECTION II.— CHOREA.- 

Definition. — The next disease which I shall notice, is very much allied to 
paralysis agitans;'' — so far as it consists of irregular, slight, convulsive motions; 
and is unattended by any serious disturbance of the intellect, unless it continues 
for a very great length of time; but it is one which occurs, on the contrary, in 
young persons. It is called " St. Vitus's Dance."" 

Sijmptoms. — This disease is characterized by a catching of the fingers and other 
joints, a twitching of the head, corrugations and contortions of the face, very ex- 
tensive flexions, extensions, and rotations of the extremities; — in short, by per- 
petual motion, with a rolling of the eyes. The patient is observed, in the first 
instance, to drag one foot; and, frequently, there are such catches of the tongue, 
and of the muscles of the neck and throat, that articulation, deglutition, and masti- 
cation, are difficult; and so likewise is walking, standing, sitting, or lying. I have 
seen the skin of the chin and breast rubbed off, by the perpetual scraping of the 
one on the other. I have sometimes seen the patient, unable to lie on the bed, 
rolling off it; so that it was necessary to strap him down. These, however, were 
very severe cases. It is often very difficult to feed patients. It will sometimes 
require the aid of two or three people, to give them their meals: — two to hold them 
still, and one to catch the favourable opportunity of putting the spoon into their 
mouths. The motion is increased temporarily by fear, or any mental emotion. 
Nothing is more common than for the motion to increase when a medical man 
appears. Any mental agitation will have the same effect. If a child be made 
cross, the motions will be doubled almost directly. These motions are a little 
under the power of the will: persons can restrain them temporarily, but their best 
effort in the disease is little more than a sudden catch. 

Persons walk quickly better than slowly; and Dr. Heberden mentions the case 
of one individual, who could not walk, though he could run;^ — exactly as in 
paralysis agitans.^ The movements are suspended during sleep, unless in extreme 
cases. If we hold one patt, then another is agitated the more; and, generally, one 
side is more affected than the other. This is very common in all convulsive dis- 
eases; and, indeed, in diseases of sense as well as of motion. In many of these 
diseases, it is common to see only one side affected; but where both are attacked, 
it is usual to see one more affected than the other. This circumstance occurs in 
St. Vitus's dance; and the side most affected will, in the progress of the disease, 

a The Latin word "cAorea," comes from the Greek word ■xo^ti.a,. There is the best au- 
thority for calling it ^' chorea, ^^ and not '■'■ coreaP The latter word has been used; but only 
by a poetical license: the proper one is " cAorm." 

b See Page G20. c See Page 626. 

* A boy had his leg so violently agitated, that the involuntary motions overpowered all 
he weaker efforts of his will to move them; but a stronger exertion of the power which ex- 
cites spontaneous motions, was able to control his distempered agitations; — so that he could 
run, but could not Vjcdk: the same is observable in men intoxicated, to a certain degree, with 
strong liquors. — Dr. Heberden^s ^^ Commenlaries;''^ Chapter 20. 

« See Page 620. 



DISEASES OF MOTION. 62S 

frequently change; — so that the right, at one time, shall be most affected; and, at 
another, the left. 

One \eg and one foot generally first show the disease. The arms are generally 
more affected than the legs. The face has very frequently a fatuous appearance: 
the mind is apparently a little affected; and persons are certainly a little childish in 
this disease. The pulse is sometimes very quick, when the motions are very 
rapid; and sometimes there is headache, heat of the head, vertigo, and drowsiness. 
Sometimes patients will scream, and even epilepsy will come on; and sometimes' 
there is hardness of the abdomen; but, in a large number of cases, we find nothing 
the matter with the patient, except this extraordinary movement. We may meet 
with additional symptoms; hut, in a great number of instances that I have seen, 
such has not been the case. 

Duration. — The disease may last some weeks, or some months; and may then 
disappear; — either spontaneously, or as the result of treatment. Now and then it 
continues during life; but the majority of patients recover, and even regain their 
looks. The fatuous aspect of countenance, and the imbecility of mind, disappear. 
In a local form, this disease will continue for life. Many persons always have a 
catching of one leg, or one arm; or a catching of some of the muscles of the face. 
Some are always winking; some run with their head forwards, like a goat; and 
some throw their head down; — so that they have been a great inconvenience to 
auctioneers, who imagined they were bidding. There are many persons, with 
these unfortunate local forms of the disease. When it is so local, it almost always 
continues for life; and it often runs in families. I have observed, that where one 
part of a family has these catches, another has something else peculiar in the ner- 
vous system. That is very common. 

Termination. — When the disease occurs in adults, I believe it is seldom cured. 
It is where it occurs universally, and in very young adults, that it is cured. It is 
hardly a proper mode of speaking to say, that the disease may terminate fatally; 
but tiiat state of the nervous system which produces it, may end in death. I recol- 
lect a case, in a strapping girl about nineteen, which ended fatally. She did not 
die of St. Vitus's dance, but of apoplexy. The congestion of the head, which in 
one degree produced chorea, in another gave rise to apoplexy; and pathologically 
it could not be said she died q/'the disease, but hi the disease. It was an affecting 
circumstance; and I have no doubt might have been prevented, had she been well 
bled and purged.^ 

Usual Period of its Occurrence. — This is a disease which occurs, chiefly, be- 
tween three or four years of age, and fourteen. Dr. Heberden says it is most 
frequent between the ages of ten and fifteen;^ but my experience leads me to say, 
from three ox four years to fifteen. 

More Frequent in Girls than Boys. — It occurs, too, more frequendy in girls 
than in boys. Dr. Heberden says, that one-fifth only of the patients under his care 
were males;*" and that has been about the proportion I have met with; at least, in 
1826, 1 looked over my cases of this disease; and found that, in the hospital,*^ I 
had had seventeen patients altogether; and twelve of them were girls, three were 
boys, and the rest were adults. I may mention that, at the same time,. I looked 
over my cases of epilepsy; and found ihey were just the reverse; — that out of 
twenty-five cases of epilepsy, nineteen of the patients were males. Dr. Heberden 
made die same observation. *" In 1829, I had (altogether) thirty patients labouring 

a See Page 624. 

b See the twentieth chapter of his " Commentaries." He adds: — " It has come on so early 
as the sixth year, and so late as the tioenticth.'^ 

«^ Among the p>nienis I have attended, there have been four limes as many girls as boys. 
— Dr. Heberden' s ' ' Comvientaries;" Chapter 20. 

d St. Thomas's. 

e One would expect, that the weaker sex would be greater sufferers by epilepsy; but it 
has appeared to me, that though boys and girls be equally subject to epileptic convulsions, 
yet fewer women are afflicled with them than men.— Z>/-, Heberden' s ''Commentaries;'' 
Chapter 33. 



624 



DISEASES OF MOTION. 



under St.Vitus's dance; and twenly'two of them were females, and eight males; — 
about the same proportion as in 1826. With respect to epilepsy, out of thirty- 
seven patients, in 1829, twenty-seven were males. 

Causes. — The tendency of this disease is constitutional. I do not know that it 
is hereditary; because adults, frequently, cannot tell whether they had St. 'Vitus's 
dance when they were young or not; but it is very common to see two or three 
children in a family have it; — not at the same time, but at different periods. It 
affects all sorts of children; — those who are pale and sickly, and those who 
are ruddy. It frequendy affects those who are otherwise in perfect health, and 
generally there is no obvious cause, either predisposing or exciting. All I can 
make of it is, that it is a morbid excitability of a certain portion of the centre of 
the nervous system, (the " medulla oblongata," or spinal marrow,) with which the 
nerves of voluntary motion are connected; but not a sufficient irritation to pro- 
duce that violent action which characterizes tetanus. As to its being inflamma- 
tory, almost every case may be cured, not by antiphlogistic measures, but by 
those which are just the reverse. It has been said to arise from an irritation of the 
alimentary canal; but I am quite sure that, in nine cases out of ten, (I might almost 
say nineteen out of twenty,) the alimentary canal is healthy. If the cure arose 
from purging, the faeces would be unhealthy. Now and then a distant exciting 
cause may be found; but I have never been able to discover any, except in one 
instance; where it came on after a discharge from the thigh had been suppressed. 
A scrofulous sore had continued in the thigh for some time; and when this healed 
up, St. Vitus's dance began. Whether it was accidental or not, I cannot tell; but 
it was not cured by re-exciting the discharge, but by iron; and that with the greatest 
rapidity. 

Proximate Cause. — The proximate cause, I have no doubt, is seated in the head, 

. as well as the spinal marrow; for the very highest nerves are affected. The eyes 
roll; the very highest muscle of the body (the " corrugator supercilii") is affected; 
the countenance is fatuous; and the mind is frequently a little impaired. Now and 
then we have constipation, and now and then headache and throbbing; but these 
form only a very small proportion of the cases. 

Treatment. — With regard to treatment, if there is drowsiness, headache, or heat 
of the head, we ought to purge the patient well, take away blood either by the arm 
orby leeches, and treat it as a case of congestion, or an inflammatory state of the head. 
It is a much shorter mode to apply leeches to the head, and take away blood from 
the arm, than to go on with purging. Purging is good; but it is a roundabout way 
of affecting the head; and if there be much congestion of that organ, the best way 
is to take blood from it directly. Sydenham's practice was to take away blood 
from the arm, and purge; but what his success was, I do not know. It was rather 
a violent practice; and I am quite sure that, in a great number of instances, neither 
bleeding nor purging is required; but had those measures been practised in the case 
where apoplexy supervened, "^ the patient would probably have lost her St. Vitus's 
dance, and not have become apoplectic. If there be costiveness, it is our duty to 
remove it; if there be pain of the abdomen on pressure, besides emptying the 
bowels, we ought to try the common remedies of inflammation. There can be no 
doubt, that purgatives will sometimes cure the disease; sometimes by relieving a 

'loaded state of the alimentary canal; and, in other cases, by circuitously emptying 
the head. But purgatives very often fail; — as I have repeatedly found. Children 
are continually brought to us after they have been well purged; and yet they are 
none the better for it.** An inflammatory or congested state of the head, is by no 
means more necessary to this disease, than it is to hydrophobia or tetanus; but it is 

a See Page 623. 

b Very free purging is generally recommended. Dr. Hamilton brought away, in a few 
days, faeces amounting in weight to that of the whole body. But such treatment will not do 
in London; where tonics must be used. " -^' "' 

plied to the spine.— Z?r. Fletcher. 



1 mv^ «i>iiv>xv^ tj\j\xj . jjui oui^ii iicaniiciii will llUl uu 

Antispasmodics may be given, and blisters ap- 



DISEASES OF MOTION. 625 

always right to look out for congestion, and an inflammatory state, and to remedy 
them if found. 

Tonics: Sulphate of Zinc— My reason for maintaining that the disease is not 
essentially inflammatory, and that, more frequently than otherwise, it is a mere 
morbid irritability, is this; — that tonics are the best remedies. Sulphate of zinc 
will cure a very large number of cases; and it may be given to a very considerable 
quantity. We may begin with a grain, in the form of a pill; but we must not ex- 
hibit it on an empty stomach, but after meals; and, in many cases, we may increase 
it to six, seven, or eight grains. I have given to adults from twenty to twenty-five 
grains, three or four times a day; but children will bear six, seven, or eight grains, 
three or four times a day, without nausea. This is not a newly-discovered fact. It 
was mentioned, long ago, that these doses may be given in epilepsy, without nau- 
seating. The circumstance is ascribed, by Dr. Good, to the insensibility of the 
stomach in epilepsy;* but there is no reason for supposing that to be the cause; for 
it is now proved that persons in health, with no insensibiUty of stomach, will take it 
in these quantities, if we begin with a grain, and gradually increase it every day. I 
have repeatedly given it in this quantity, and seen others do the same. 

Copper; Silver. — The sulphate, and other preparations of copper, will cure the 
disease; and so also will the nitrate of silver; but the latter is an objectionable remedy, 
on account of its producing a discoloration of the skin. 

Sesquioxide of Iron, — The sesquioxide of iron^ has, undoubtedly, very great 
power over the disease. I have had (I should suppose) forty cases in succession, 
all cured by this remedy. Perseverance is sometimes required; but I never had a 
case occurring in a child, where it was fully given, that the patient was not cured; 
though I have never cured a case in adults, where the disease was quite local,-— 
situated in the head or arm. When cases occur in children, they generally become 
better, and the disease gradually ceases. I have not yet met with a single failure. 
In one, after it had been cured, the child had fever; and during the excitement of 
fever it returned. The child was brought to me again; and the disease ultimately 
disappeared. In general, the affection disappears when the remedy has been given 
about six weeks or two months; but I have had some obstinate cases, when it was 
necessary to continue it twelve weeks. I believe that a large dose will sometimes 
cure it, where a small one fails: but I should not give a large dose, where a small 
one would do; but if that would not answer, rather than give it up, I would double 
the quantity. Children generally like it; and, after a time, they ask. for it; because 
I exhibit it in double its weight of treacle. Generally there is no necessity to give 
purgatives. I have seen headache, drowsiness, and giddiness disappear, under the 
use of this remedy; — an occurrence which would not, a priori^ be expected; but if 
there be much heaviness of the head, I should employ leeches instead of giving 
this remedy; — at least at first. Some have an idea, that if we purge the patient 
well first, and then give the remedy, it answers better; but I have not seen that to 
be the case. I tried the sulphate of iron only once; and in that case the disease 
gave way; — the child was of a plethoric habit. It is right to continue the iron, for 
some time after the disease is cured; for, if we do not, the disease is very likely to 
return. 

The oil of turpentine has sometimes been used with success; and some say col- 
chicum. Electricity along the spine, the cold bath, the shower bath, hot and cold 
baths in succession, and musk, will undoubtedly do good, and will now and then 
cure die disease; but I have tried most of them, and never found any thing so use- 
ul as the sesquioxide of iron. 

* Such has been the state of exhausted irritability produced by this disease, in some in- 
stances, that the patient would bear almost any quantity. — "-Study of Medicine-" Class 4; 
Order 4; Genus 7; Species 3. 

b Dr. EUiotson first directed the attention of the profession to the efficacy of this remedy 
in the treatment of chorea, in a paper which was published in the Tliirteenth Volume of 
the " Medico-Chirurgical Transactions;" Page 23-2; where the details of eight successful 
cases are given. 
VOL. I. — 40 



626 DISEASES OF MOTION. 



SECTION III.— LEAPING AGUE. 



History. — The form above described,* is that in which the disease usually 
occurs; but, now and then, persons have it in another form; — so that they dance 
or leap; and then it is called •' leaping ague." Perhaps it is called " ague" from 
not being constant, but coming on in paroxysms. This form of the disease has 
been very frequent in the northern parts of Scotland;" and also in Germany, and 
some other places. In this form of the affection, persons will sometimes run, with 
extraordinary facility, over dangerous places. If they have a place fixed in their 
imagination, they will dart forward towards it; and on arriving at it, they will drop 
down exhausted. Horstius states, that certain women in Germany were affected 
with restlessness of body, and disorder of mind; and went annually to the chapel 
of St. Vitus, nearUlm; where they danced, night and day, till they dropped down 
exhausted. They then remained well till the following May; when the affection 
returned, and they went through the same ceremony. It is from this circum- 
stance that the common form of the disease is called " St. Vitus's dance."* The 
French call it " the dance of St. Guy;'''' but, not being a Catholic, I do not know 
who St. Guy was. Sometimes it is said, that a roll on the drum gives persons 
this tendency to dance; and that it is assuaged by music; — ^just like fits of dancinor 
in chorea. Some do not believe that the beating of the roll has much power; but 
that the effect results from the motions of the body, arising from the excited state 
of the feelings; just like the other form of the disease which I have mentioned.* 

Symptoms. — In this extraordinary form of the disease, some will climb in a 
very singular manner; others will have fits of rolling; others, fits of leaping; others 
will whirl round; others will tumble regularly; and others will spring and dart 
forwards, in any direction, to a given spot. Paroxysms of this kind will some- 
times come on daily, or even oftener; and sometimes not so often. Occasionally 
they have been observed to be periodical to the minute; and, as in comu)on chorea, 
this affection is somewhat under the will. It is a strong desire for motion, and a 
pleasure in yielding to it; but a strong effort will produce a little diminution of the 
motion. A curious case of this kind (occurring in a woman), is given by Dr. 
Watts, of Glasgow, in the Fifth Volume of the " Medico-Chirurgical Transac- 
tions."'' In this woman, there were various movements at different limes; and the 
doctor states, that he witnessed them himself. He says that she would roll over, 
fifty or sixty times in a minute; and would be sometimes seized with tetanic 
rigidity; but that she was conscious of her own existence during these fits. In 
the Seventh Volume of the same " Transactions,"*^ a case is mentioned by Mr. 
Kinder Wood; and which, likewise, occurred in a female. She had violent fits of 
dancing; and it was observed by some one, that (when dancing) she struck the 
table, and every thing that came in her way, in regular time; and that she danced 
in very good time. A drum was procured, and a man beat it to the time in which 
she danced; and she immediately turned towards it, and danced up to it. It was 
-not known that she had ever danced before; but she now danced in regular time, 
and very gracefully; — showing an infinite variety of steps. Beating ths drum 
suddenly in a roll, or a little out of lime, always stopped her; and by perseverance 
in this plan, whenever she began to dance, she was cured. This repeated inter- 
ruption at last broke the chain. She was sensible during the paroxysm; and 
between the paroxysms she nursed her child, and attended to her household affairs, 
and had a great wish for her recovery. All the account she could give of it was, 
that she had a tune in her mind, which irresistibly compelled her to dance. Occa- 
sionally there are these motions, without any musical ideas whatever; and occa- 
sionally patients have involuntary musical ideas; — causing them to hum a tune, 
without any motion taking place in accordance with it. 

«» See Page 622. ^ Particularly Forfarshire. 

«= Page 1. d Page 237. 



DISEASES or MOTION. 627 

Jlttribiifed to Tfltchcraft. — When these cases occurred formerly, they were 
ascribed to witchcraft. A case of this description occurred in Renfrewshire in Scot- 
land, in 1696; and the ministers watched the patient in turn. A commission was 
appointed by government, to examine into the business, and was signed by eleven 
privy councillors; and it was declared that she was bewitched. A warrant was 
granted, and several persons were apprehended, and afterwards brought to trial, for 
having bewitched her. After six hours' deliberation of the jury, three men and 
four women were found guilty; and were condemned to be burnt for having caused 
the disease; and the sentence was actually executed at Paisley, on the tenth of 
June, 1697. A case exactly like this, but not ascribed to witchcraft, is recorded 
in the "Edinburgh Medical Journal" for 1829. Bishop Jewel, in a sermon 
preached before Queen Elizabeth, said: — " It may please your Grace to understand, 
that this kind of people, (I meane witches and sorcerers,) within these last few 
years, are marvellously increased within this your Grace's realme. These eies 
have scene most evident and manifest marks of their wickedness. Your Grace's 
subjects pine away, even, unto the death; — their coUour fadeth; their flesh rotteth; 
their speech is benummed; their senses are bereft. Wherefore your poore sub- 
jects' most humble petition unto your Highnesse is, that the lawes touching such 
malefactors may be put in due execution. For the dole of them is great; their 
doings horrible; their malice intollerable; the examples most miserable. And I 
pray God they never practise further than upon the subject." In the next session 
a bill was brought into parliament for making witchcraft felony; and those who 
know any thing of history, must be aware that thousands of victims were sacri- 
ficed. All singular nervous diseases, and many other calamities, were ascribed 
especially to witchcraft. 

There is an account, in the " Ephemerides," of a girl who sprang up while in 
a horizontal posture, and came down again. The mother consulted a medical man; 
and he told her he could do nothing for her. He attributed it to the devil; and 
directed her to go to a clergyman. Voltaire says, that the greatest enemies the 
devil has are the doctors; — that it is the doctors who do away with one half of his 
dominions; — so much was formerly ascribed to him, and to those connected with 
him. 

Pathology. — One has some clue, I think, to these motions, in the experiments 
of Magendie. He says, that if the white matter of both " corpora striata" be 
cut, the animal darts forward; or, if this be prevented, it still retains a progressive 
attitude. He says, that if the " crura cerebelli" or the " pons varolii" be cut, 
from before backwards, an animal rolls over sixty times in a minute. That I have 
witnessed myself. He likewise states, that if we cut vertically from the " crura 
cerebelli," through the arch of the fourth ventricle, it has the same eflect; and the 
motion is more rapid, as the section is nearer that point. If incisions have this 
effect, we may easily conceive that a certain local affection may have a similar 
eflect in being the cause of this disease. Cases are recorded of persons, who had 
a mere propensity to rush forward or backwards.* 

Causes. — Some of these affections are clearly the result of mere excitement of 
mind; — some violent passion. Sometimes they raise from witnessing other people 
under the disease: but occasionally they appear to arise from certain causes within 
the nervous system itself, independently of all external circumstances. When they 
arise merely from external circumstances, a large number of cases occur together; 
and in Germany they have been epidemic; — that is to say, they have affected a 
large number of people at a time. 

Treatment. — When these cases are sporadic, we should naturally be inclined to 

* Sometimes there is an uncontrollable propensity to running; which appears to be from 
both " corpora striata" being affected. If only one of these bodies be engaged, a rotary 
motion is produced; as is often seen in dogs labouring under inflammation of the brain. 
When the uppe; limbs are convulsed, it is probably from an alfecliou of the optic thalaini. 
— Dr. Fletcher. 



628 TETANUS. 

treat lliem like St. Vitus's dance;^ and I have no doubt they would be cured in the 
same way. Wiien they are epidemic, we ought to have recourse to mental reme- 
dies. We sliould separate the patients; and not allow one to be excited by seeing 
another. Strong corporeal measures can be of little use, and medicine must be out 
of the question; but when these cases occur without any external excitement, from 
simple irritation (although I never had such a case), I have no doubt that the cold- 
bath, oil of turpentine, and those things which cure St. Vitus's dance,* will also 
cure this affection. 



CHAPTER XII. 

TETANUS. 
SECTION I.— SYMPTOMS AND PROGRESS. 

Definition. — The name of the disease I am now about to consider, (tetanus,) is 
derived from the Greek word 'tstvco, to stretchy — in consequence of the great 
stretching and spasm that exist in this disease. There is a constant rigidity and 
contraction of certain voluntary muscles, not alternating with relaxation; yet there 
is a much more violent contraction at one moment than at another. There is a 
constant contraction of the muscles affected; but they are not constantly contracted 
to the same extent. There are paroxysms of spasm, as well as constant spasms; 
and the paroxysms are more frequent, and also more violent, in some cases, and at 
some periods in the same case, than in others. Synchronous with these violent 
spasuis, there is violent pain; and the muscles so affected by spasm, are always 
very hard. There is one extraordinary case mentioned by Sir Gilbert Blane, of 
a man in the navy who had tetanus; and, instead of experiencing a violent agony 
from the spasm, he had nothing but pleasurable sensations. It is considered a 
Tery extraordinary case; and the disease could not be trifling, for he died on the 
fourth day. I do not believe that Sir Gilbert Blane saw the patient himself; but 
he relates the case on the authority of a surgeon in the navy. 

Varieties. — Tliese painful spasms chiefly affect the muscles of the lower jaw, 
of the neck, and of the trunk. When they affect the jaw, that variety of the dis- 
ease is called " trismus." When the spasms are such that the body is drawn 
backwards and arched (the convexity of the arch being forwards, and the whole 
body (\r:iiwn baclnvards), this state is called "opisthotonos;" when the body, on 
the other hand, is drawn forivards, it is denominated "emprosthotonos;"'' and 
if the body be drawn to one side, then it is termed " pleuroslhotonos."*^ Trismus 
and opisthotonos are the most common. Sometimes the spasms affect the muscles 
of the extremities; but in general they do not; and the fingers are often flexible to 
the very last; while the trunk, the neck, and the jaw, are in a state of the utmost 
rigidity. 

QSome writers divide tetanus into " general," — when the whole muscular sys- 
tem is affected; and " local," — when there is rigidity of one or several muscles, 
as in cramp, priapism, &;c. Tetanus has also been distinguished, as regards its 
duration, into "acute" and " chronic;" though the limits where the one terminates, 
and the other begins, have not been fixed. Two varieties have also been estab- 
lished, — " idiopathic" and " symptomatic;" — the former arising from causes act- 
ing directly on the nervous system, the latter from the irritation in other organs 

" See Page 624. ^ See Pages 624 to 625. 

<: From e/u7rgo<r9£v, forwards; and reivw, to draw. 
'' l''rom TTAEyj;©'/, i/ie side; and teivoof, to draw. 



TETANUS. 6,29 

being propagated indirectly to the nervous centres. Thns tetanns following wounds 
(termed "traumatic") belongs to the latter variety. It has also been divided into 
the "continued" and "periodic:" in the former the rigidity does not disappear 
entirely, but the symptoms sometimes suddenly increase; in the latter there are 
complete intervals, or interruptions of the tetanic rigidity; — the symptoms, in some 
cases, recurring at stated or fixed periods. The "continued" forms are always 
ac-ute or subacute; the "periodic" always chronic. Dance has recorded four 
cases of the latter variety.'' Hufeland'' has also seen a case that for years returned 
at regular periods, which lasted eight hours. *"] 

Symptoms. — The muscles of the face are affected; and the consequence of this 
is, that the brow becomes very much corrugated. The " corrugator supercilii" of 
each side suffers in the spasm, and the other muscles of the face are affected; so 
that the angles of the mouth are drawn up into an agonizing expression; and the 
patient is compelled to a wretched grin; which is, no doubt, greatly increased by 
the agony which the patient suiTers, The nose is drawn up; and the eyes are fixed, 
staring, and startling. The tongue is continually protruded, during the patient's 
sleep, if the jaw be not completely closed; and when it is protruded, spasms con- 
tinually affect the masseter and temporalis muscles; so that the jaws snap, and the 
tongue is caught and wounded. The diaphragm, too, is greatly affected; on which 
account there is a catching of the breath, and violent pain at the end of the sternum. 
At any rate, these spasms produce a catching of the breath; and, I presume, the 
pain at the end of the sternum arises from the same source. From the spasmodic 
state of the abdominal muscles, the abdomen is extremely hard and swollen; — in 
fact, as hard as a board. The recti muscles are seen prominent in all their depart- 
ments. The least motion, or the least attempt at motion, frequently excites these 
violent spasms; so that if the patient attempt to move in bed, violent spasms follow. 
The " sphincter ani" sometimes seems to be violently contracted; so that a clyster 
cannot be given. This, however, is not invariably the case. From this violent 
muscular action, there is great heat and great sweating. Dr. Fribo, of Geneva, 
found the temperature of the body 110 degrees in the axilla. In this disease the 
pulse is quick, exactly in proportion to the severity of the affection. It is much 
quicker at the moment the spasm is aggravated, than at any other time. The first 
symptoms of the disease generally show themselves about the neck and tongue. 
Usually the first symptom of which the patient complains, is a difficulty in masti- 
cation and deglutition; and then there is generally a slight stifiJ'ness about the back 
of the neck.^ 

Duration. — The course of the disease is various. Sometimes it proceeds very 
rapidly, and sometimes very slowly; so that it may last only one day;— destroying 
life in twenty-four hours; or it may last many weeks. It frequently kills before 
the fourth day; and when it does terminate fatally, it generally proves so before the 
ninth day. As to duration, Dr. Parry mentions that a horse attacked with this 
disease, did not die before the eighteenth day of seizure. When a patient dies, it 
is either during the violence of the paroxysms, or from being completely exhausted.^ 
The mind is usually quite unaffected, except sometimes towards the last. It is 
common to almost all diseases, for the mind to become slightly affected. The 
bowels, in this affection, are always costive.^ If the patient recover, it is generally 

' " Dictionnaire de Medecine et Chirurgerie Pratique." 

b " Manuel de Medecine Praiique; par Jourdan;" Page 234. 

"= "Library of Medicine;" Volume 2; Page 231. 

^ Teianus beg^ins in the jaw;— the raotific branch of the third division ("inferior maxil- 
lary") of the fifih pair of nerves (" trigemini") being first affected. There Is " risus sardo- 
nicus;" the eye.s are half open; the disease extends to the neck; and then to the trunk. In 
the extremities, the flexors are first attacked, and then the extensors; — as in all cases of 
spasmodic disease; whereas, in paralytic diseases, (as in the aficction of ihe wrist from 
"painters' colic,") the extensors are first attacked. Thus, added and diminished nervous 
power affects dilFerent sets of. muscles first. — Dr. Fletcher. 

e Death generally results from asphyxia, nervous apoplexy, or a general convulsion. — Dr. 
Fletcher. 

f This costive state has been attributed to spasm of the anus; to spasra^ extending from 
the voluntary muscles to those of the intestines; to the opium administered; and to a spasm 



630 TETANUS. 

by a very gradual cessation of the symptoms; and the disease lasts from two to 
four weeks, and sometimes six or eight. It is from these long-continued cases, 
that recovery usually takes place. It now and then, of course, remits; and then 
again it is aggravated. 

Morbid Appearances. — After death, in most cases, nothing wrong is found; and 
therefore the morbid appearances which are sometimes found, are not essentia^ but 
incidental. Occasionally, we find inflammation of the spinal marrow; but some- 
times (and I cannot but fancy 1 have seen instances of it myself) the congestion so 
common about the spinal marrow, when the body lies long, has been mistaken for 
inflammation of the spinal canaL In the ordinary position in which dead bodies 
lie, the blood gravitates towards the spine; and if the body be not soon examined, 
and the weather be hot, we may expect great redness of the spinal membrane from 
the blood efl'used there; and yet there may be no inflammation. When we consi- 
der that, in the majority of cases, there are no signs of inflammation, we cannot but 
conclude that, although inflammation of the spinal marrow may sometimes give 
rise to tetanus, yet the disease is not necessarily the result of inflammation of that 
kind. 

State of the Nerves. — [In traumatic tetanus, the nerves in the neighbourhood of 
the wound have often been found more or less injured, or to have undergone morbid 
alterations. In certain cases they have been contused, lacerated, partially divided, 
irritated by spicula of bone, or other foreign substances, included in ligatures placed 
on arteries, or participating in the inflammation of the surrounding textures. In 
the latter case, the appearances have differed according as the inflammatory action 
was acute or chronic; — injection (more or less intense), and softening being evi- 
dence of the former; and thickening, induration, and discoloration of the latter. 
Lobstein* and Andra^ have observed signs of inflammation or redness in the semi- 
lunar ganglion; and Swan'' has often seen the ganglia of the sympathetic system in 
general considerably injected; — an appearance which has been occasionally observed 
by other authors. 

Other Morbid Lesions. — In an individual who died of opisthotonos, Dupuytren 
found the muscles gorged with blood, and lacerated. Larrey and Curling give cases, 
where one of the " recti abdominis" muscles was torn across. The pharynx and 
oesophagus were often seen by Larrey contracted; and their mucous membranes 
red, inflamed, and covered with a viscid reddish mucus. The large papillae at the 
root of the tongue, have occasionally been found thickened; and the mucous lining 
of the larynx, injected and covered with frothy mucus. Andral gives a case, where 
unequivocal marks of gastritis were discovered; and, in four cases, M'Arthur found 
inflammation of the alimentary canal, with a peculiar yellow matter covering the 
mucous membrane of the stomach and oesophagus; which, in one case, eflfervesced 
on being exposed to the external air. Worms have been discovered in the intesti- 
nal canal by Sauvages, Laurent, Larrey, O'Beirne, and others. The last writer 
states, that distension of the caecum and colon is a constant pathological appear- 
ance. In a case related by Mr. Howship, the heart was much indurated, and pre- 
sented considerable resistance to the knife.**] 

SECTION II.~CAUSES. 

Predisposing Causes. — The predisposing causes of the disease, are, in the first 
place, hot climates and hot seasons. The disease is far more common in hot cli- 
mates, than in temperate ones; and more common in hot seasons, than in those 

of the extremities of the intestinal arteries. But none of these causes are satisfactory. — 
Dr. Fletcher. 

• " De Nervi Sympathelici;" Page 152, 

^ " Clinique Medicate;" Tome 1; Page 49. 

«:" Diseases of the Nerves." 

d " Library of Medicinej" Volume 2; Pages 237 and 238. 



TETANUS. 631 

which are mild. It appears that, in hot climates and hot seasons, it prevails most 
from the want of ventilation, the want of good food, the want of comfort, and the 
want of attention to the bowels. On this account it is much less frequent in the 
army and navy now, than formerly. Dr. Lind says that, in the West Indies, at 
the end of the former war, five cases of amputation out of six proved fatal, through 
the occurrence of tetanus;** but Dr. Dickson, physician to the Fleet, (in an article 
published in the Seventh Volume of the " Medico-Chirurgical Transactions," Pa^e 
448,) says that there were not under his care, in the West Indies, above six cases 
of tetanus arising from amputation, for upwards of seven years. He ascribes this 
fact to the improvement in the treatment of sailors, both in sickness and in health; 
and to their having- more comforts, and being less exposed to noxious causes. Dr. 
M'Arlhur, of the Naval Hospital at Barbadoes, says" that only four cases occurred 
there, in the course of nearly four years; and yet there were many wounds, and 
many amputations during the war.*^ This is another instance of the ejETect of ex- 
ternal circumstances upon the existence and severity of various diseases. Fever 
prevails most among those who manifest a want of cleanliness; and so, it is said, 
do cholera and typhus. But diseases very dissimilar to each other, will be pre- 
disposed to by a want of comfort; for the more the comfort of the body is attended 
to, the less is the influence of all noxious agents, and noxious circumstances. 

Males are thought to be more disposed to the disease than females; but this is 
not proved; for males are more exposed than females to the exciting causes of the 
complaint. It is also thought, that the strong and muscular are more liable to it 
than the weak; but whether that is really the case I do not know; fori have seen a 
great number of instances of tetanus, in persons of all sorts of constitutions, both 
strong and weak. It is supposed to occur particularly in young adults; but it occurs 
also, in the West Indies, in infants. Children there (though now less frequently 
than formerly) die of locked jaw; so that one variety of the disease is called "tris- 
mus nascentium.^^^ 

Exciting Causes. — Among the exciting causes of the disease, is to be mentioned 
sudden refrigeration, when the body is hot; but the most common is a wound; and 
(what is singular) it is wounds of the hands or feet, that most frequently cause it, 
and, among wounds of the hands and feet, it is wounds of the fingers and toes, that 
most frequently cause it; and among wounds of the fingers and toes, it is most fre- 
quently wounds of the thumbs and great toes, that produce it. 

Depends on the Kind of JVound. — Every wound has not an equal tendency to 
produce tetanus; for contused w^ounds much more frequently occasion it than any 
others. A wound will sometimes not produce the disease, till the person is sud- 
denly exposed to cold; and then he will have it immediately. This is a similar 
occurrence to that which takes place in ague; namely, that a person may be ex- 
posed to the causes of ague, and yet the disease will not appear, until he is ex- 
posed to cold and wet. The cause then becomes efficient. So a wound will fre- 
quently not produce tetanus, till another cause of the disease takes place; — sudden 
refrigeration; and then the affection makes its appearance. The reverse of this, 
however, sometimes happens. The person is exposed to wet; but the disease will 
not show itself, until a wound takes j)lace. 

The State of the Wound. — It occurs in all states of the wound; — in healthy and 
unhealthy wounds. Sometimes it appears when the wound is nearly healed; and 
sometimes when it is perfectly healed. It occurs, too, whether the wound be large 
or small. 1 had a case of tetanus, as severe as any I ever saw, where there had 
been merely a contusion of the thumb. There was no pain, — no irritation. The 
nail was separated and loose; but under it, all was dry. No secretion was going 
on, and there was no irritation to be found; and yet the contusion of the thumb 

» " E^say on Diseases lacideatal to Europeans in Hot Climates. By James Lind." Part 
3; Chapter 1; Section 4. 

'' In a letter dated February 22, 1808; and published in the Seventh Volimie of the 
"Medico-Chirurgical Transaciions;" Page 4G6. 

c " Medico-Chirurgical Transactions;" Volume 7; Page 476. 

«* See Page 633. 



632 TETANUS. 

produced the disease. There is a case mentioned in the " Transactions of the 
London Medical Society,"^ in which the disease occurred after a burn; at the time 
when there was merely a dry scab on the leg, and no inflammation around it; nay, 
the disease has sometimes declined and ceased, while the wound every day grew 
worse and worse. I had a case of tetanus from compound dislocation of the great 
toe; in which the disease declined, and ceased, while the pain continued in the foot. 
Inflammation and suppuration went on, accompanied by great suffering; and yet the 
disease was declining all the time. Trismus nascentium, — the "lock-jaw" of new- 
born infants,^ has been ascribed to the state of the navel, — to the condition of the 
parts connected with the umbilical cord;"' but it appears, that it is greaUy disposed 
to by the unheal thiness of the circumstances in which the children of the West 
Indies are placed. 

Period at ivhich it may Occur. — Sir James M'Grigorsays that it appeared, from 
his immense experience in the Peninsula (as army-surgeon), that a person wounded 
was safe, as it regarded tetanus, if the disease had not begun by the twenty-second 
day after the infliction of the wound. But Sir Gilbert Blane (who had, if not 
equal, yet very great experience in the navy, many years ago) says, that he has 
seen the disease occur at all periods of a wound, between the second day and the 
end of the fourth week. Sir James M'Grigor found the twenty-second day the 
limit; but Sir Gilbert Blane has seen it up to the end of the fourth week, from the 
time of the infliction of the wound; so that a person is not safe, according to him, 
even if he have passed the twenty-second day. Dr. Parry mentions seeing a horse 
seized with the disease on the thirtieth day. I may mention, that tetanus is not 
only common in horses; but that lambs are affected with it, if their ears be bored 
with a red-hot iron, to check the rot. It has been said to arise, frequently, from 
worms in the intestines. 

Pathology. — All I can venture to say as to the nature of the aflfection is, that it 
is a peculiar state of that part of the brain or spinal marrow, which is immediately 
connected with the nerves of the voluntary muscles. What that state is, I cannot 
pretend to define; but that is the situation of the proximate cause, I have no doubt. 
The mind is entirely unaffected in the disease; and so is sensibility. It appears 
to be an affection of the voluntary muscles, through the medium of the voluntary 
nerves. 



SECTION III.—DIAGNOSIS AND PROGNOSIS. 

Diagnosis. — In almost, every case, we observe that the tongue is bitten. Before 
the mouth is completely closed, and the patient falls asleep, the tongue is protruded 
by the spasms. The spasms afl^ect the entire set of muscles; and therefore we 
may expect, in most cases, a biting of the tongue. A second symptom, very 
characteristic of the disease, is the pain at the *' scrobiculus cordis." It is a pain 
not increased by pressure; but a sudden, violent, sharp, stabbing pain. It may be 
more or less constant; but at periods it is exceedingly severe. There is also a 
peculiar swelling and rigidity of the muscles; — -a state which is spasmodic, but 
constant, woi convulsive. It is what they call ^^ a tonic spasm;" — not a spasm 
alternating with relaxation ("clonic"). Then, again, the body is drawn into a 
peculiar posture;— opisthotonos, emprosthotonos, or pleurosthotonos;^ and in tris- 
mus the jaw is closed, or nearly so, without any inflammation around, and without 
any organic disease to account for it. 

Fronn Hydrophobia. — There is no terror in this disease; — no excitement of the 
mind; — no morbid corporeal sensibility. We shall see, tliat in hydrophobia there 
is excessive terror, — excessive excitement of mind, — a great sensibility to external 

« Volume 6; Page 77. ^ See Page 631. 

« It has also been attributed to cold, and to retention of the meconium. Hide-bound 
children often die of this disease. — Dr. Fletcher. 
d See Page 632. 



TETANUS. 633 

sensation; so that neither noise, nor light, nor a sudden draught on the body, can 
be borne;* but in tetanus, altliough the patient is miserable enough from the agony, 
yet there is no mental distress, — no terror of mind; neither is the body extraordi- 
narily sensible to external applications. 

From Rheumatism. — Rheumatism, when it occurs, chiefly takes place in the 
joints, and not in the bellies of muscles; or i^ it do, the joints are affected likewise; 
and there is no spasm, but a difficulty of motion, and great pain wlien the patient 
moves; and many joints are. frequently affected at the same time. As to the dis- 
tinction between a locked jaw and rheumatism, it may be observed that, in the 
latter, other joints are most probably affected. The jaw may be stiff; but there is 
violent pain flying from one part to another; and the patient is not subject to a 
snapping of the tongue. In rheumatism, too, there is generally tenderness in some 
part of the jaw; and generally there is a great deal of heat, as well as constant pain. 

From Hysteria. — Tetanus, more especially trismus, is very frequently hysteri- 
cal; but this occurs, in ninety-nine cases out of a hundred, in females; and there 
are other hysterical symptoms; — such as " globus hystericus," great flatulency, 
and 'irregular convulsions. If hysteria be present, and trismus (or any other form 
of tetanus occurs), we may take it for granted that it is an hysterical affection 
altogether. 

Occurring during Ague. — I mentioned, when speaking of ague, that tetanus 
sometimes occurs during that affection, particularly during the cold stage;^ and I 
presume it is not dangerous. The utmost that I have observed, is a constant tonic 
spasm of the arm; — that is to say, I had two patients under my care, whose hands 
were clenched during the cold stage. 

Narcotics. — Narcotics sometimes have occasioned this disease. A tobacco- 
clyster will sometimes occasion it; but it is strychnine, more particularly, that has 
this effect. In these cases, if we knew that poison had been swallowed, we should 
ascribe it to that; but if a narcotic had been taken, I presume we should, in most 
cases, find some other symptom present in addition to the tetanus. 

Prognosis. — The prognosis, in this disease, is always bad; unless it be a sym- 
pathetic affection. If hysteria be present, or if the disease have been produced by 
a narcotic, the prognosis will not be so unfavourable; for the narcotic will frequently 
be got the better of. In such circumstances, the prognosis is very various. If, 
however, the disease be what is called "traumatic" (arising from a wound),*' or if 
it be occasioned by worms in the intestines, k\v persons recover from it. But 
every description of tetanus, whatever be the cause from which it occurs, admits of 
recovery. Dr. Parry says, on the subject of prognosis, that if the pulse be not 
above 100, or 110, up to the fourtli or fifth day, patients almost always recover; 
but that if the pulse be quicker early, the disease almost always proves fatal; and 
that there have been but very few recoveries, when the pulse has been 100 the first 
day. There is less danger in proportion to the length of time which the disease 
lasts. If we are called to a case which has lasted some time, our prognosis may 
be favourable. 



SECTION IV.— TREATMENT. 

Bleeding. — If the wound be inflamed, or if there be any internal inflammation, 
or if there be fulness of the system, undoubtedly we should bleed. It is said, that 
enteritis sometimes exists in the disease; but I have not seen it. We are not to 
imagine, that because the blood flows freely, the patient must be benefited by 
blood-letting; because, while there is such violent action of the voluntary muscles, 
the effect must be the same as that which we every day procure in common vene- 
section, by making a person contract his hands, so that the muscles may press on 
the internal veins. When all the muscles are in a slate of violent spasm, as in 

> See Page G38. b See Page 235. « See Pages 631 and 632. 



634 TETANUS. 

tetanus, we may expert that the circulation will be irregular; — that a great quantity 
of blood will be forced to the superficial veins; and consequendy that the blood will 
flow freely; and bleeding is not at all useful, unless the wound is inflamed, or there 
is some decided internal inflammation, or the patient is clearly in a state of plethora. 
Purgatives. — Purgatives are often useful; especially in the case of children, 
when they are labouring under " trismus nascentium."* I believe there is benefit, 
in general, from clearing out the intestines well; and some cases have done well 
under the use of purgatives in adults, where there has been some irritation in the 
intestines (worms, or something else) producing the disease. In general, both 
bleeding and purging do good; but, at any rate, it is always right to clear out the 
bowels. Among purgatives, I think the oil of turpentine is one of the best. It 
clears the bowels thoroughly; and, in cases o{ hysterical locked-jaw, 1 have seen it 
produce an instantaneous effect. Cases are on record (and I have seen several 
instances myself) where, in trismus of a hysterical nature, the jaw opened the 
moment an injection of oil of turpentine was passed up; and in other cases I have 
seen it open a few hours afterwards. If two or three ounces of this medicine can- 
not be got down by the mouth, (and it is of no use to give less,) we may exhibit 
three ounces (diffused in gruel) by the rectum. Should this not answer, a large 
dose of calomel should be given. If the pills cannot be swallowed, we may place 
the calomel in the mouth. Mercury to ptyalism has been said by some to do good. 
Narcotics. — Opium and other narcotics have been tried in this disease; but the 
agency of all remedies is greatly resisted, and therefore very large doses of 
narcotics are borne. Haifa pint of laudanum has been given without doing injury. 
Dr. Morrison, a gentleman who has practised in the West Indies, says he has 
been in the habit of treating these cases there; and that it is very common to give 
one hundred drops of laudanum, as a starting dose; and to follow it up every two 
liours; — increasing each dose by one-third of the preceding one. He also allows 
the patient wine and ardent spirits; employs the warm bath; and exhibits mercury 
to ptyalism; — -paying due regard to the bowels; and he states, that the result of 
this practice was the recovery of more than one-half of his cases, although the 
tetanus was of a traumatic character. However, we have all seen opium exhibited 
in a large quantity, even to stupefaction, without doing any good. Prussic acid 
appears to have failed entirely in this disease. It has been frequenfly and freely 
given; but it has failed; and so likewise has belladonna. Some cases appear to 
have done well, by means of an injection of tobacco. It appears to have relaxed the 
spasm, and cured the disease. Dr. Latham (Senior) praises opium and ipecacu- 
anha; which, he says, produced copious sweating. He states, that the success 
from a combination of these remedies, has been very great. 

Warm and Cold Bath. — The warm bath appears to have done no good, and 
sometimes to have been really injurious, while, on the other hand, the cold bath 
and cold affusion have relaxed the spasm; but have sometimes killed the patient at 
once, as if he had been shot. I presume, if the cold bath or cold affusion be em- 
ployed, it ought to be at the moment that the violent spasm is on. I know of an 
instance where a patient was taken out of bed, in a hospital;'' put on a chair; placed 
in a tub in the middle of the wan!; and a pail or two of water dashed upon him. 
He fell down dead, as if he were shot; — never spoke again: and all the other 
patients were very much shocked. Yet there are cases in which that very remedy 
appears to have cured the disease. There are many cases of the latter description 
on record; so that the practice, I should imagine, is justifiable; though I have no 
experience of it. The error, if there be error, consists in the cold water not being 
thrown on the patient when he is at the very worst. The moment we find a 
catching of the breath, from violent spasm, I would dash on the water; for I think 
its agency, in that case, would not be sufliciently severe to produce danger. But 
Sir James M'Grigor says, from the result of very extensive trials of the cold bath, 
in the Peninsular war, that it was worse than useless." 

» See Pages 631 and 632. " St. Thomas. 

* See Note (b) to Page 635. 



TETANUS. 635 

Blisters, — Blistering along the spine may be serviceable; but it is often found 
useless, and is unquestionably a very cruel remedy. 

Result of Sir J. M' Grigor' s Experience. — Sir James M'Grigor says, as the 
result of his experience in the army, that all remedies (except one that I do not see 
spoken of, — iron) have been fully tried in some hundreds of case^^; and that ihere 
is little or no dependence to be placed upon them. I have. looked over the list he 
has furnished; and, upon my word, there is almost every tiling mentioned th. t ever 
was used in medicine. Sir James M'Grigor says, that the mode of treatment is 
certainly still to be discovered;" and that, as there is no analogy to guide us, there 
is little hope that any remedy will ever be found out." Recovery has taken place 
under all means of treatment; and recovery has taken place under no means. 

Iron. — It struck me, from seeing the benefit that iron produced in St. Vitus's 
dance, that as this is a similar disease, altiiough infinitely more severe, (charac- 
terized, not by a slight catching of the muscles, but by violent spasm,) that iron 
might still have the same effect. I saw clearly that, in the exhibition of narcotics, 
we were on a wrong scent; because we may give opium till the patient is stupid, 
and yet the disease generally proves fatal; — at least, in this country. In these 
circumstances, I determined that, if ever a case came under my care, I would give 
iron a fair trial. 

Case. — At length a case did occur; this remedy was fairly exhibited; and the 
man recovered. The case was one of traumatic tetanus, arising from compound 
dislocation of the great toe. It was a well-characterized case; and several persons 
went to look at it. The sesquioxide of iron was made into an electuary, with 
double its weight of treacle; and each dose was mixed with a quantity of beef-tea, 
and stirred up well, as it was going into the patient's mouth. It was given every 
two hours. He took it ad libitum; and recovered. 

Case. — It was not long before I had another case. It arose from a contusion of 
the thumb; and was the case in which I stated the nail was separated.'' This was 
as severe a case, not terminating fatally, as ever I saw. It was a frightful case; 
and, in this patient, the sesquioxide of iron was administered in still greater quantity. 
There was no limit fixed; and it was found that he had taken two pounds in a day! 
His bowels were carefully attended to; and an injection was given three times a 
day. The iron came away in large lumps; — very similar to the balls of faeces 
which come from a horse; and they were perfectly red. However, the man in two 
days was decidedly better; and he repeatedly came, after his recovery, to thank 
me for what had been done for him. 

Case. — A third case came under my care, some years ago: and occurred in a 
boy who had had a chilblain on his heel, or a little higher up. He was brought 
to the Hospital,*^ in a most frightful state: and the disease was so violent, that I 
had no hope of doing him good; — fearing that he would die, before the remedy 
could be brought into operation upon his body. It was prescribed for him; but he 
died before twenty-four hours had elapsed. Iron is a medicine that will not pro- 
duce an immediate effect. To produce its efiect upon the system, it must be given 
for a few days. This patient died in a violent paroxysm. I saw him in the after- 
noon, about one or two o'clock; and he died early the next day;- — so that it was 
not a case in which the remedy could exert its influence. It is not a remedial 
agent which produces an instantaneous effect, like bleeding. In St. Vitus's dance, 
it is sometimes months before it produces its elTect; and so it is in tic douloureux, 
and also when given as a tonic. 

Whether the two first of these were cases cured by the iron, I will not pretend 

« " Medico-Chirurgical Transactions;" Volume 6; Page 459. 

^ "Sketch of the Medical History of the British Armies in the Peninsula of Spain and 
Portugal, during the late Campaigns. By Sir James M'Grigor, M. D.'" Read at the Medi- 
cal and Chirurgical Society of London, June 20, 1815; and published in the Sixth Volume 
of its " Transactions;" Page 381. The department of the paper allotted to TetanuSj ex- 
tends from Paffe 449 to Page 463. 

c See Page G31. <i St. Thomas's, 



636 



TETANUS. 



lo say; I dare not assert that they were. I employed it from the analogy of the 
affection to St. Vitiis's dance; both cases were traumatic; and the patients did 
well, — not by lingerinu^ out; for in two or three days they began to mend; and 
were well speedily. There is a probability^ but no certainty, that the disease 
was cured by iron. The cases, however, are interesting; as they make it an object 
to give iron a fair trial, in any other cases that may occur. I have had but three 
cases of tetanus, from the time that I determined to give this medicine a trial. In 
two of these it appeared to succeed; in the third there was no time for the fair 
exhibition of it. 

I was mentioning the circumstance to a gentleman, whom I had met in consulta- 
tion some few months ago, and who had practised in the West Indies; and he 
informed me that, in consequence of the publication of those cases in the " Medico- 
Chirurffical Transactions,"* he had used it in the West Indies; and I think he 
said eioht cases recovered out of ten; and in the two cases which did not recover, 
the symptoms vt'ere so severe, and the jaw so thoroughly closed, that it was im- 
possible to get the iron, or any thing else, down the throat. 

Constant Refrigeration. — There is a case mentioned by Sir James McGrigor, 
in the sixth volume of the " Medico-Chirurgical Transactions;"^ and also in his 
reports (which are very interesting) of the diseases of the army in the Peninsular 
war. It proceeded from a slight wound in the finger. The patient (a soldier, of 
course) was carried in a bullock-car after the battalion to which he belonged, in a 
severe state of tetanus, in the midst of pouring rain; which completely drenched 
him in the early part of the day; — the iieat being 52 degrees; and then they 
ascended the highest mountain in Gallicia, the snow on the summit of which was 
knee-deep; and there the temperature was only 30 degrees. He was exposed in 
this condition, from six o'clock in the morning till ten o'clock at night; and arrived 
at his journey's end, half starved from cold, but perfectly cured of his tetanus. 
Whether such a mode would succeed, if it were put into practice intentionally, I do 
not know. I stumbled on a similar case, published in 1827. A horse which was 
in a state of tetanus, happened to be in a wet park, and was drenched with rain; — 
precisely as was the case with this unfortunate man; and the horse also did per- 
fectly well. Whether the depressing power of cold and wet, regularly kept up 
for a certain number of hours, has a tendency to cure the disease, I do not say; 
but I think that, in a disease of violent excitement as this is, the constant, — not 
sudden, but constant refrigeration (by means of a low temperature, united with 
moisture,) is likely to be of great service. There are at least two such cases on 
record; and it is surprising to find a soldier, so exposed from morning to evening, 
recover; and especially in so short a time as one day. 

Whirling Machine. — For the purpose of lessening the spasms, some have pro- 
posed a whirling machine; so as to make the patient giddy, and powerless; but I 
do not know that it was ever attended with success. 

Amputation. — If there be a wound, the removal of the part is perfectly useless. 
I had a case of tetanus, some years ago, in which an operation was proposed; — in 
consequence of the disease having arisen from a compound fracture of the leg. 
The extremity was cut off, but the patient was no better; and now it is with me, 
and I believe most others, an established rule not to remove the wounded part. 
After a long search for cases, in scores of journals and medical books, I have been 
able to find only one instance, where the removal of the part appeared to be attended 
with the removal of the disease. Instances are so rare, that (I believe) amputation 
of a part is never thought of at the present day. 

Division of the Nerves. — [Whenever the symptoms appear a short lime after 
the reception of a wound, and there can be no doubt that the wound is the exciting 
cause of the disease, all nervous communication between it and the spinal marrow 
should be cut off as soon as possible. It is a singular fact, that this practice, — 
which our knowledge of pathology and physiology shows to be necessary, and 



» Volunjo 15; Page 161. 



Page 449. 



HYDROPHOBIA. 637 

likely to be successful, — has only (as far as medical records go) been performed 
four or five times, but in all these wiih perfect success. In a case related by Dr. 
Murray,* occasioned by a wound in the left foot, the posterior tibial nerve was 
divided; and although the patient could not articulate distinctly before, from the 
closure of the jaws, he immediately opened his mouth with an exclamation, and 
expressed himself as being benefited-. He rapidly recovered.''] 

Protect the Tongue. — In treating the disease, whatever remedies we employ, 
it is risjht to introduce a cork (or something of that kind) into the mouth, to save 
the tongue; or the latter will be dreadfully bitten. This should always be care- 
fully attended to. 

Support the Patient, in the Chronic /brm.— When the disease runs on, and 
becomes chronic, it is necessary to support the patient well. By doing this, we 
give him a greater chance of recovery. Dr. Currie, who wrote on Cold Affusion, 
has given" an account of a man labouring under tetanus so chronic, as to last forty- 
two days; and who in this time drank one hundred and ten bottles of port (so that 
he got something by his tetanus); and yet not the least approach to intoxication 
occurred; and he recovered perfectly. Certainly one hundred and ten botdes of 
port, in forty-two days, was very good allowance; and, I should think, made him 
pass his time pleasantly. There is also, in the same paper, an account of a horse 
labouring under tetanus; which, during the disease, drank as much port wine as he 
was worth. I do not know his value; but his owner was so fond of him, that he 
allowed him port wine; and he recovered, after drinking as much as his original 
cost. In the chronic form of the disease, therefore, we ought to support the patient 
as well as possible; and wine is highly serviceable. 



CHAPTER XIII. 

HYDROPHOBIA. 

SECTION I.— SYMPTOMS AND PROGRESS. 

Dysphagia. — I now proceed to another disease, bearing a certain resemblance 
in some of its symptoms to tetanus, of which we have jusi spoken; — I mean 
hydrophobia (i;5co^, ivater; and q)o,3fio, to fear); — so named because it is imagined 
there is a fear to plunge into, to swallow, or even to look at water. But although 
the disease has its name from a dread of water, yet this dread of swallowing water, 
as well as other things, is seen in certain common nervous and other affections. 
People will take an antipathy to all liquids; and sometimes, in common sore-throat, 
there is such a spasmodic disposition in the throat, that the attempt to swallow 
excites great irritation; and the recollection of it excites fear at the very sight of 
water; while the attempt to drink it is terrific. On the other hand, the fear of 
water, — the fear of swallowing, is not universal in hydrophobia. Persons some- 
times swallow very well in hydrophobia, and put their hands into cold water;'' dogs 
will swim across a stream; and some persons, it is said, drink quite well to the very 
last. I believe I have seen this occurrence myself. 

In many cases of this disease, there is as great difficulty in swallowing solids as 
liquids; an instance of which is published by Dr. Marcet, in the first volume of 

a " Transactions of the Medical and Physical Society of Calcutta.'" 

* "Library of Medicine;"' Volume 2; Page 242. 

c In a paper published in the " Trausaciious of the London Medical Society." 

d See Pages G38, 639, and G40. 



&38 HYDROPHOBIA. 

the " Medico-Chirurgical Transactions."* Still, in this disease, it must be allowed 
that it is most usual for a person to have a fear of swallowing, touching, seeing, or 
hearing the sound of liquids. Some years ago, there was a patient in St. Thomas's 
Hospital, labouring under this disease; and the circumstance of one of the dressers 
who sat up with him making water within his hearing, threw the boy into a violent 
agitation. But the dread of drinking, and of touching water, is only a symptom; 
and there can be no doubt that even though it never happened, death would equally 
occur. 

Extreme Sensibility of the Surface. — The real ch^iracter of the disease, is to 
be taken from the circumstance of the extreme sensibility of the surface of the 
body, and the extreme sensibility of the nerves of deglutition and respiration; so 
that any attempt at swallowing, the application of cold air to the surface, the 
application to the surface of a drop of fluid, whether warm or cold, if made sud- 
denly (as by sprinkling); — even the circumstance of an insect crawling on the face 
or hands, or the slightest agitation of the bed-clothes; any of these things will 
produce a catching of the breath, — a sudden inspiration; — just such as we experi- 
ence when we step into a cold-bath. The diaphragm descends; — ^just as if cold 
water were thrown upon us, or the wind blew suddenly upon us. Contemporane- 
ously with the descent of the diaphragm, tliere is a violent spasm about the larynx 
and pharynx; so that swallowing is impossible, and so likewise is breathing. The 
diaphragm will descend; but a spasm of the glottis occurs, and the air will not go 
down. The glottis will relax again, and a number of successive closures take 
place; and, at the same moment, from the fear of being choked, there is extreme 
anguish, and extreme terror. 

Intolerance of Noise and Light. — Even noise and light will produce this. Not 
merely the circumstance of cold air blowing on the patient, but the mere draught 
occasioned by a pocket-handkerchief, or by waving the hand, — so as to cause the 
air to come with full force against him, — may produce this violent spasm; and not 
only so, but the mere reflection of a looking-glass will have the same effect. If a 
looking-glass be allowed to play before the eyes, or if a loud noise be suddenly 
made, this descent of the diaphragm, and this closure of the glottis, immediately 
take place. Bright colours will have the same effect as the use of a looking-glass; 
— at least when the disease has become very severe; nay, at length, — from the re- 
collection of what has been suffered,— the very mention of swallowing will produce 
extreme agitation. 

Every muscular effort, of whatever kind, has the same tendency; and if the 
patient be compelled to make an effort to swallow, when he really cannot, it will 
throw him, not only into agitation, but into absolute convulsions. There is extreme 
anxiety of mind and despondency; and the patient looks around him, with an eye 
of suspicion. He has a great aversion to strangers; and the countenance is expres- 
sive of his anxiety and distress. We notice, in this disease, very frequent sighing. 
Breathing is not carried on in a regular uniform manner, but is altered. The 
patient is extremely restless; tosses about his hands; rolls his eyes; and whatever 
he attempts to do, he overdoes. Such is his agitation, that if he attempt to rise, 
he makes more effort than is necessary; or if he attempt to lake any thing into his 
hand, or to swallow, he dashes the cup to his mouth, and gets it all down at once. 

Irritability of Mind and Body. — There is also such extreme irritability, both 
of body and mind, that violent fits of passion are induced; and these are more 
particularly observed, on a proposition being made to swallow; and, in their fury, 
patients will sometimes bile. Not that they will bite like a mad dog; but the tem- 
per is so irritable, in this disease, that they will bite a stranger. This I have seen 
myself; but I believe it depends, very much, upon the natural temper of the indi- 

" P.ige 132. The following extracts illustrate the fact menlioned above: — " He swallowed 
his bolus before us with great determination, though not without much pain and difficulty." 
(^Page 141.) "He look his bolus before us, with great-self-command; but, in the act of 
swallowing, he had a convulsive paroxysm, very much resembling those which occur ia 
tetanus;— his body being drawn backwards, with great violence." (Page 145.) 



HYDROPHOBIA. 639 

vidua!. The mind is often so strong, in the midst of all this, that at the moment 
they have attempted to bile or strike, they will apologize, instantly regret it, and 
endeavour to make all the amends they can. They are conscious of their morbid 
irritability; and they beg others to get out of the way, lest they should injure them. 
They will make very great efforts to swallow, in order to please bystanders; but, 
for the most part, after declaring they will swallow, or after taking up the cup into 
their hands, as soon as they have got it near their moulh, they turn their heads 
away, and declare it is impossible. Sometimes, again, they have more firmness of 
mind. They will open their mouths; put the liquid into it; and then a regular 
paroxysm of the disease will occur. They are seen sometimes so to command 
themselves, that they will not only drink, but even wash their hands. 1 had under 
my care a patient, who (to please me) washed his hands, stirred the water about, 
and played with it. 

Symptoms in the Latter Stage. — Those paroxysms which I have mentioned as 
coming on in the disease, sometimes take place without any external excitement. 
When the disease has become more violent, these paroxysms occur, from time to 
time, without any external circumstance having occurred to provoke them. There 
is, for the most part, sleeplessness; or, if the patient do drop asleep, he wakes in 
great agitation, and is sometimes delirious. The delirium, when it does occur, is 
generally of a peculiar nature; and the patient will talk violently of the past, as 
though it were present; and yet, in a moment, he will become calm and perfectly 
rational. At last, however, there is sometimes complete delirium. The eyes, to- 
wards the close, do not roll; but become red and glassy. The pupils are dilated; 
and the mouth is very clammy. There is extreme thirst; and, from the clammy 
nature of the secretion, the patient suffers as much as if his mouth were dry. It 
very frequently makes the sufferers cry out for something to relieve their thirst; 
and yet, when fluid is brought, for the most part they cannot take it. From the 
clamminess of the mouth, they are continually hawking, and scraping their tongue 
against their teeth; and, in the midst of their rage, they will spit at those about 
them. They will sometimes put their fingers into their mouth, and pull out a very 
viscid secretion. The pulse is very rapid and irregular; and during their agitation 
it is particularly so. It is for the most part feeble at last; but it is constantly quick, 
even when respiration is slow. Patients generally, at last, sink very rapidly. We 
are surprised, on our visit, t# find them dead. 

Duration. — The duration of this affection may be from rather less than 
twenty-four hours, to six or seven days; but the patient generally dies in two 
or three days; or, at the utmost, on the fourth day from the first appearance 
of the true signs of hydrophobia; — the dread, the difficulty of swallowing, and 
the extreme sensibility of the surface. I had two patients with this disease; — . 
little girls; who died in less than twenty-four hours from the symptoms beino- 
first observed. In two American cases which I have read, (one occurring in a 
subject under four years of age, and the other in a .person aged seventy-three,) 
both patients died on the sixth or seventh day; — showing that the duration of 
tlie disease has not any relation to the age of the patient. I might have imagined, 
from having had two patients, under ten years of age, die in less than twenty-four 
hours, that the young die soonest; but here is a case of a child and an old man, 
both of whom lingered the same length of time; and I have found this verified in 
otiier cases. Old persons will sometimes die very quickly; and young ones will 
sometimes live as long as 1 have staled. This is the general character of tiie 
disease. 

Order in which the Symptoms Appear. — The first symptoms in hy(!roj)hobia 
are uneasiness or feverishness, a general feeling of indisposition, and a dizziness in 
tlie head; together with chilliness and flushes; and these symptoms may continue 
some days. Dr. Parry furnishes instances, where these symptoms lasted five or 
six days; and I believe they may go off entirely; — just as other specific diseases 
(diseases from morbid poison) are seen to do. We all know, in tlie case of gonor- 
rhoea, that a person will have every trait of the affection one morning, or one eve- 
ning, and it will entirely go away; although he knows he has been where he was 



640 ' HYDROPHOBIA. 

very likely to contract the disease. Continued fever will thus go off; so I believe 
will the plague; and ague certainly will do so. A person who has been exposed 
to nrialaria, will have a mere shivering; which will go away and not return. I 
believe it is just the same in hydrophobia. I saw two little girls (sisters) who 
were bitten by a dog at the same moment, and in the same place, — -the face. One 
of them died; and the sister had exactly the symptoms I have described,* as usher- 
ing in hydrophobia; but, after lasting four or five days, they ceased; and she did 
perfectly well. 

After these symptoms have continued some little time, perhaps a couple of days, 
suddenly the person is surprised by a difficulty in swallowing liquids; and finds a 
spasm of the throat, and an impossibility of swallowing. At the same moment, 
perhaps, he has great anxiety and great terror; or perhaps a draft of wind suddenly 
blows upon him; his breath catches; and he wonders (as do also those around Iiim) 
what is the matter. That was the case in a boy whom I once saw. The first 
symptom of his disease, was induced by a draught from a door. A person went 
into his bed-room, in the morning; and, on opening the door, the draught occa- 
sioned by it came full upon him; and he was observed to go almost into fits. The 
sudden impression of the air took away his breath; and agitated him to this violent 
degree. 

Sometimes Remittent. — In the course of the disease, there is sometimes a re- 
mission. The disease does not necessarily go on in an uniform tenor. In a case 
published by Dr. Satterley, one of the physicians to the Middlesex hospital, the 
patient had fits of biting; and between these he was perfectly well; — even took 
warm fluids, and had a sound sleep. The disease is not so continuous but that, in 
some persons, there will be a decided remission; so that the patient can absolutely 
swallow liquids very well, and will go into a quiet and sound sleep. Some say 
(but one can hardly believe it) that there are absolute intermissions; that the dis- 
ease altogether, — every symptom of it, — will sometimes cease for a time; and will 
even become periodical! There are cases of remission and recovery mentioned, 
as having occurred in dogs; but it is doubtful whether recovery ever took place in 
the human subject. 

Peculiar Symptoms. — Now and then peculiar symptoms arise; — such as are 
not observed in ordinary cases. One case of this kind occurred at Guy's Hospi- 
tal; the particulars of which were published by Dr. J^Iarcet, in the first volume of 
the " Medico-Chirurgical Transactions.""' From some disturbance of the brain, 
or of the olfactory nerves, the patient complained of an intolerable stench around 
him." This is sometimes observed in ague. In some cases, (from irritation, I 
presume, in another part of the nervous system,) there has been an erection of the 
penis; and an oozing from the mouth of the urethra. These are all accidental 
circumstances. 

Dysphagia not aliuays Present. — Sometimes, in this disease, there is no inabi- 
lity to swallow either liquids or solids. There is a mere tremor; — a mere agitation; 
and that not very considerable; together with great debility, rapid pulse, and 
extreme restlessness. This has been said to occur, chiefly, when a cat has in- 
flicted the bite. Dr. Fothergill mentions this circumstance, in the fifth volume of 
the "Medical Observations and Enquiries;" but it is not universal; for I saw a 
man who had been bitten by a mad cat, and who swallowed perfectly well. I saw 
him eat a basin (holding a pint) full of bread and milk, an hour or two before he 
died. All his symptoms were rapid pulse, extreme restlessness, and great agita- 
tion. He thought nothing about the cat; — his mind seemed at ease on that subject; 
and he sat up, if desired. During the whole of the case, there was no delirium 
whatever. The man died, I believe, on the second day after the commencement of 
the symptoms; and a short time after I saw him. He was not my patient; but I 
saw him in the wards of the hospital."^ He had been bitten six weeks before; but 

* See Page 639. " See Note (a) to Page 638. 

« " Medico-Chirurgical Transactions;" Volume 1; Page 152. 
d St. Thomas's. 



HYDROPHOBIA. 641 

had forgotten it; — the friends alone remembering- the circumstance. A case is 
published by Dr. A. T. Thomson, in the " Medico-Chirurgical Transactions;'* 
where hydrophobia, well formed in every respect, arose from the bite of a cat.'' 

All Ages liable to the Disease, — This is a disease which affects children as 
well as adults. We seldom hear of women labouring under it; but children of 
both sexes, and men more frequently than either, become its victims. I have 
already cited two cases, from the American Philosophical Transactions, where the 
disease occurred in patients, one of whom was a child four years of age, and the 
other a man who had attained his seventy-third year;" so that we have here the ex- 
tremes of life. Infants may not be exposed to a rabid animal; and the reason it 
attacks men more than females, is because the former are so much more out of 
doors than the latter. Dr. Parry mentions a child, only three years and a half old, 
having the disease. 



SECTION II.— PATHOLOGY AND CAUSES. 

Morbid Appearances. — Aifter death, there is sometimes found a fulness of the 
vessels of the head; and sometimes marks of decided inflammation, not only in the 
head, but within the spine. Sometimes there is an effusion of serum, either pale 
or bloody; and sometimes lymph has been found effused, particularly about the 
base of the brain. In the case of an old man who died without suspecting the 
nature of his affection, and the particulars of which are contained in the " Medical 
Gazette,"" there was inflammation of the whole of the base of the brain, of the 
spinal cord, the cerebellum, the " cruri cerebri," and the two " thalami nervorum 
opticorum;" and the "corpora striata" were redder than natural. This was an 
inflammatory case of hydrophobia; but in other cases no such thing has been dis- 
covered. I have seen patients opened, where there was no effusion, or redness, or 
any thing that would lead the best anatomist to say, that the brain and spinal mar- 
row were not perfectly healthy; — just as is the case in tetanus. 

Sometimes red spots are found in the fauces, larynx, trachea, and bronchia; and 
likewise in the stom.ach. In a great number of cases, there is considerable redness 
of the glottis and epiglottis; and great congestion of the lungs. The latter circum- 
stance would be expected, a. priori; in consequence of the difficulty of breathing, 
and the spasm which takes place and disturbs their functions. Sometimes, how- 
ever, nothing has been found from head to foot; and Magendie says, that sometimes 
he has opened dogs and found nothing. I mentioned, that red spots are sometimes 
found in the stomach; but sometimes there are none at all. It appears, therefore, 
that the disease (like tetanus'^) is not necessarily of an inflammatory nature. Now 

a Volume 13; Page 298. " See Page 639. 

•^ Volume 3; Pages 123 and 124; No. 56; December 27, 1828. The morbid appearances, 
as there detailed, were the following: — "On opening the chest, the heart was observed to be 
free from disease, with rather more water in the pericardium than natural; the lungs were 
completely gorged with grumous blood, and the pleura adhered on the right side. On re- 
moving the cranium (which was remarkably thin), and cutting the substance of the brain, 
numerous red spots presented themselves in the medullary portion; there was about a table- 
spoonful of water in each ventricle; the plexus choroides was turgid; the corpora striata, 
thalami, and basis of the brain were everywhere preternaturally injected; and the cerebel- 
lum, and crura cerebri and cerebelli, in a high state of inflammation. On removing the 
spinous process of the vertebra, the whole cord was considerably inflamed; and opposite 
the two last cervical and dorsal vertebrae, the cellular substance was studded wiih dark 
patches of coagulated blood, the theca vertebralis thickened, and the cord in an active state 
of inflammation. The larynx and pharynx bore not the slightest vestige of disease. The 
preparation of the cord is deposited in the Museum of the London University. The post- 
mortem examination of this case, tends to prove the correctness of Professor Thomson's 
theory of the proximate cause and seat of this afflicting malady, and the plate accom- 
panying a case recorded by him in the thirteenth volume of the 'Medico-Chirurgical 
Transactions' [Page 298], gives a faithful delineation of the state in which the spmal cord 
was found in this case."— For the previous history of this case, see Note to Page 644. ^ 

1 See Page 630. 
VOL. I. — 41 



642 



HYDROPHOBIA. 



and then signs of inflammation may be found; but in many cases they are not; and 
'it is clear, that the nature of the disease is not essentially inflammatory. 

JSature of Hydrophobia. — Some gentlemen, from observing redness and con- 
gestion about the air-passages, and others from observing similar ap[)earances in 
the alimentary canal, have ascribed hydrophobia to a morbid state of these parts; 
but I think the extreme sensibility of the surface of the body, the extreme agitation 
on attempting any muscular effort, the convulsive movements that take place in 
swallowing, the spasmodic catching of the breath, — even on touching the lips with 
liquid, or the application of cold air to the surface, — the anguish and irritability of 
the mind (anguish not arising from pain), the great suspicion, and at last delirium, 
all show something more than an affection of the lungs or stomach. Such symp- 
toms as these indicate an aflfection of the nervous system. In tetanus there is no 
morbid irritability either of body or of mind.* There is only a spasm of the volun- 
tary muscles; and this, in all probability, arises from an affection of the origin (or 
termination) of the nerves, in the head or the spinal marrow. Such a state, I said, is 
not necessarily inflammatory; though occasionally inflammatory signs are found.'* 
But in hydrophobia there is no irritation of the voluntary muscles in general; but 
a morbid sensibility of the nerves of sense; — particularly those of touch, and of 
those running to the muscles of deglutition and respiration. In addition to this, 
the mind is altogether in a state of suspicion and irritability; — showing that it is 
the centre of the nervous system, that is particularly aff'ected. What it is exactly, 
it is impossible for me to say; but so far we may trace it. One cannot attribute it 
to the nerves; or to that part of the brain connected with the nerves of deglutition and 
respiration; because we see extreme suspicion of mind, — extreme mental anguish; 
and we see that many parts of the nervous system are aflTected.*" 

The blood, in this disease, is not buffed; neither is the urine high-coloured. On 
the contrary, it is pale. The tongue is perfectly clean; but the mouth is clammy, 
and is filled with viscid mucus. The pulse is not full. It is not at all an inflam- 
matory pulse; but it is, nevertheless, rapid and irregular; — frequently very much 
so. I may mention, that many persons have not found any inflammation what- 
ever; but there have been cases where local inflammation has existed, particularly at 
the base of the brain. The thirst in the disease does not arise from an inflammatory 
state, or from feverishness; but is either a part of the disease, arising from the dis- 
turbance of the nerves, or from the clammy secretion of the mouth. When all the 
parts of the mouth are dry, or are covered with only a viscid secretion, and not 
moistened by a thin fluid, thirst is the necessary consequence. There is, in gene- 
ral, only morbid heat from time to time, when the patient is particularly excited. 
I will not pretend to say what the state of the nervous system is; — any more than 
in tetanus.* We may limit the disease to the nervous system; particularly to the 
nerves of touch, and the nerves running to the muscles of deglutition and respira- 
tion; together with general excitement of the brain itself; but what the particular 
state is, it is impossible to say. 

7s it Contagious ? — When speaking of contagion in general, I mentioned that 
the contagiousness of this disease had been denied.'* There was a surgeon, (I 
think at Brighton, though I have not the pleasure of knowing his name,) who 
lately denied that this was a contagious disease; and, from his conviction th^it his 
opinion was correct, he inoculated himself with some of the saliva from the rabid 



» See Page G32. '' See Page 630. 

e The disease seems to begin in the pharynx, and to spread through the body. The pha- 
ryngitis is rather a co-nsequence than a cause of it. Some think it arises from turgescence of 
the spinal marrow; but that may be a consequence of the general convulsions. Rush places 
the cause in the stomach and bowels; Morgagni in the brain; and ii has also been placed in 
the bronchi; and ailribuied to an exanihemaious disease under the tongue. Some have 
maintained, that it is not a specific disease; but a variety of tetanus in men, and hysteria 
in women; but the sympioms are different from both. The patient often dies of a universal 
convulsion, or a spasm of the diaphragm or respiratory muscles, or nervous apoplexy from 
exhaustion. The organic disease appears to be the result of ihe functional.— Dr . Ficicher. 

1 See Page 304. 



HYDROPHOBIA. 643 

animal; and did so with perfect impunity. So, perhaps, he might have exposed 
himself, with impunity, to the danger of contracting sypliilis or gonorrhoea; but 
that would be no proof that tftere was no such contagion. However, unfortunalelv 
there is no novelty in this denial of contagion. Gerard also denied it; and there 
could be no other reason for denying it, than a desire to be peculiar. De Foe de- 
nied the contagion of plague; but he was soon convinced of his error. ^ I men- 
tioned that two students, at Paris, denied the contagion of syphilis; and inoculated 

* I could give several instances, within the compass of my own knowledge, where, when 
a servant had been taken sick, and the family had either time to send him out or to retire 
from the house and leave the sick person, they were preserved; whereas when, upon one 
or more sickening in a family, the house has been shut up, the whole family have perished, 
and the bearers have been obliged to go in to fetch out the dead bodies; — nbt being able to 
bring them to the door; and at last none left to do it. This put it out of the question to me, 
that the calamity was spread by infection; that is to say, by some certain steams or fumes 
(which the physicians call "effluvia"), by the breath, or by the sweat, or by the stench of 
the sores of the sick persons, or some other way, perhaps beyond even the reach of the phy- 
sicians themselves; which effluvia affected the sound, who came within certain distances of 
the sick; — immediately penetrating the vital parts of the said sound persons, putting their 
blood into an immediate ferment, and agitating their spirits to that degree which it was 
found they were agitated; and so those newly infected persons communicated it, in the same 
manner, to others: and this I shall give some instances of, that cannot but convince those 
who seriously consider it. And I cannot but with some wonder find some people, now the 
contagion is over, talk of its being an immediate stroke from heaven, without the agency of 
means, — having commission to strike this and that particular person, and none other; which 
I look upon with contempt, as the effect of manifest ignorance and enthusiasm: likewise the 
opinion of others, who talk of infection being carried on by the air only;— by carrying with 
it vast numbers of insects, and invisible creatures; who enter into the body with the breath, 
or even at the pores with the air; and these generate or emit most acute poisons, or poison- 
ous ova (or eggs); which mingle themselves with the blood, and so infect the body; — a dis- 
course full of learned simplicity, and manifested to be so by universal experience. I have 
so many examples fresh in my memory, to convince me of it, that I think none can resist 
their evidence; and I must be allowed to believe, that no one in this whole nation ever re- 
ceived the sickness or infection, but who received it in the ordinary way of infection from 
somebody, or the clothes, or touch, or stench of somebody, that was infected before. The 
manner of its first coming to London proves this also; — namely, by goods brought over from 
Holland, and brought thither from the Levant; the first breakinof of it out in Long Acre, 
where those goods were carried and first opened; its spreading from that house to other 
houses, by the unwary conversing with those who w^ere sick; the infecting the parish offi- 
cers who were employed about persons dead; and the like. These are known authorities 
for this great found a! ion-point; — that it went on and proceeded from person to person, and 
from house to house, and no otherwise. In the first house that was infected, there died four 
persons; a neighbour, hearing the mistress of the first house was sick, went to visit her; 
went home, and gave the distemper to her family; and died, and all her household. A 
minister called to pray with the first sick person in the second house, was said to sicken im- 
mediately and die; with several more in his house. Then the physicians began to consider; 
for they did not at first dream of a general contagion; but, being sent to inspect the bodies, 
they assured the people that it was neither more or less than the plague, with all its terrify- 
ing- particulars; and that it threatened a universal infection; — so many people having 
already conversed with the sickor distempered, and having (as might be supposed) received 
infection from them, that it would be impossible to put a stop to it. 

The people of London thought themselves so plague-free now, [when the disease began 
to decline,] that they were past all admonitions. They seemed to depend upon it, that the 
air was restored; and that the air was like a man that had had the small-pox;— not capable 
of being infected again. This revived the notion, that the infection was all in the air; — 
that there was no such thing as contagion from the sick people to the sound; and so strongly 
did this whim prevail among the people, that they all ran together promiscuously, — sick 
and well. Not the Mahometans, who — prepossessed with the principle of predestination — 
value nothing of contagion, let it be what it will, could be more obstinate than the people of 
London. They that were perfectly sound, and came out of the wholesome air (as we call 
it) into the city, made nothing of going into the same houses and chambers, nay, even into 
the same beds, with those that had the distemper upon them, and were not recovered. Some 
paid for their audacious boldness with the price of their lives. The physicians had more 
work than ever; only their patients generally recovered. There were more people infected 
and fell sick now, when there did not die above a thousand or twelve hundred a week, than 
when there died five or six thousand a week;— so entirely negligent were the people, in the 
great and dangerous case of health and infection. — "■ Joii.rnal of the Plas:uc-Ycar {\(s^b\ 
By Daniel Defoe.'' Edition pub lish:-.d in the " PuUeney Library]'' Pages 21, 66, 61, andl^; 



644 HYDROPHOBIA, 

themselves with the virus.* Both of them became affected with the disease; and 
one committed suicide. If the disease were an imaginary one, why should it 
attack children, who have never heard of it? Two little children, whom I attended 
in this disease, one a year after the other, could have had no idea of it; and they 
died, perfectly unconscious of what was the matter with them. Adults have died 
of the affection, without recollecttng that they had been bitten. The thought of 
the disease has not preyed on their spirits in the least; but they have been suddenly 
surprised by it; and it has never occurred to them what the disease was, or that 
they had formerly been bitten. Mr. Godrich (of Brompton) mentions the case of 
an old man, sixty years of age, who had been bitten and died of the disease; but 
who was unconscious of its nature to the last.'' Two cases are mentioned by Dr. 

a See Page 304. 

b On Thursday morning, November 25 [1828], I was called up, at seven o'clock, to see a 
man who (I understood) was exceedingly ill, and wailing in the surgery very impatiently 
for my arrival, I found my patient (Mr. Barham) a fine-looking old man, about sixty; la- 
bouring, at intervals of about five minutes, under strong spasmodic paroxysms, affecting the 
muscles concerned in breathing and deglutition. There was a wildness and an impatience 
depicted in his countenance, totally difierent from any thing I had ever observed in other 
spasmodic affeciions. His bowels were open, tongue clean, skin moist, pulse full, and a 
little accelerated. I took a way twenty ounces of blood, and prescribed a mixture containing 
half a drachm of laudanum for a dose every hour, until I should see him again. He walked 
home, half a mile from my house (Gloucester Road, Old Brompton); and left me ruminating 
on the possible cause of so much mischief occurring suddenly in a fine healthy subject. At 
ten, a message was sent that he was much worse, and requesting me to call as soon as pos- 
sible. He received me very tranquilly, and said he was very glad I had come to see him, 
for he was very ill. His symptoms were now more distressing than when I first saw him; 
he looked wildly and suspiciously at every one entering his apartment; and his breathing 
was accompanied by a short convulsive sobbing. On looking at his medicine, I perceived 
that he had taken none; and, on my expressing my surprise, he assured me that it was im- 
possible for him to swallow a single drop; as the attempt had been followed by violent 
spasms; and produced so much distress, that he had desisted. At this period, no one had 
the slightest idea of the origin of his malady. I poured out some medicine into a teacup; 
the very act of which produced much excitement and alarm. My first impression as to the 
true nature of his disease, arose at this period; from the circumstance of his requiring a 
teaspoon, with which he endeavoured to take .some of the medicine. The attempt produced 
much excitement and alarm; and, after two or three painful efforts at deglutition, with one 
desperate effort he swallowed a teaspoonful; threw away the spoon; and begged, unless I 
wished to destroy him, that he might have nothing more to swallow, I now left his room; 
and inquired of a bystander whether any thing particular had occurred to him within the 
last few weeks. On recollection she said — " About a month since, late at night, a strange 
dog came into the premises, and fought with his own dog. He got out of bed to separate 
them; and the strange dog bit him, in two places, on the left arm and hand; and bit a puppy, 
which died (about a fortnight afterwards) in a strange way, which was thought to be some 
kind of a fit." To ascertain if this occurrence had produced any effect on his mind, while 
again bleeding him, I said— " You have been in the wars. Sir; and had your hand and arm 
torn: how did it occur?' " O!" said he, carelessly, " that was done by a dog a long time 
since; but it healed." The circumstance was never again mentioned to him; and he died in 
total ignorance of the cause of his malady. The wounds were perfectly cicatrized; nor 
was there going on the least action indicative of recent absorption. He bore the bleeding 
pretty quietly. Forty ounces were removed; and, on cooling, presented strong marks of 
inflammation. He was ordered four minims of hydrocyanic acid, every hour, in a little 
water. 

Twelve o'clock. — With much difficulty, he has taken two doses of the acid; pulse full 
and hard, 110. Thirty ounces more blood were removed. 

Three o'clock. — Has taken two more doses; complains of a dreadful sense of suffocation, 
and implores that nothing more may be given him. Pulse full, and beating at 120 to 130. 
The acid was ordered to be continued. 

Eight o'clock. — Pulse full and hard. He has taken in all twenty-four minims of the acid; 
but so painfully distressing has the deglutition now become, that all attempts at repeating 
his medicine are discontinued. He was again bled to thirty ounces. During the bleeding, 
he looked wildly at the basin, and requested that no more might be spilt (a drop or two had 
fallen); — repeating frequently, in great agitation, as the blood was running— " Take care! 
take care!" Between two and three o'clock, next morning, my assistant (Mr. Davies) visited 
him. He found him tolerably passive, but observing every movement with intense anxiety. 
Pulse full and hard; face flushed; eyes denoting cerebral irritation. He had been at limes 
outrageous. On its being intimated that bleeding was again necessary, a paroxysm more 
intense than any preceding, came on; and with great effort he submitted. As the blood 



HYDROPHOBIA. 645 

Parry, in which the bite was forg^otten; and anotlier case in which the bite was 
spoken of with the greatest indifference. In the last case 1 had, the boy knew 
that he was bitten; but he thought nothing of it; and never seemed to attach the 
least importance to it. That there is such a disease, that its character is so pecu- 
liar, and that it unquestionably arises from a morbid poison, cannot admit of a 
moment's doubt. It is also to be remembered, that many persons who are bitten, 
and fancy they will have the disease, never have it at all. I have seen many per- 
sons bitten by dogs, wash the parts, take physic, have the parts cut out, and do all 
they could to torment themselves into the disease; and yet they have never had it. 
The character of the disease is too plain, to allow of any doubt as to its existence. 

Exciting Cause. — The exciting cause of the disease, however, is well known. 
It is a secretion from the mouth of a rabid animal. It is said to be the saliva 
which is poisonous; and it may be that fluid; but I do not knovv that it is proved 
to be the saliva, rather than the mucus. The saliva of the human subject is equally 
poisonous with that of the brute; or, at least, it is also poisonous; for Magendie 
says, that he inserted the secretion from the mouth of a rabid human being (that is 
to say, a person labouring under hydrophobia) into dogs; and they became the 
subjects of the disease. 

Dr. Hertwig says, that he inoculated fifty -nine dogs with diseased secretion from 
hydrophobic dogs; and that only fourteen took the disease. He states, that he 
made experiments with the blood; and found that it was equally poisonous with 
the secretion of the mouth. He says the saliva will act, in producing the disease, 
at all periods of the affection; and in twenty-four hours after death, if it be taken 
from the body, it will still give rise to it; but he says, that if the poison be swal- . 
lowed, it is perfectly inert. The poison of serpents, we are told, may be swal-. 
lowed with impunity. 

Period of Incubation. — After the poison has been applied, there is usually an 
interval before the appearance of the disease, of from one or two weeks, to three 
months. I believe the average interval is from one to two months. The disease 
is said to have appeared, sometimes, in five or six days; and a case was mentioned, 
in which the affection appeared to come on the next day; — at least, it was so said. 
In other cases, the disease has not appeared for nine or twelve months. There is 
a case mentioned in the " Philosophical Transactions," where the affection did not 
come on for nineteen months. Dr. Bardsley, in the " Literary and Philosophical 
Transactions of Manchester," has furnished an account of a case where the dis- 
ease did not occur till twelve years after the bite. The case has given rise to a 
great deal of doubt. In the first place, we may almost doubt whether the disease 
was genuine; but, allowing that it was, then there is a doubt whether or not it arose 
from the morbific poison. As the wound had been inflicted twelve years before, 
there is great difficulty in supposing that the poison had existed so long; and, on 
the other hand, if it was not owing to this bite, it must have sprung up de novo. 
Dr. Parry, who has written on Cases of Tetanus and Rabies Contagiosa, thinks 
the case was not genuine; and he also considers that the shortest well-authenticated 
interval, is two or three days: but I have reason to believe it has occurred at a 
shorter interval. I also think, that Dr. Parry is wrong on another point; for he 
states that he can find on record only thirty-eight well-authenticated cases of hydro- 
flowed, he became more and more alarmed; till at length he became quite unmanageable; 
he raged violently at his nephew, who was holding the basin: and ordered it, peremptorily, 
to be taken away. Thirty or forty ounces were lalcen away. It was found necessary to put 
on the strait- waistcoat. About four o'clock, Mr. Davies wished him to take more of his 
medicine. He said — " I can take no more;" and, on Mr. D.'s reaching the bottle to put out 
afew drops, he became violently agitated, threw himself from side to side; and, as well as 
the incessant spasmodic sobbings would allow, he begged that not one more drop of any 
thing might be offered him, and that the bottle might be taken from his sight. He did not 
become tranquillized until its removal. He lingered on till ten (A.M.), in the same state; a 
few minutes before which he insisted on getting up, and walked a short way down his gar- 
den; returned, lay down on his bed, and died. — '* London Medical Gazette;" Volume 3; 
Pages 123 and 1-34. {No. 56; December 27, 1828.) 



646 HYDROPHOBIA. 

phobia. Now, in my limited period of practice, I have seen six or eight cases in 
London; and, during tiie same period, there have been others which I did not see. 
Two of these cases occurred in private practice; and four or five in the hospital; and, 
having seen these myself, I must think the disease is far more frequent than Dr. 
Parry intimates. The fact was, Dr. Parry saw a great number of cases called 
*' hydrophobia," that were not instances of the disease; and he was too scrupulous 
in allowing that cases which he found recorded in books were genuine hydropho- 
bia; and therefore he put too many in the spurious list. The interval, he wever, 
is various. It is said to be about the same in the dog as in the hum^n subject. 
Among Lord Fitzwilliam's hounds, in Yorkshire, the interval varied from six weeks 
to six months. His pack were bitten by a rabid animal; and the disease appeared 
at various intervals, from six weeks to six months. 

The Poison must be inserted into a Wound. — Persons usually escape, if the 
poison be not inserted into a wound. Cselius Aurelianus mentions the case of a 
woman, who was seized with the disease three days after eating some game which 
had been sent to her; and which v/as supposed to contain hydrophobic poison, in 
consequence of having been killed by a mad dog. If the case was true, there 
was probably a crack in her lips. Dr. Bardsley mentions a case, which occurred 
(at the common interval) in a shepherd, who had only been licked by a dog. His 
dog was rabid; but then shepherds continually have cracks in their hands; and 
nothing is more likely, than that there was a crack in some part of his hand. 

Communicable by an Animal not knorvn to be Mad. — It is possible for the 
brute to give the disease to the human subject, when the animal is not known to 
be mad. Many cases have occurred of persons being bitten by dogs, and becoming 
niad, though the dog was not, till afterwards, supposed to be mad. The disease 
must have existed at the time, or the dog could not have communicated it; but it 
exhibited no signs of madness, — so as to be considered in that state. It has been 
imagined, that all bites of animals have something venomous in them; and we are 
told that many bites of brutes have caused signs of hydrophobia, epilepsy, and 
even death; but, in all piobability, these were nervous symptoms, induced by fear. 

Many are not attacked tuhen bit by a rabid Dog. — On the other hand, most 
persons bitten by rabid animals do not suffer hydrophobia. Dr. J. Hunter men- 
tions, that twenty-one persons were bitten by a dog; and among them only one 
became affected with the disease; although none of them took any steps to pre- 
vent it. Dr. Vaughan mentions, that between twenty and thirty persons were 
bitten by a mad dog. Some did nothing; others took the " Ormskirk medicine,"* 
and had a dip in the sea; and yet, of this number, only one had the disease. Dr. 
Parry mentions, that several sheep and dogs were bitten; and that, among these, 
not one sheep had the disease, and only two dogs; and I may remark, that one of 
these dogs was bitten before the sheep, and the other just afterwards. I had a 
case of this disease in a little girl, who was standing at her father's door, when a 
dog snapped at her face, and did the same at another sister; and then passed on. 
At the expiration of six weeks, or two months, the sister who was bitten second 
had hydrophobia, and died;** but the other sister never had the disease, or the pre- 
monitory symptoms went off; and she may be alive now. We might imagine, 
that the girl^rs^ bitten would have been most likely to suiTer the disease; because 
the teeth must have been covered with secretion; however, it was the second that 
died from the disease. Nothing, I understand, was done in this case; except that 
nitrate of silver was applied. 

Much depends upon whether the part is bare or not. Hence we find that, by- 
far most frequently, persons who have hydrophobia through a bite, have had the 
wound inflicted on the hands or face. In three cases that I had under my care, in 
private practice, one patient was bitten on the face, and two on the hands. If the 
part be not bare, the tooth is wipea as it passes through the clothes; and therefore 
no fluid is conveyed with the bite. It is a bite on the bare surface, that is gene- 

« See Page 650. 



HYDROPHOBIA. 647 

rally productive of the disease. Some persons have so little disposition to the 
affection, that notwithstanding they are bitten on bare parts, and no precaution is 
taken, they do not suffer the disease; and sometimes persons will not experience 
it, till they are thrown out of health; or lill tiiey are frightened; or till they catch 
cold; or till something happens to disturb the constitution, and then it appears. 
This is precisely what happens in the plague, in ague, and in other affections.* 

The Woimd generally heals before the Attack. — The wound is generally healed 
when the disease appears; and, as I stated formerly," it is sometimes entirely for- 
gotten. Some say, that if there be a wound, it becomes livid when the disease 
appears; or that it looks yellowish; and that it re-opens. Sometimes, when it 
appears, there is pain and numbness in the bitten part, extending along the course 
of the nerves. This was the case in an instance I had under my care. The boy 
had been bitten in the hand, and the part had been cut out entirely; but pain was 
felt along the nerves, and extended to the neck, at the time that the disease began. 
It was curious that there was no pain in the wound, or in the hand, or in the upper 
arm. More frequently than not, it is along the course of the nerves, and not along 
the course of the blood-vessels, that the pain has been observed. 

Various Animals liable to it. — The animal which most commonly gives the 
disease, is the dog; but other brutes will have it; and probably all of them will 
imbibe it, and also communicate it. The wolf, the fox, and the dog, are all of the 
canine species; and they are well known to give and receive it: and they appear to 
originate it likewise;— that is, there is every reason to believe it will originate in 
them; — unless the poison may remain dormant as long as some people imagine. 

Cause, when produced De Novo, — Unless it can exist in a dormant state for a 
long time, there is every probability that hydro[)hobia is produced de novo.^ The 
cause of it, if it can arise de novo, is not well known. It is not putrid meat; 
for the Caffres, in Africa, feed all their dogs on putrid flesh; neither is it salt meat; 
neither is it a want of drink. The disease is unknown in Syria;° and, according 
to Dr. Parry, in the interior of the Cape of Good Hope, where there is plenty of 
heat; and, in some instances, plenty of putrid meat.'^ It is said never to be known 
in South America; but then two-thirds of the pups there die of "the distemper;^^ 
and some persons contend, that the distemper prevents the spontaneous occurrence 
of hydrophobia. I do not know whether that is correct. 



SECTION III.— DIAGNOSIS. 

Spurious Hydrophobia. — Spurious cases of nervous fever, or nervous irritabi- 
lity, are very different from these. If the case be spurious, the difficulty in swal- 
lowing generally occurs far too early after the bite. A certain period (usually 
some weeks) elapses between the bite, and the appearance of the disease; but 
where persons have a difficulty in swallowing from mere nervous terror, it gene- 
rally begins at an early period. There is much too early delirium and general 
convulsions; the agitation of the mind arising from fear, brings on a degree of 
insanity. 

In the spurious form, again, there is generally no catching of the respiratory 
organs. The great feature of this disease is the sudden inspiration, as though the 
patient were plunged into cold water; and this produced not only by an attempt at 
swallowing, by the sight of water, and by speaking of water, but by a breath of 

» See Page 314. " See Page 645. 

« Considering ihe heat of the summer, climate, and' the thirst which the dogs [in Syria] 
then suffer, it seems strange that they are not subject to hydrophobia. Indeed, some distrust 
as to the popular ideas connected with that dreadful disease might be deduced from the fact, 
that hydrophobia is least known in the warmest climates. In Constaniinople, cases of this 
disease sometimes occur, although they are exceedingly rare; but they become increasingly 
infrequent as we advance southward, and in Egypt are altogether unknown. — '^Pictorial 
History of Palestine;" Partll. {'' Physical History;*' Chapter 8; Page Zbl.) 

d It has been attributed to the want of sexual intercourse. 



648 HYDROPHOBIA. 

cold air, or the crawling of an insect upon the surface, or by any sudden impres- 
sion. Patients who only fancy they have hydrophobia, have a difficulty of swal- 
lowing; but they forget to have a catching of the breath. They are not aware 
that that is a symptom. They only think of the difficulty of swallowing liquids; 
and therefore that symptom only arises. They are not conversant enough with 
the disease, to know another remarkable symptom; and therefore that never takes 
place; or, if it do, it is only a simple local affection, producing irritation of the 
organs of respiration. So characteristic of the true disease is this sudden but deep 
inspiration, that when a paroxysm takes place during sleep, the person always 
awakes with a sudden deep inspiration. In the true disease, patients (in order to 
please their medical attendants) will make every possible attempt to swallow. They 
will say they cannot; but then they will try.* They will make the greatest efforts, 
and succeed to a certain length, and very frequently succeed entirely; whereas, if 
a person have ihe fancied disease, he concludes it is quite impossible. He will 
not hear of such a thing; and considers it almost an insult to have it supposed that 
he can swallow. In the fancied disease, the patient has not sufficient firmness of 
mind to make the attempt; and shudders at the very sight or name of liquid; 
whereas, in the true disease, patients will not only do this, but will even put their 
hands into cold water; and, as I have already said,'' will stir it about. 

The people who fancy it, d.re not surprised by the disease; — it does not take 
them suddenly. They anticipate it; they look forward to it with a low melan- 
choly; and then, at last, they begin to find they cannot swallow; whereas, in the 
true disease, the symptoms come on suddenly. In the spurious affection, also, 
there are generally a variety of nervous symptoms; such as " globus hystericus," 
and other symptoms common to nervous derangement. There are not the usual 
effects, in the spurious disease, from the sudden impression of cold air, and the 
sprinkling of cold water. The former certainly does not produce the agitation, 
which it occasions in the true disease. It is to be remembered that the disease 
may be spurious, when a person has actually been bitten by a mad dog. He may 
have been bitten, and the poison may not have taken effect; and yet the person has 
agitation of mind, sufficient to produce difficulty of swallowing. It is probably in 
such cases, that persons have been said to recover from hydrophobia; but they have 
done so such thing. The persons have been bitten by a mad dog; and, for want 
of the practitioner being fully acquainted with the disease, he has not made a suffi- 
ciently accurate diagnosis; and has supposed that recovery has taken place from 
the disease. 

From Distemper. — Dr. Jenner, in the first volume of the " Medico-Chirurgical 
Transactions,"" lays down the diagnosis between hydrophobia and " the distem- 
per." He says, that in the latter the eye is dull; — the dog looks stupid, and has 
an insatiable desire for water. *'The distemper" is a violent kind of catarrh; and 
we may therefore imagine that the eye will look heavy, and that the animal will 
become thirsty. The dog wanders from home; and, at length, he is disposed to 
be sluggish. But in hydrophobia. Dr. Jenner says, the eye of the dog is bright. 
He looks furious; and generally declines water. When a hydrophobic dog bites, 
it sneaks off directly, and is not found again; or, if found, it is dead. It goes away 
from the place, and is frequently afterwards found dead. It only gives a sneaking 
bite, and does not continue its attack like another dog; and after it has bitten an 
individual, it skulks into a corner, and then runs off. Hence it is, that many per- 
sons who have been exposed to hydrophobia, will say they were bitten by a 
strange dog, that was perhaps passing by; — that it attacked them without any pro- 
vocation, and then made off. 

Character of the Voice. — A German physician (Dr. Hertwig) says that the 
voice of the dog, in hydrophobia, is peculiar and pathognomic. He says that the 
bark of a dog labouring under the disease, ends in a howl; and the mouth at the 
time of barking is hfted up. 

» See Page 644. ^ See Page 639. c See Pages 267 and 268. 



HYDROPHOBIA. 649 



SECTION IV.— TREATMENT. 



Excision of the Fart. — With regard to the prevention of the disease, it is cer- 
tainly our duty to cut out the bitten part as soon as possible; and, perhaps, at any 
time between the bite and the appearance of the disease. If the part cannot be cut 
out, I should think it proper to remove the whole limb. I am not sure that exci- 
sion prevents the disease; because I know, that in many cases in which this has 
been done, the disease has occurred. A perfectly authenticated case was men- 
tioned- to me, in which not a moment was lost; for the person, the instant he was 
bitten, walked across the way to a surgeon, and had the part freely cut out; but, 
notwithstanding this, at the usual time he had the disease. It is, however, but 
common sense to do every thing we possibly can to prevent it; and excision is the 
most proper plan. 

Cupping- Glasses. — Some have applied cupping-glasses; and this is a most 
ancient practice. It is mentioned by Celsus-.'' Dr. Parry also recommends it; and, 
still more recently, it has been recommended by Dr. Barry; who says that its use 
has been shown, by experiments with various mineral and vegetable poisons. If 
these poisons be applied to a wound, and the poisonous effects begin, and the cup- 
ping-glasses be applied, in proportion as they act, the influence of the poison disap- 
pears. It is therefore reconimended to us immediately to apply cupping-glasses to 
the wound; and to excite the part thoroughly; — so as, if possible, to draw out 
every particle of the diseased fluid. The stream, of course, will be towards the 
glass; and, as the fluid will be washed away, circulation and absorption will be 
prevented at the moment. Then we may cut the part out, and cup again. Whether 
it would be useful to adopt this plan, I cannot tell. If we could have a fair oppor* 
tunity to cut the part out at once, I should think that would answer every purpose. 

Caustics. — Caustics are by no means to be depended upon; but if they be used, 
they should be very strong; — such as caustic potash, or strong mineral acids; or 
(what perhaps is better than all) the actual cautery should be employed. I do not 
know (as I said before) that even excision is to be depended upon; but, after exci- 
sion, in order to make what is considered certain doubly certain, caustic might be 
employed; or the actual cautery. Some have recommended the chlorides; and it is 
very possible that they may destroy the poison; but even supposing they vi'ill, one 
cannot be sure that every particle of the poison has come into contact with a part 
of the solution of the chlorides. We are not sure that every particle has been 
decomposed; and, therefore, if the chlorides be applied, still I should cut the part 
out in the first instance, and apply them afterwards. The use of these other things, 
in addition to excision, may be very great. If the part be one that cannot be cut 
out, — if the wound be so deep that it is impossible to cut it freely out, and the re- 
moval of the part by amputation be not possible, then" use the actual cautery, or 
caustics. When the part is cut out, we are advised not to allow it to heal, but to 
keep it open; so as to produce a discharge for a length of time.^ However, I know 
of plenty of cases where this has been done; and yet the disease appeared; though, 
certainly, one would fancy it was better than mere excision. After we liave cut 
out the part, then we may apply caustic, or the actual cautery, and keep up a dis- 
charge. 

Mercury. — In the way of prevention, we are strongly recommended to give 
mercury to ptyalism. A great many cases are recorded, where the disease never 
appeared after this was had recourse to; and it is stated that, in some instances in 
"which mercury had not been employed, the disease appeared; but there are cases 
enough on record of the disease occurring, after mercury had been exhibited to the 
greatest extent. Not knowing what to do in the way of prevention, in the case of 
the sister of the little girl who died of hydrophobia" (two months having elapsed 

• Liber 5; Caput 37; Sectio 2. 

^ With this view, Dr. Fletcher recommends powdered cantharides. ' See Page 646. 



650 



HYDROPHOBIA. 



since the bite), I exhibited mercury freely. I was not content with its exhibition 
by the mouth; but she was washed with a strong sohuion of bichloride of mer- 
cury, till a rash was brought out; and then it was discontinued, lest inflammation 
should come on. In this way her mouth became tender; and she had nothing 
more than the premonitory symptoms. Whether the mercury had any effect I do 
not know; but I should think not; because I believe the symptoms went off before 
the mouth was affected. I should think there is no reliance to be placed on mer- 
cury. Dr. Good thinks, that belladonna united with the bichloride of mercury, in 
large quantity, has acted as a prophylactic in his hands. 

Scutellaria Laterifolia. — Dr. Spalding tells us, that the exhibition of '* Scutel- 
laria laterifolia" is successful; nay, that it prevented the disease in thousands of 
cases of men, dogs, oxen, and swine. 

Ormskirk Medicine. — The " Ormskirk medicine" was once held in very high 
estimation. It is said to consist of powdered chalk, Armenian bole, alum, powder 
of elecampane-root, and oil of anise. 

Sea-Bafhing, — In London, sea-dipping was formerly thought very good; so 
that when a person was bit, he took a trip to Gravesend, which is the nearest point 
where the water contains a large portion of saline ingredients/ Any thing may do 
good which will fortify the mind; and the disease may, by that means, be more or 
less opposed. 

Genista Tinctoria. — Dr. Marochetti published a pamphlet, a few years ago, in 
which he asserts that if the disease will appear, pustules form under the tongue 
after the bite; and if these pustules be abraded by a needle, and the mouth be 
washed with a decoction of "genista tinctoria" ("butcher's broom"), and it be 
taken internally, the disease is prevented. Others have, subsequently to the ap- 
pearance of this publication, made a point of attending to this circumstance; but 
they have found no pustules, even in cases where the disease came on; and, 
though the genista tinctoria was fairly tried, the disease nevertheless made its 
appearance. 

Venesection.— -Y enesecnon has been strongly recommended, on account of its 
supposed efhcacy in some Indian cases; but it is doubtful whether it is serviceable. 
It was fairly tried by Dr. Rutherford, many years ago; and also by Dr. Parry. I 
employed it in one case; and I fancy I sent the patient out of the world, some 
hours sooner than she would otherwise have gone. As the blood flowed, the pulse 
became weaker, and the disease much more intense; and the patient died in a very 
short lime. In Mr. Godrich's case, to which I have before alluded,'' the patient 
was an old man; and was bled to the amount of one hundred and fifty, or one 
hundred and sixty ounces. No relief was afforded; he became worse and worse, 
and died in twenty-seven hours from the period of the attack. Magendie and 
Dupuytren have employed venesection, and failed. M. Breschet also says, that 
the more he bled his patients, the more quickly they seemed to die. I am speak- 
ing of a rational degree of bleeding; and it certainly does harm. 

Emetics. — In some cases published by Dr. Satterley, it is said that an emetic 
proved useful. All medicines, however, have been found useful in the hands of 
some. 

Narcotics. — All narcotics — opium, belladonna, nux vomica, and prussic acid— 
liave failed. Opium injected into the veins, has seemed to give no sort of relief; 
and musk also has been given without any real benefit.'' I was told of a case 
where prussic acid was given, to a very considerable amount; and yet no benefit 
whatever arose from it. 

Chlorides. — The chlorides and muriatic acid have also failed. I should tire if I 
were to enumerate all the drugs that have been recommended in this disease, and 
have failed. Every article that ever was swallowed, in the way of physic, has 
been given without any benefit. 

» See Page 651. «> See Page 644. 

* The Tonquin remedy is musk and cinnabar; the Carnatic or Mysore Pill contains arse- 
nic'f the Eussiao remedy is waler-planiaiii.-— Z>r, Fletcher. 



HYDROPHOBIA. 651 

Guaco. — I made a fair trial of a vegetable matter (guaco), which was said io 
cure the disease to a certainty; and Dr. Roots also made a fair trial with it; and 
the patient was better. Now and then, however, there are irregularities in the 
course of the disease; and whether the improvement was ascribabie to the medi- 
cine, I cannot tell; but I should think not; for the patient died at the usual time. 
Some have recommended a whirling machine. 

Submersion. — Van Helmont used to recommend putting the patient under 
water, and keeping him there till he was nearly drowned;^ but I believe nothing 
will do good when the disease is formed; and I doubt whether much good can be 
done, even in the way of prevention. 

Transfusion of PFarm Water. — [Injection of warm water into the veins has 
been tried by Magendie; — from his having observed nervous debility produced in 
animals which had been subjected to it; and that the fluid parts of the blood were 
diminished by the impossibility of taking fluids, and the great cutaneous and pul- 
monary transpiration. A pint of water, heated to 30° (Reaumur), was injected 
into the arm of a man labouring under advanced and violent hydrophobia. Imme- 
diately after the operation, the patient became tranquil; and tlie pulse fell, in 
twenty minutes, from 150 to 80. The spasms ceased, and the individual drank a 
glass of water without difficulty. He continued to improve until the fifth day; 
when swellings and acute pains in the wrists, knees, and elbows, appeared; and 
an abscess formed in the leg; — occasioned by the broken points of two lancets, 
which remained in the foot, from former unsuccessful efrt)rts to bleed. He died on 
the ninth day. The swollen joints were found filled with pus; and, it is probable, 
these secondary purulent deposits were the cause of death. Dr. Pearson recom- 
mended the injection of small quantities of warm water, impregnated with narcotic 
substances, into the veins, — in order to relieve the spasms which prevent degluti- 
tion, followed up by cathartics, antispasmodics, the mineral and vegetable tonics, 
and sponging the body with cold water and vinegar. 

In the midst of so many remedies which have been lauded by partisans, and in 
turn found to be useless — with a knowledge that the most powerful drugs are ap- 
parently inert — overwhelmed with the sad conviction that the learning and talents 
of the most experienced and energetic physicians have utterly failed in arresting 
the progress of this dreadful malady, the practitioner, when called upon to act, must 
still respond to the awful question — "What is to be done?" It is in such a situa- 
tion only that he can experience the benefit of having studied the whole train of 
nervous diseases; of being able to detect and appreciate the analogies and dissimi- 
larities which exist between each respectively; and of having deduced from the 
whole such general principles, as will enable him to act conscientiously in every 
case, as far as the present state of the art will permit. In hydrophobia, therefore, 
as in tetanus, and several other nervous disorders, no exclusive line of treatment 
should be followed. If the patient exhibit signs of plethora, be strong, of a vigorous 
constitution, and there be symptoms of increased vascular excitement, venesection, 
cupping, or the application of leeches to the occiput or back of the neck, and anti- 
phlogistic remedies, should be actively employed; — so as to make an impression 
upon the nervous system. But if there be evidence of anaemia, and general de- 
pression of the vital powers, stimulants and tonics are indicated, and should be 
used energetically. With a view of overcoming the spasms, the tobacco enema, 
or cold affusion, may be had recourse to according to circumstances; and the same 
kind of treatment as has been recommended for acute tetanus,'' should be perse- 
vered in."] 

* He kept his patients under water, till the psalm " Miserere" [the fif>y-first; containing 
nineteen verses] was suns:; and, in one case, a poor girl was drowned.«-/?r. J^le(cker. 
«» «ee Page 633. " o u Library of Medicine;" Volume 2j Page 261. 



653 



NEURALGIA. 



CHAPTER XIV. 
NEURALGIA. 

Definition. — The disease of which I spoke last (hydrophobia), is characterized 
by morbid sensibility; and the disease of which I shall now speak, is also charac- 
terized by morbid sensibility. It is called "tic douloureux," or "neuralgia;" — vio- 
lent pain of the nerves. It is said to be called "tic douloureux" (which is a very 
odd appellation) because it resembles the sudden sharp pain arising from the bite of 
an insect; or because the horse bites the manger, when (as is supposed) he labours 
under it. The word ^'neuralgia'" is very appropriate; but the word "/?c" is one that 
I do not approve. It signifies a sudden catching or convulsive motion, — such as is 
noticed in the face or other parts of some persons; and is (as it were) a local cho- 
rea. Persons with such catchings, experience no pain; but when twitchings occur 
in neuralgia, they are attended by pain; and, therefore, to their name ^^tic^^ in this 
disease ^^ douloureux''^ was added. As the disease was first noticed and distin- 
guished on the face, — where there is an abundance of small muscles, and conse- 
quently twitchings usually attend it, — the twitchings usually attracted as much 
attention as the pain; and the disease obtained its designation from both symptoms. 

Symptoms. — The disease is marked by a violent, stabbing, plunging pain, in- 
creased (or even brought on, when it does not exist) by the slightest touch of the 
skin. When it is present, it is increased by the least touch; but very firm pressure, 
I know, will relieve it. It is increased, too, when present, by blowing on the 
skin, or by the shaking of the room; and is then exactly like an electric shock. 
Sometimes, between the shooting pains, there is constant aching; and sometimes 
the part feels painfully benumbed. I have known the neighbouring parts, which 
were not in pain, benumbed. There is generally no swelling or redness. There 
may be; but it is not essential to the complaint. Tic douloureux generally takes 
place in the course of some well known nerve; and hence the disease is now more 
appropriately called " neuralgia;" — "ner-ye-ache." Sometimes the pain does not 
follow the course of a nerve; but still we must consider it according to general 
rules. Sometimes it is not an aching of a nerve, but the whole of a part is affected 
together; so that the disease will exist in the breast, in the heart, or in the peri- 
cardium; and once I saw it in the loins; — apparently not following the course of 
any nerve, but affecting various nerves in the mass. If the nerve affected have 
small muscles in the neighbourhood, they are generally twitched; so thai, when a 
patient has the disease in the face, we see the side of the face catching every mo- 
ment. From these circumstances some have called the disease "neuralgia spas- 
modica;^^ but, I think, most improperly; because they are only incidental, and the 
severest neuralgia may occur without ihem. If the disease be dreadfully severe, as 
sometimes it is, then we have convulsions of the large muscles. 

Parts liable to it. — When it is a distinct nerve that is affected, it is (more fre- 
queutly than not) the supra-orbital, the infra-orbital, or the " pes anserinus;" and 
next to these the inferior maxillary.* When it is situated in these parts, there is a 
twitching; because the muscles of the face are small; and from the disease occur- 
ring in the neighbourhood of glands, there is commonly, in these cases, a great 
flow of tears or of saliva. Some doubt that it is ever felt in the "portio dura;" 
others declare they have known it in that nerve. A patient of mine in St. Thomas's 
Hospital, complained of it not only in the cheek, but in the course of the " portio 

a Neuralgia of the second division ("superior maxillary") of the fifth pair of nerves 
(" trigemini"), is distinguished from disease of the antrum, by its not being attended with 
fever, by its following the course of the nerve, by its warning three. of the four signs of in- 
^ammation (redness, heat, and swelling), &c.—'/?r. Fletcher, 



NEURALGIA. 653 

dura," — from the stylo-mastoid foramen. I do not see why the disease should be 
confined to nerves of sensation. Two, or even all the three branches of the fifth 
pair are sometimes affected; and the pain may extend even to the other side of the 
face. I have known it extend down the neck to the shoulder, and along the inside 
of the arm, to the ends of all the fingers and the thumb. Various nerves of the 
legs, arms, fingers, and toes, are occasionally the seat of the disease; and an inter- 
costal, a lumbar, and even the spermatic nerve has been attacked. The pain may- 
be confined to one nerve, or to it and its branches; may extend to other nerves in 
the neighbourhood, or at a distance; or may affect nerves distant from each other, 
simultaneously or successively; and change its seat backwards and forwards. The 
pain does not always shoot in the course of the nerve; but frequently in the oppo- 
site direction. It may not shoot from a nerve through all the twigs, but only- 
through some. 

Progress. — The disease comes on in paroxysms, and the pain is dreadful; so 
that, occasionally, it brings on delirium. After a time it will, in some instances, 
cease spontaneously, without our knowing why; and, in other cases, it will produce 
great emaciation, and end in insanity, or some other disease of the nervous system. 

In hysterical females, portions of the surface occasionally become exquisitely 
tender; so that the least pressure with the extremity of the finger, such as would 
not occasion pain were the peritonaeum or viscera inflamed, — even the sudden fall- 
ing of the bed-clothes upon it, causes anguish. The surface of the front of the 
body is most frequently affected, sometimes only of the abdomen, sometimes only 
of the chest; sometimes portions of the back only suffer, particularly at the spine; 
and sometimes nearly the whole surface of both the trunk and extremities. As no 
pain is felt while the part is not compressed, perhaps this condition ought not to 
be called "neuralgia." But the absence of heat, swelling, redness, and of all 
signs of internal no less than of external inflammation, and of structural affection 
and serious disease, the perfect inutility of all the remedies of inflammation, the 
power of the remedies of pure nervous affection and neuralgia, prove it to be a 
morbid sensibility of the nerves of touch, and perhaps make it merit the epithet 
neuralgic. Cases of this description are occasionally mistaken for chronic peri- 
tonitis, and other inflammatory diseases; and, when the tenderness is felt in the 
course of the spine, it is too often set down as a mark of disease of the spine or its 
ligaments, or perhaps the whole case is referred to an aflfection of that portion of 
the spinal cord; while the morbid sensibility of the spot is merely one of the num- 
ber of symptoms. I saw this tenderness in a hysterical and neuralgic middle-aged 
man who had been exposed to malaria. 

The nature of neuralgic aflfections may be evident during life, and immediately, 
or not till after a lapse of time; may become evident after death only; or may never 
be discovered. Inflammatory conditions of the nerves and structural changes, as 
well as mechanical causes of irritation, may be detected during life, if the seat of 
these conditions is within the reach of observation: and symptoms may be induced 
which clearly point out inflammation or structural change, even should these be 
beyond our observation. 

History. — This disease is said to have been well described, first of all, in 1756, 
hy a surgeon named Andre; who lived in London, and who wrote on diseases of 
tlie urethra. It is a strange place in which to look for an account of neuralo-ia. 
Dr. Fothergill wrote upon it, in the fifth volume of the " Medical Observations and 
Inquiries," published in 1776. He tells us he saw fourteen instances of it. I 
have not seen so many. He observed it oflener in women; but this greater fre- 
quency is not a general fact. He never noticed it in persons much under forty 
years of age; and this observation, I believe, is confirmed. It is rare in children; 
yet Continental writers record cases of it in subjects only seven and nine years old. 
It is a disease which (I suppose) has always existed; but, like true hydrophobia, it 
has not been well described till modern times. 

Morbid Appearances. — After death nothing morbid has been found. Sir Charles 



654 



NEURALGIA. 



Bell and Dr. Magendie both say, that they have examined neuralgic nerves, and 
found no morbid appearance; but, by the long continuance of the pain, the neu- 
rilema (the coveringof the nerve) becomes thicker. The irritation has occasionally 
produced a tumour during life. From the great thickening of the surrounding 
parts, the veins around the nerves have sometimes been found varicose. Andral, 
the most recent writer on this subject, says that in acute and chronic sciatica, 
which is a kind of neuralgia, he never but once found any alteration of the nerve; 
and, in that one case, the nerve was merely a little redder than usual; — it having 
been injected. He says, that in a woman who had constant pain at the back of the 
neck, on the left side, he found nothing either in the trunks or branches of the 
brachial plexus. In the nerves, in a case where rheumatic pain existed at the mo- 
ment of death, he found nothing wrong. The true nature of the disease, therefore, 
is very often a mystery. 

When a portion of a nerve has been seen of an uniform dark-red colour after 
death; when a portion has been found diseased and enveloped in gangrenous cel- 
lular tissue; or about double its natural size, of a violet-red colour, and strewed 
with ecchymoses of the size of pins' heads; or a serous, bloody, or purulent effu- 
sion has been discovered among its fibres; or nerves have been found hypertrophied 
and connected with fungous ulcers; when a nerve has been bruised, lacerated, or 
half divided; — pain of greater or less intensity had been felt in the nerve or the 
parts upon which it is distributed.* Cotugno, Cirillo, Chaussier, Bichat, &c., 
have seen similar appearances after neuralgia. In some cases of disease of the 
brain or spinal marrow, even where paralysis is produced, pain is felt at a distance: 
the paralyzed parts sometimes ache severely in hemiplegia. In epilepsy and hys- 
teria, pain is sometimes felt in the course of nerves. A portion of the pain in 
structural diseases of all organs, may occasionally occur in the branches and twigs 
of the nerves irritated by it. 

Causes. — Neuralgia certainly arises, in many cases, from cold; and in some it 
certainly arises from mechanical irritation of the nerve; such as is occasioned by 
the stumps of old teeth, or by an exostosis. Many cases have occurred, in which 
the bones of the cranium have been found in a state of exostosis, or carious, when 
the disease appeared; but this is not by any means necessary. 

To show that in some cases of neuralgia the cause becomes obvious after a time 
only, we may state that Dr. Abercrombie quotes one case of exquisite neuralgia of 
the face, that ceased on the removal of a piece of ciiina which had been there four- 
teen years; and another, of ten years' duration, that ceased on the extraction of a 
tooth. Sir Henry Halford mentions the case of a lady who laboured under violent 
tic douloureux, till an apparently sound tooth was extracted, — on account of the 
attacks being frequently preceded by uneasiness in it; and that a large exostosis was 
found at its root. He relates the case of a nobleman, who was liberated from the 
disease by the exfoliation of a portion of bone from the "antrum maxillare." To 
ascribe neuralgia, however, to these causes, in most cases, is very unpathological. 

The disease frequently occurs, when we cannot explain it at all; and after death 
nothing has been found. Dr. Macculloch thinks that it arises from malaria;** but 
then he ascribes almost every thing to malaria. I have no doubt he is quite right 
in a great deal of what he says; but still he ascribes too much to malaria. He 
considers, that almost every case of toothache arises from that source. Dr. Mac- 
culloch appears (to all but himself) to ride his hobby a little too much. Errors 
have been committed on the other hand; and teeth have been pulled out, where 
the pain did not arise from the teeth. I have seen cases, where a person has lost 
almost every tooth; and has then been cured by quinine. However, it is possible 
that the nerve or the neurilema, one or both of them, may be inflamed; and, if that 
be the case, we must expect violent pain.'' 

* See Abercrombie's " Researches on Diseases of the Brain and Spinal Cord." 
^ See Pages 253 and 264. 

* Parry altribiUes neuralgia to inflammation of the neurilema; but it comes and goes sud- 
denly; is relieved, not by bleeding, but by opiates; is not increased by firm pressure; wants 



NEURALGIA. 655 

Rheumatic Neuralgia. — Nerves also frequently suffer pain from rheumatism. 
There is decidedly a rheumatic neuralgia. The exquisite neuralgia, described as 
tic douloureux,'' may arise from those vicissitudes of temperature that occasion 
rheumatism, and may be rheumatic. But pain, not of that description, though 
perhaps very acute, perhaps dull and aching (as is usual in rheumatism), is every 
day witnessed in the situation of nerves, in persons who have rheumatism in those 
situations, and who have been exposed to cold, or perhaps cold and wet; and it 
yields as readily to the treatment of rheumatism, as the ordinary rheumatism of 
other parts. The neurilema, which is a fibrous membrane, is probably still more 
affected than the nerve; since rheumatism is chiefly a disease of the fibrous mem- 
branes. 

Symptoms. — In rheumatic neuralgia we observe all the varieties of suffering 
occasioned in other parts by rheumatism: sometimes acute pain, with tenderness, 
heat and even throbbing, and aggravation of the pain by heat; sometimes dull aching 
only; sometimes pain on motion, pressure, or other modes of mechanical irritation; 
sometimes remittent, intermittent, or even periodical, pain. The pain is sometimes 
exquisite and sudden, assuming the character of tic douloureux; which, we may 
remark, not only when rheumatic, but sometimes when not apparently so, may 
assume a periodical type. It is the clear situation of the pain in a nerve, and not 
the character of the pain, when it is not like the pain called " tic douloureux," that 
justifies us in rheumatism to pronounce it neuralgic. 

The nerves chiefly attacked by rheumatism, are the sciatic and the branches of 
the fifth. It is very frequently inflammatory; so that the surface is tender, hot, 
swollen, and even red. Sometimes no marks of inflammation are discoverable, and 
warmth and other stimuli relieve. In the case of the face especially, (one side only 
of which is usually affected, and perhaps not only the nerves, but some of the sur- 
rounding parts,) there is a great tendency to periodical intermission, and the 
paroxysms usually occur in the evening. 

Treatment. — When inflammation is obvious or presumable, whether rheumatic 
or not, local bleeding, merctury, colchicum, and the whole antiphlogistic plan, gene- 
ral and local, are appropriate. Should these not succeed soon, anodynes may be 
added; and the pain may, from an inflammatory commencement, degenerate into 
pain without inflammation, and demand at last solely the treatment of another form 
of the disease. 

Remedies for Rheumatic Neuralgia. — When rheumatic and yet not inflamma- 
tory, the remedies of this form of rheumatism in other parts are required;-— 
stimulants internal and external, tonics, mercury, and all modes of counter-irri- 
tation. 

Coldness indicates stimulants. Among internal stimulants, besides generous 
diet, the ammoniated tincture of guaiacum is one of the best. It should be exhi- 
bited in such quantity and frequency as to keep the patient comfortably warm. 
A dose of half a drachm may be sufHcient, or six drachms may be required; and a 
frequency of three times in the twenty-four hours may be sufficient, or the dose 
may requiie repetition every two hours; and in general both may be diminished 
after the remedy has been continued for some time; because it stimulates more 
and more, and its effect lasts longer. When there is debility, and especially pale- 
ness, iron in full quantities operates in the most salutary manner; much more so 
than quinine.'' The hot-hath (of water or vapour,) the douche, electricity, blisters, 
moxas, sinapisms, tartanzed antimony, croton oil, and acupuncture, frequently 

three of the signs of inflammation; is not attended by fever; and does not go on to the ter- 
minations of inflammation; while, on the other hand, inflammaiion of ihe nenrilcmn maybe 
artificially produced, without giving rise to neuralgia. Monro looks on ihe iwitchings of 
the muscles as the cause of the neuralgia. His opinion was favoured by a ca<e in Guy's 
Hospital; in which the ointment of white lead was rubbed over the affected parts for monihs. 
It pal>ied the muscles, and cured the pain. Armstrong thinks it is a partial disease of the 
brain;— displaying itself in particular parts of the nervous system. His remedy is calomel. 
— Dr. Fletcher, 

« See Page 653. «> See Note to Page G57. 



656 NEURALGIA. 

cure, if combined with all other appropriate means. Mercury carried to ptyalism fre- 
quently cures; provided the strength will bear it, and the rest of the treatment is well 
conducted. Even the cold shower-bath, or cold douche, if followed by good friction, 
will cure. A warm temperature of the atmosphere around the patient, and warm 
clothing, may be indispensable. Anodyne narcotics may be absolutely necessary; 
and the salts of morphia, stramonium, and belladonna, carried to a due extent, are 
by far the best, and sometimes alone will cure. 

Removal of Decayed Teeth. — If there be an obvious exciting cause, it should 
(of course) be removed. If carious stumps in the gums produce it, they should 
be taken away: but when we consider how large a number of people have this 
cause of irritation, without any such disease being produced, one is more inclined 
to trust to the general remedies, than even to the removal of the stumps; for I know 
that after they have once excited the disease, or have existed with it, the disease 
will continue after they are removed; and though it would be but common sense 
to get rid of an obvious cause, yet the sulphate of quinine will cure many cases, 
notwithstanding the old stumps are allowed to remain. 

Sesquioxideof Iron. — Should no structural or mechanical cause, and no inflam- 
mation be discoverable, and should the disease be of the exquisite character, then 
iron is the best remedy. 

The usual doses of the sesquioxide of iron are, I believe, from fifteen to thirty 
grains; and these are given two or three times a day. Some few practitioners, I 
know, exhibit (occasionally) a drachm at a dose; but they consider this a large 
quantity; and Dr. Hutchinson — who has written upon the virtues of the medicine 
in neuralgia, and probably employed it more than most others — tells us, that the 
greatest quantity he has ever found necessary, is ninety grains in the twenty-four 
hours. His mode of expression leads to the supposition, that this is the largest 
quantity he has ever given. Mr. Carmichael has employed it as extensively as 
Dr. Hutchinson; and appears — from the narrations in his work upon the efficacy 
of iron in cancer — to have generally given less than a drachm in the twenty-four 
hours; and once only so much as four scruples. But I have ascertained, by very 
numerous trials, that, when the use of the medicine is proper, it may be given in 
far larger quantities; that two, three, and four drachms may be given every six, 
nay, even four hours; that this dose of half an ounce may be at once commenced 
with; and does not require, in order that it may be borne, to be reached by slow 
degrees; and that it may be continued many weeks, without the slightest inconve- 
nience. 

It had, for many years, been my custom to prescribe the medicine in drachm- 
doses; but having several cases in which its exhibition appeared proper, and never 
having observed any sensible effect from it, I began to think that a drachm was 
probably not the utmost quantity which the stomach would bear; and resolved to 
ascertain, by cautious augmentations of the doses, how much might be taken. It 
soon became evident, that there was no occasion for timidity; and my uniform ex- 
perience, in nearly a hundred cases, enables me to present the results just stated. 
When the medicine is proper, I believe there is no limit to the quantity which may 
be taken; except the unwillingness of the patient to swallow it, and the inability of 
the stomach to manage so heavy a mass. Neither headache, thirst, heat, foulness 
of tongue, griping, nor constipation has occurred,*" nor been increased if already 
present. Nay, pain and heat of the head, and giddiness existed already in some 
cases, and ceased during its employment."' I am enabled to say, that these quan- 
tities are ordinarily borne, (exactly as is the case with antimonial powder,) not 
because the operation of the medicine is resisted by an unnatural condition of the 

■ I wish not to assert, that such inconveniences will never occur; but the absence of them 
in all my trials justifies me in believing, that they will not prove common occurrences, with 
even half-ounce doses. Many practitioners are no longer deterred from giving iron by 
headache, foulness of tongue, &c., if other circumstances indicate its employment, I be- 
lieve, that when it excites and disturbs, this arises from a peculiar susceptibility to its influ- 
ence; unless, of course, the system is already in a highly excitable state. 

^ See Page 625. 



NEURALGIA. 657 

sj-stem, not because tlie quantity is gradually reached, and not because the article 
is bad. The article was procured from a variety of druggists, — from many of the 
most respectable houses in London; and was in fact, in several examples, known 
to be a genuine ariicie, prepared according to the letter of the PharmacopcEia.* 

Whether there is any advantage in these very large doses, I cannot say. A 
drachm-dose may perhaps be as useful as one of half an ounce. Even when (as in 
many cases) large doses effected all the good desired, after all the small ones had 
failed; it may be urged, that not the increased quantity but the continuance of the 
remedy produced the effect; and the question can be decided only by a comparison 
of cases, similar in every respect, treated one half by common and the other by 
large doses. Reasoning analogically, one would conceive that large quantities 
must be more serviceable. Cinchona, for instance, will cure an ague, in doses of 
a drachm, given every two hours; when two or three tablespoonfuls of the decoc- 
tion three times a day, or even a drachm of the substance given not more fre- 
quently, will altogether fail.* We are accustomed to increase the doses of all medi- 
cines, for the purpose of increasing the effect. In the very example of sesquioxide 
of iron, practitioners sometimes prescribe what they consider a small dose, some- 
times what they consider a large one; — according to the force which they judge 
necessary to bring up against the disease; and they increase the quantity as the 
disease proves obstinate. Now, since it appears that the dose of this medicine has 
a much wider range than has been thought, and that the terms " large'^ and " smaW^ 
must relate to quantities different from those to which they have been hitherto 
applied, the same habit of practice would incline us to these large doses in obsti- 
nate cases; unless such comparative observations as have been just alluded to, 
prove them to be nowise superior to what have hitherto been considered large. It 
may be worth while, too, here to quote a passage from Cullen: — " We are per- 
suaded, that the good effects of the preparations of iron have often been missed, by 
their being given in too small doses. The saline preparations, in large doses, are 
ready to irritate the stomach; and — both on this account, and on some other con- 
siderations — it may always be proper to begin with small doses, and to increase 
them by degrees; but we have often found, that no great benefit is to be obtained, 
but when large quantities — either by the size of the doses, or by the continuance 
of them — have been thrown in." I may remark, that Sydenham's favourite form 
of iron was the filings; and that Cullen says — " We have found the simple rust as 
effectual as any other preparation; and we have always found the stomach bear it 
better." It is right, however, while quoting Cullen, to mention that he also says: 
— " We have been informed of its being given to the quantity of six drachms in 
one day; but we have hardly found any stomach that would bear the third of that 
quantity without sickness." The apparent variance of his experience from mine, 
is easily explained. He employed the rust of iron. Such only was the " car- 
bonate" of the Edinburgh and also of the London Pharmacopceia, when he pub- 
lished his ♦* Materia Medica." My observations relate, of course, to the present 
preparation of the London Pharmacopoeia; — procured hy precipitation, and therefore 
an impalpable powder. The gritliness of the rust would soon turn the stomach 
of any one, if administered in large quantities. I may state, from abundant ex- 
perience, that a scruple of the sulphate of iron, made into pills with the extract of 
gentian, is borne just as well as half an ounce of the sesquioxide; and that every 
observation that I have made respecting this dose of the latter, applies to that dose 
of the former. I have occasionally given more, and even in solution, without sen- 
sible effect." 

* If the articles used by me were all proved to be bad, the importance of my facts would 
remain little diminished; because the variety and respeciabiliiy of the houses at which the 
medicine was purchased, show that the facts, if not true of genuine sesquioxide of iron, are 
true of the sesquioxide now in common use. 

" See Page 273. 

" See Dr. EUiolson's paper on the "Medical Properties of the Siibcarbonaie of Iron;" 
published in the " Medico-Chirurgical Transactions," Volume 13, Page '23"2. A lew sup- 
plementary observations on the subject, will be found at Page 466 of the same volume. 
VOL. I. — 42 



658 



NEURALGIA. 



Quinina, S^'C. — Quinina, arsenic, belladonna, slramoninra, and colchicnm, are said 
sometimes to rnre this exquisite form. The want of attention to the stomach and 
bowels, and of the observance of good habits, will aggravate it. Relief is said to 
be obtained occasionally by the application of steam to the part, and sometimes by 
ice. The application of the strongest narcotics, and all irritants and escharotics, 
as well as the actual cautery, have occasionally done good. 

Division of the Nerve. — When all has failed, the division of the nerve, or the 
removal of the part, if possible, may be proposed;-r-provided no cause in another 
part is obvious, and provided the pain is invariably limited to one part. Galen was 
acquainted with the division of the nerve as a remedy in the disease; but a royal 
French surgeon-marechal appears to have been the first who performed the opera- 
tion. Unfortunately it very rarely cures. One portion of the divided nerve suffers 
again, or the disease reappears in some other part. Too often there has not been 
even temporary relief. Yet amputation of the finger or thumb, in which the dis- 
ease was seated, has succeeded, when the cause of the afl^ection was local. 

A case is mentioned by Mr. Wardrop, in the eighth volume of the '*Medico- 
Chirurgical Transactions,"* where the pain occurred in the nerve of one of the 
fingers, and where nothing short of amputation succeeded; but that succeeded per- 
fectly. There is a case mentioned in the fourth volume of the same Transactions,** 
in which amputation also proved successful." But even where amputation has been 
resorted to, the disease has sometimes reappeared in other parts. 

« Page 246. ^ Page 50. 

c The case is contained in a letter from Mr. Alexander Denmark, Surgeon lo Hasler 
Hospital, to Mr. H.Leigh Thomas. It is entitled — "An Example of Symptoms resembling 
Tic Douloureux; produced by a wound in the Radial Nerve;" and is as follows: — "Henry 
Croft, a healthy young man, belonging to the fifty-second regiment, was wounded on the 
night of the sixth of April, 1812, at the storming of Badajoz. A musket-ball entered the 
•triceps extensor cubiti,' about an inch and a half above the inner condyle of the 'os humeri;' 
and grazing the inside of that bone, passed obliquely downwards through the 'brachialis in- 
ternus,' and out anteriorly near the bend of the arm. The wound soon healed, and without 
manifesting any particular morbid symptoms during the cure. On his admission into this 
hospital, I found him labouring under excessive pain, which the largest opiates could not 
assuage, with almost constant watching. The Utile sleep he had, (if it could be called 
such,) was disturbed by frightful dreams and starting. I always found him with the fore- 
arm bent, and in the supine posture, supported by the firm grasp of the other hand; the wrist 
also bent; — beinj? unable lo move it into any other position, by the voluntary exertion of its 
own muscles. He could suffer me to extend the hand; but with increased pain; and it always, 
on the removal of the extending power, fell into its former bent situation. The act of pro- 
nation he could also suffer me to perform; but, in like manner, with increase of pain. A 
small tumour could be felt in the site of the wound, on the anterior part of the arm, which 
he could not bear to be touched without evincing additional torture. He described the sensa- 
tion of pain as beginning at the extremities of the thumb and all the fingers, except the little 
one, and extending up the arm to the part wounded. It was of a burning nature, he said; 
and so violent, as to cause a continual perspiration from his face. He had an excoriation 
on the palm of the hand, from which exuded an ichorous discharge. The cause of this he 
ascribed to a shell rolling over it. His agonies, he observed, were insuff'erable; — depriving 
him of sleep, and the enjoyment of his food, for which he had sometimes an appetite. He 
declared himself incapable of enduring it longer without some relief; and earnestly requested 
the removal of the arm. Before proceeding to any operation, I recommended him to try the 
effects of the warm and vacpour-baths, anodyne embrocations, &c.; but from none of these he 
experienced any alleviation of his sufferings. 

" The symptoms were sufficientlv clear, I conceived, to lead to a correct prognosis. The 
part wounded, the nature of the pain, and its course from the fingers, with the exception of 
the little one, indicated the affection to be in the radial nerve. The increased pain attendant 
on the act of pronation, further corroborated that supposition; — from the pressure of the 'pro- 
nator teres' upon the nerve, in its passage through that muscle. The man said he had pro- 
fuse bleeding after receiving the wound; yet I found the pulsation of the radial artery to be 
as strong^ as in the other arm. It was difficult to suppose the radial nerve wounded, and the 
humeral artery to escape; such, however, proved to be the case. 

" [ proposed to my patient the possibility of saving the limb, and relieving the pain, by 
cutting down upon the nerve, and removing a part of it, above the wound; which he wil- 
lin^^^ly consented to; but observed, that he would rather have the arm amputated at once, 
than run the risk of a secfflid operation. In a consultation which I held with my colleagues 
upon this case, when we ^^/t^j^n.-^idered the chance of failure, together with the injured state of 
the arm, and contracted ,eiI^|9,;vv'-j"oint, we determined on the propriet, '■ of amputation. 1 im- 



PARALYSIS. 659 

Neuralgia arising from Malaria. — When neuralgia arises from malaria, whe- 
ther ague has also been produced or not, quinina and arsenic, long continued in 
the largest and most frequent repeated doses that can be borne without the least 
inconvenience, are the best remedies; and when it is periodical or intermittent, 
without evident connection with malaria, they are all excellent. But sometimes a 
full dose of extract of stramonium or belladonna, repeated every hour or two, from 
just before the attack is expected to the termination of every paroxysm, succeeds 
better.* 



CHAPTER XV. 
PARALYSIS. 



The next disease which I shall notice, is one which very often follows apoplexy; 
and is the result of that state which, in the first instance, is apoplectic. 1 refer to 
paralysis. *• 

Definition. — It may be defined to be a loss or diminution of sense, or of mo- 
tion, or of both; independent of any stiffness of the part, or of inflammation, or 
any mechanical impediment; but dependent entirely upon the condition of its 
nerves, or some other part of the nervous system. This disease frequently begins 
with sopor; or even with coma, and downright apoplexy. If it begin with a great 
degree of heaviness, it is called " sopor" (" sleepiness.") 

Varieties. — It is usually divided into three varieties: — " hemiplegia," affecting 
one-half of the body divided vertically; "paraplegia," affecting one-half of the 
body divided horizontally; and " paralysis par/ia/is," affecting only one particular 
limb, or one particular sense. The partial paralysis may be of the eye — " amauro- 
sis;"" of the smell, — "anosmia;""* of taste, — " ageustia;"^ of the touch, — "anaes- 
thesia;"^ or of hearing, — "dysecsea.^ There is no particular name for paralysis of 
one leg, one arm, or one side of the face. 

The disease may not only vary according to the part it affects, but it may also 
vary in degree; so that the person shall have no use whatever of his senses, or of 
a portion of his body; or he shall have a use of them, only that it is impaired. 
Then the paralysis may differ according as it affects sensation, or motion, or both. 

mediately performed the operation, with instantaneous rehef to my patient. He was dis- 
charged cured in three weeks;— having, in that time, rapidly recovered both his health and 
strength. 

" On dissecting the arm, I traced the radial nerve through the wounded parts. It seemed 
to be blended with, and intimately attached to them, for the space of an inch. It had been 
wounded; and, at the place of the injury, was thickened to twice its natural diameter; and it 
seemed as if contracted in its length. This contraction, I thought, partly accounted for the 
bent position of the arm, and the increased pain on attempting its extension; but, on further 
examination, I was surprised to find, on dividing the fibres on the posterior part of the wounded 
nerve, that there was firmly imbedded in it, a small portion of the ball, which had been driven 
off by grazing the bone. "This description of the injury, more fully accounts for the ex- 
quisite pain felt by the patient. The 'os humeri' was discoloured, where it was grazed by 
the ball; and the humeral artery was uninjured! The nerve was evidently thickened, both 
above and below the wound. 

a For further details we refer to Dr. Elliotson's paper on Neuralgia, in the third volume 
of the "Cyclopgedia of Practical Medicine;" Page 165. A very severe case of the disease, 
with Dr. Elliotson's treatment of it, and remarks upon it, will be found in the "Lancet;" 
No. 484; Page 322. (1832-3, Volume 1; December 8, 1832.) 

bSeePage5I3. cFrom afxav^eat, to darken. 

(1 From av, loitkout; and o^», to smell. 

e From a, wit/wut; and ytuo/xat, to taste. 

f From av, without; and aia-Qaiofxat, to feel. 

6 From 5w;, with difficulty; and awn, hearing. 



660 



PARALYSIS. 



It is very common to see paralysis affect only sensation; this must, of course, be 
the case with parts which have naturally no motion. If such a part be paralyzed, 
it must be paralyzed in sensation. Wiih respect, for instance, to the internal part 
of the nose, the paralysis which affecis it must clearly be a paralysis of sensation; 
and so with respect to the internal part of the ear, and likewise of the eye. If the 
paralysis be within llie orbit, — so that motion is affected, — it is not the fault of the 
eye, but of the muscles which move it; but paralysis affecting the globe itself, must 
be paralysis of sensation. Sometimes, however, in the extremities we have a loss 
only of sensation; but that is rare. Sometimes a person loses the sense of touch, 
in particular parts of the body; but it is not of frequent occurrence; for generally, 
where a part is endowed with both sense and motion, the part either has only 
motion affected, or sensation and motion together. 

There is still another variety. When a part is paralyzed both as to sensation 
and motion, the proportion of the two is very various. Sometimes a person will 
be powerless entirely in a limb, or in one-half of the body; and yet he w'lWfeel a 
little, while he cannot move at all; and sometimes the paralysis will be so perfect 
in both respects, that we may pinch him as hard as we please, and he may endea- 
vour to move as much as he will, and yet both will be in vain. 

There are some still rarer varieties than these. What I have now mentioned is 
almost of daily occurrence: but there are some variations not so common. For 
example; a person will sometimes lose sensation on one side of the body, and 
motion on the other. He may lose sensation as to a leg, and motion as to an 
arm; and vice versa. There is even a more minute variety than this. There 
will be di perfect loss of sense and motion in one limb; while in another limb, on 
the same side, the loss of either sensation or motion is imperfect. The patient 
wWXfeel a little with his arm, although he cannot move it; while, in his leg, he 
can neiilier feel nor produce the least motion. Nay, what is si ill more curious, this 
state has sometimes alternated. The part which could not feel, has become mO' 
tionless; and the part which was motionless has, by and by, lost sensation. 

Sometimes, when half the body is paralyzed, the other half is in a state of great 
agitation, and convulsions. These are cases of rare occurrence; but they are men- 
tioned by the most respectable authors; so that there is not the least doubt as to 
their truth. Occasionally there is an opposite state to the loss of sensation; — the 
senses become morbidly acute; so that a person is quite powerless as to the motion 
of an arm or a leg, on one side of the body; and yet he will have such a morbid 
acuteness o( sensation, that the creeping of a fly along the arm, will give him great 
uneasiness. I have seen many persons who could not use their arm, or say if a 
fly lighted upon it; but occasionally there has been such a morbid degree of sen- 
sibility, that the descent of a fly upon them has been most uncomfortable. 

Morbid Sense of Temperature. — Cases occur where there is a morbid sense as to 
temperature, in the paralyzed parts. Some persons whose limbs are paralyzed, can- 
not, in the paralyzed parts, bear the slightest breath of cold air. It has often been 
known to excite convulsions. But, more frequently, patients will feel parts which are 
only of a moderate temperature to be exceedingly hot. I have met with several cases 
of this description. The first of the kind which occurred to me, took place in a gentle- 
man, who was first induced to think there was something the matter with him from 
what he experienced on going to the water-closet. When he took his seat, he fell one 
side so hot, that he thought some person in a burning fever must have been there be- 
fore him. He wondered how the heat could be on one side; and he soon found that 
if he clapped his hand against the part, it felt hot. He tried the other side; but no 
such sensation was experienced. It excited his astonishment; and he soon found 
that, as he walked along, he shook his toe about. After a time, giddiness and hemi- 
plegia occurred, and subsequently paraplegia of the lower extremities; of which he 
died. Some not only feel every thing hot, in this way; but they have a constant 
burning sensation, whether the parts are touched or not. This is very different 
from what we often see; for some persons (many indeed) have so litile feeling, 
that a red hot iron has been applied to the paralyzed parts, for medical purposes; 



PARALYSIS. 661 

and yet not the slightest heat has been felt. Many paralytic persons have sat near 
a fire, and their legs have been charred; and yet they have known nothing about it, 
at the moment. 

I have seen many cases such as that I have just mentioned, respecting a morbid 
sensibility to heat; and it is a thing which has been mentioned by old, as well as by 
modern authors. The cases are by no means uncommon. Dr. Heberden men- 
tions a case of hemiplegia, where there was a morbid sensibility of the sense of 
smell; — where the patient smelt every thing so acutely, that any strong odour gave 
him great pain.* He reminded one of Pope's line, — 

" Die of a rose in aromatic pain,"'* 

This I have never seen; but I have had two or three extraordinary cases of para- 
lysis, where persons had a morbid sensibility to cold. I made a note of one, which 
occurred in December, 1823. A man, aged fifty-six, had been for twelve years so 
sensible to cold, that he had regularly worn four flannel-waistcoats; and on his 
wife once putting her foot against him in bed, he had rigors; which made the bed 
shake, and lasted for a 'whole hour. Once, he said, his grand-daughter put her 
cold hand upon him; and he felt an icy coldness in that spot for a month. Three 
years and a half before I saw him, he had a fall on the back of his neck; and from 
that time he had been considerably worse, as to all these sensations. He had ver- 
tigo; and laboured under a loss of the power of attention. He could not fix his 
attention; and his spirits were much depressed. I found him thirsty and flushed, 
and frequently he had heat all over him; but, notwithstanding that, he always felt 
cold. No one else, on touching him, could discover that he was so. 

1 had another patient under my care in 1829; — a man forty years of age. He 
had a morbid sensibility to low temperatures, throughout his trunk, and along his 
arms, as low as his elbow; but no farther. He said that things of an ordinary 
temperature felt cold to him; and when he put on a calico night-shirt it felt, at first, 
as though It had been dipped in cold water; and the sensation remained for a quarter 
of an hour. The sensation of putting it on next to his skin, would have been 
intolerable; and therefore he was obliged to case himself in flannel; and he kept 
his flannel-waistcoat on as long as it would stay. He said that hot things felt hot; 
but that any thing of a low temperature felt exceedingly cold. 

It was owing to observations of this description, that Dr. Darwin (and perhaps 
others) imagined that there must be a particjilar set of nerves for temperature. 
Seeing that persons sometimes lost the sense of touch, and yet had a morbid sensi- 
bility of temperature, — -sometimes feeling things very hot^ and sometimes very 
cold^ — he drew the conclusion to which I have just referred. It was analogous 
facts to these that led persons, ages ago, to imagine there must be a distinct set of 
nerves for motion and sense; and the fact has since been proved by Sir Charles 
Bell, and still more fully established by Magendie. A French surgeon (who pub- 
lished in 1780) states, that there must be distinct nerves of sense and motion; 
because sometimes the function of motion only was affected, and sometimes only 
sensation. That has been proved to be the case; but it has never been proved with 
regard to temperature. 

Temperature of Paralyzed Parts. — The temperature of paralyzed parts, gene- 
rally follows the temperature of the surrounding air, or of bodies placed in contact 
with the part affected. It is said that the temperature of the paralyzed parts, is 
generally below what it ought to be; but that is not a proper expression; and I think 
Dr. Abercrombie's statement is the most correct: — "They have lost in some degree 
that remarkable power, possessed by the living body in a healthy slaie, of preserv- 
ing a medium temperature; and according to the temperature to which they have 

* Though paralytic persons often find the perception of the five senses dull and confused, 
yet I attended one whose sense of smelling:, instead of being impaired, became so exquisite, 
as to furnish perpetual occasions of disgust and uneasiness, and from some very ridiculous 
causes. — Heberden- s ^^ Commentaries;''^ Chapter 69. 

b " Essay on Man;" Episile 1; Section G; Line 200. 



662 PARALYSIS. 

been exposed, paralytic parts become hotter or colder than sound parts, which have 
been exposed to the same temperature."" 

Mode of Invasion. — Paralysis may invade very slowly, — quite imperceptibly; 
or it may attack very suddenly. After it has once begun, it may extend or not; 
and it may proceed very slowly or speedily; and may likewise increase in inten- 
sity, or never increase at ^11. The patient may live many years, without any 
further increase. It may, therefore, take place suddenly, or very slowly; it may 
remain stationary, or it may cease; or, if it do not cease, it may remain stationary, 
or it may extend; or, on the other hand, it may become more intense. Sometimes 
one organ becomes affected after another. 

Sometimes Intermittent, — Occasionally it is intermittent, and even periodical. 
I had long read of such cases without witnessing- an instance; but at last I met with 
a case, which was decidedly mtermittent; and, indeed, in some measure periodical. 
The attacks always came on about half-past ten, or eleven o'clock in the morning. 
They did not always occur after the same interval, though sometimes they did; 
but the hour at which the invasion took place, was always the same. After the 
lapse of many months, the disease became less; ceased to be periodical; and 
appeared to have more of the form of fixed paralysis.* 

^ "Researches on the Diseases of the Brain and Spinal Cord. By J. Abercrombie, M. 
D." (Third Edition; Page 276.) 

^ I have read of intermittent palsy; and it is mentioned by Cullen; — "paralysis intermit- 
tens.^' Now among all the patients I have ever seen, and which are between thirty and 
forty thousand, — including those in various public establishments and private practice, — 
I had never seen an instance of this description. This was a case of interraiiient hemi- 
plegia. The man was admitted into Jacob's ward [in St. Thomas's Hospital], some lime 
ago; and I mentioned his admission at the time. I gave him no medicine; because I was 
desirous of seeing whether his account was true or not. I seldom gave medicine in aguish 
or intermittent complaints, till some one in the hospital has witnessed the occurrence of the 
paroxysms. He stayed here [in the hospital] three weeks, without having a paroxysm; he 
was, however, a very respectable man; and 1 did not doubt his account. He then went out 
of the hospital; — enjoined by me to return, if his disease reappeared. One day when I came 
to the hospital, some time afterwards, I found him in the courts; and he said he had been 
seized with paroxysm that morning, and he actually was then in a state of hemiplegia on 
the left side. I saw it myself. . I made him walk, and he dragged his leg in a semicircular 
way, — as patients usually do when they are labouring under hemiplegia; and he could not 
raise his left arm. It began at ten o'clock; and this was the usual course of the disease. 
He had told rae, originally, that the paroxysms came on at ten o'clock in the morning; not 
every day, but every third or fourth day; and never after a longer period, except on one 
occasion; when there was an interval of sixteen days. He had been subject to this affection 
for two years and a half; he was forty-eight years of age; and the paroxysm would last 
from three to four hours; but, although it only lasted that time, he was not perfectly clear 
from it the whole of the day. He never knew the paroxysms begin later than eleven 
o'clock; or earlier than ten; till a week before he had been admitted, when one attack came 
on at half past ten in the evening; — the usual hour, but in the evening instead of the morn- 
ing. The affection was not more frequent then, than when it first began. The man looked 
sickly, — as if he had ague; but still more as if he bad suffered from a hot climate; and it 
appeared, that he had been in the East and West Indies, and had a fever both at Bombay 
and Batavia. He had suffered from dysentery; and, when in the hospital, he had diarrhoea. 

I do not doubt, that this man's disease was the effect of malaria; — that his hemiplegia was 
a form of ague. I will not quarrel about words. You may say it was not ague; because 
unattended by shivering, fever, or sweating: but I have no doubt it was as much the effect 
of malaria, as ague is. It was merely a variety of the same affection of the system. Sup- 
posing this to be the case, and witnessing a paroxysm myself, I now gave him the sulphate 
of quinine; and, as the disease was of long standing, I began with a good quantity;— five 
grains every six hours. This medicine very soon put a stop to the complaint, but not till I 
had increased the dose to ten grains, every six hours;— so that he took forty grains in the 
twenty-four hours. This is the dose that is often required in a quartan ague; and this was 
a worse forrn of the disease than quartan, because it occurred on the third or fourth day; 
and the longer the interval between the attacks, the greater is the difficulty of curing the 
affection, which may be considered so much the more of a chronic character. It is not a 
matter of wonder, therefore, that so large a quantity was required. He continued in the 
hospital from his admission on the thirteenth of October, till the twenty-third of December, 
— which was more than two months, — without any other attack whatever; and his health 
greatly improved. It is wrong to suppose, that malaria does nothing more than produce 
these particular forms of intermittent disease. It poisons the whole body; and many per- 



PARALYSIS. 663 

Coexistent with other Diseases. — Paralysis is very frequently united with other 
nervous diseases; particularly with mania and epilepsy. Persons who are e[)ilep- 
tic, frequently become paralytic at last; though perhaps, if they be adults, not till 
after many years have elapsed. Insane persons, too, frequently are seen to be 
paralytic. When recovery takes place, it is in general very slowly; but sometimes, 
though rarely, recovery is sudden. 

Causes. — This disease may be induced by any thing which compresses a por- 
tion of the nervous system; which divides any portion of the nervous system; or 
by the disorganization of a portion. It is obvious, that whether a part of the 
nervous tract be compressed (so that the function cannot continue along it), or 
whether it be divided (so that the function cannot continue along it), or whether it 
be disorganized, the result must be the same. Accordingly, if a nerve be divided, 
the parts below are paralyzed. If the spinal marrow be divided, or completely- 
compressed, or softened at any spot, the parts below are necessarily palsied. The 
compression may arise from fluid effused around, from fluid effused in the sub- 
stance, from a collection of blood, or (in fact) from any thing capable of producing 
pressure. But sometimes the disease would appear to arise independently of com- 
pression, division, or disorganization. The nature of this state we cannot exactly 
ascertain; but the part is unfit for its functions. Lead will have this effect; and 
arsenic, together with various other poisons, will deprive a part of the power of 
continuing its functions; — so that paralysis takes place, without our being able to 
say what is the exact effect produced by these agents. Cold, likewise, will pro- 
duce paralysis. If a part be exceedingly benumbed, it produces common paralysis, 
for a longer or shorter time afterwards. 

Its Extent depends on the Part affected. — Although I am not aware that any 
difference would be discovered by the eye of an anatomist, in examining the parts, 
yet the higher the source of the disease, the more extensive are the effects; so that 
compression, division, or disorganization of the lower part of the spinal marrow, 
does not produce so extensive a paralysis, as the same causes acting higher up; 
and if the cause be within the head, (in one of the hemispheres, or one of the 
'•thalami nervorum opticorum," or one of the " corpora striata,") patients generally 
have paralysis of the upper part of the body. The cause of hemiplegia, therefore, 
is in the brain, l^ both sides of the brain be compressed to an intense degree, then 
we have apoplexy; for apoplexy is evidently double hemiplegia. If the cause, on 
the other hand, be very slight pressure within the head, we have an exceedingly 
slight paralysis; — merely a little numbness at the ends of the fingers. Many per- 
sons who have a little fulness of the head, will have a numbness at the end of the 
fingers, and tingling; and, on losing blood, it will go off. There is every degree 
of paralysis, according to the pressure. If the pressure be inconsiderable, we have 
no more than an affection of the nerves, at the most opposite part of the brain. 

sons are destroyed by \i, without having ague at all; — so deadly is the poison. His health, 
howev^er, regularly improved under the quinine; he became strong, his countenance was 
belter, and altogether he found that he had received very great benefit. However, on the 
twenty-eighth of December, five days after his dismissal, he came to me; saying, that he 
had had a very slight attack that morning, and that it occurred rather laier than usual,— 
some little time after eleven o'clock. When I saw him, at about half past one o'clock, it was 
nearly gone off. I increased the quantity of sulphate of quinine, to fifieen grains every six 
hours; and, if that be not sufficient, I shall give him more; as he is to come to me from lime 
to time. I had a case of a person in the hospital, who was not cured of ague with less than 
a scruple every six hours; and therefore I shall not be surprised, if it be required in the case 
of this man; but 1 have no doubt he will be perfectly cured eventually. 

This is a very interesting case; — proving that paralysis is not necessarily an organic 
affection; — and that hemiplegia does not necessarily arise from effusion, or from compres- 
sion depending on an organic nature. If anv compression do occur in this man, it can only 
be during the fit; for at other times he is perfectly well. It isentirelv, I presume, an affair 
o{ function, induced bv a particular \)o\^ow.— Extracted from a Clinical Lecture^ delivered at 
si. Thomas's Hospital, by Dr. ElHotson; and puhHshed in the ^' London Medical Gazette" 
No. 163; January 15, 1831. ( Voluvie 7; Page 486.) 



664 PARALYSIS. 



SECTION I.— HEMIPLEGIA. 

Symptoms. — I shall now describe the particular forms of paralysis; and, in 
the first place, consider hemiplegia (which derives its name from ^hjugv^, half; and 
Tt-Kfjoaoi, to strike). In this disease, one half of the body (divided vertically) is 
paralyzed. There is generally no loss of sight, smell, taste, or hearing. Indeed, 
there is one case, to wliich I before alluded, put on record by Dr. Heberden, where 
an individual labouring under hemiplegia, had an extraordinary acuteness of smell." 
But, in general, when paralysis occurs down one half the body, it is noX perfect 
paralysis; in so far as the eye and ear of tliat side, half of the nose, and the tongue, 
have their senses acutely enough. This form of paralysis, very often, is united 
•with more or less delirium and phrenitis. It frequently attacks those who are fatui- 
tous; or who labour under mania. It may be a mere hysterical affection, and 
soon recovered from. The other forms of paralysis may be hysterical; but hys- 
teria, when accompanied by paralysis, is perhaps more frequently accompanied by 
hemiplegia, than by any other form. 

Most frequent on the Left Side. — With regard to the side affected, Sir Gilbert 
Blane says, from some comparative observations made by him when physician at 
St. Thomas's Hospital, that he found three cases of hemiplegia on the left side, 
for two on the right. I have not myself made any comparative observations. 
The pulse, on the paralytic side, is smaller than on the other. 

Ji Sequel of Apoplexy. — Hemiplegia is, very commonly, a sequel of apoplexy. 
When a fit of apoplexy is over, and paralysis is left, the form is usually hemi- 
plegic." Generally, when hemiplegia occurs suddenly, there is a degree of apo- 
plexy; an imperfect apoplectic fit; — a degree of drowsiness and sleepiness. There 
may be no stertorous breathing; but the person generally loses himself for a time. 
I think hemiplegia more frequently commences in that way, than in any other; but 
where a person has a downright attack of fully formed apoplexy, the disease is 
very likely indeed to follow. Serres (to whom I formerly alluded'') says, that of 
one hundred cases of apoplexy which he examined, seventy-nine of them were 
complicated with palsy; — so frequently is apoplexy followed by palsy. Occasion- 
ally there is not only no real perfect apoplexy, but no sopor, — no loss of the indi- 
vidual to himself for a time; — but merely vertigo, — a little confusion; and then, to 
his great astonishment, the patient finds an arm or a leg palsied. 

More frequently occurs in Bed. — An attack of this description, I think, more 
frequently occurs in bed, than in any other place. Many persons who lose the 
use of one side suddenly, and who have no decided apoplectic attack, say that it 
happened in bed; — that they awoke in the morning, and found themselves in this 
situation; or that it occurred late at night, or very early in the morning. 

May commence gradually. — Occasionally, however, this form of the disease 
begins very slowly; commencing in the fingers or in the toes, and creeping up; 
and occasionally, where it does begin suddenly, the person first loses the use of a 
leg or an arm, and then (an hour, a day, or a week afterwards) he loses the other 
member of the affected side. 

General Effects. — From the voluntary muscles of half the body being more or 
less deprived of the influence of the will, the face is usually drawn to the opposite 
side. From the muscles losing the influence of the nerves connected with the 
brain and spinal marrow, they are more or less powerless; and the muscles of the 
opposite side, which are in due connection with the brain, get the better of them, 
and master them completely; so that the face is drawn to the healthy side. The 
tongue, if it be drawn at all, is usually drawn to the same side; — on account of 
the operation of the muscles. From the impaired state of the muscles of the 
mouth and tongue, the person does not swallow his saliva as soon as it is formed. 

» See Page 661. ^ See Page 513. " See Page 540. 



PARALYSIS. 665 

We are always getting rid of it in health more or less insensibly; but for want of 
this voluntary action, it collects to a certain amount, and then runs out of the cor- 
ner of the mouth; so that the patient slobbers. If the disease affect the mouth 
with any intensity, the voice is thick, from the affection of the muscles of the 
throat. The patient's utterance is altered; he "clips the king's English," as 
people say; and perhaps he can scarcely pronounce his words with sufficient dis- 
tinctness to be understood. If the paralysis be perfect, the face and gait of the 
person at once show the nature of the disease, without the necessity of asking a 
question. The mouth is drawn to one side; the saliva runs out; the arm hangs 
useless; and, if the patient attempt to walk, he drags the affected limb in a sort of 
semicircular manner; having the ball of the great toe, for the most part^ in contact 
with the ground. 

When the disease continues for any considerable time, the limbs waste; — they 
become flabby to the feel, and diminish in size. The mind, too, generally suffers 
a little. The patient does not find his attention so good as it was before; nor his 
memory. His feelings are much affected; so that he is disposed to burst into tears, 
without any evident external cause; and he is, for the most part, very peevish. I 
mentioned, when speaking of tetanus, that Sir Gilbert Blane informed me of a 
case, which was accompanied by pleasurable twitches;* and Dr. Cook, in his work 
on Nervous Disease, mentions the case of a person who had been very captious; 
but who, after a fit of palsy, became the most good-natured person possible. The 
symptoms which occurred at the time of the fit, or preceded it, (such as vertigo 
and headache,) may continue afterwards, and may increase. There is great variety, 
as to the effects of sense and motion, in the affected part. Sometimes the person 
retains his feelings perfectly, but loses all powers of motion; and, in other cases, 
a person loses both; but it is a very rare thing indeed to see a loss of the sense of 
touch. Usually motion is impaired or destroyed; and sensation more or less so, 
or not at all. 

Frequently followed hy Apoplexy. — This disease, very frequently, does not 
follow apoplexy; but is hseU folloived by apoplexy. '' We may easily imagine that, 
if the cause be in the brain, although at first it may be so inconsiderable as only to 
be just sufficient to produce hemiplegia, yet it may, if the morbid process go on, 
become more considerable; and, at last, it may be sufficient to produce apoplexy. 
While apoplexy sometimes leaves hemiplegia, hemiplegia is sometimes followed 
by apoplexy. 

Progress of Amendment. — When the disease diminishes, I believe (for the most 
part) the arm mends last; — that, after the patient has begun to walk tolerably with 
the affected limb, his arm long remains useless at his side; and sometimes it never 
recovers. There is a variety in this. Some persons recover both limbs at once; 
but if there be any difference, it is in favour of the leg. While some persons com- 
pletely recover, others do not recover at all; and while some will get worse, others 
will remain stationary. Some persons will live ten, or perhaps fifteen years, in 
the same state. Another difference occurs. They will mend up to a certain point; 
perhaps for a year or two; and then never advance further. 

Liable to recur. — This is a disease which may occur again and again. Recur- 
rences of it are frequently seen. It is a disease which I have seen, several times, 
in children; and, I believe, more frequently than not, they recover from it. 

Causes and Morbid Appearances. — The cause of this particular form of para- 
lysis is sometimes mere fulness about the head; — fulness which is often transient; 
and therefore the disease is transient. Frequently there is found, after death, 
serous effusion; and that, perhaps, in a very inconsiderable quantity, even where 
the paralysis is very great; and perhaps the effusion is rather the effect of the mor- 
bid cause which induces the paralysis, than the cause of the paralysis itself. Effu- 
sion, however, is often the cause of paralysis. The most frequent state of the 
brain which I see, (and therefore, I suppose, which other people see,) is a softened 

» See Page 513. 



G66 PARALYSIS, 

st-ate of some one spot. It is curious how small a portion is sometimes sufficient, 
when softened, to give rise to this disease. Occasionally the softening is very 
great; — extending over a great part of one of the hemispheres, or the " corpus 
callosum." This softening-, in many cases, is clearly the result of inflammation. 
A chronic inflammation of the brain, often precedes this softened state; and very 
frequently it follows an acute inflammation of the brain. Persons seized with 
acute inflammation of the brain become paralytic; and we afterwards find the brain 
more or less softened. Sometimes the disease will increase. The patient becomes 
delirious; perhaps he has epileptic fits; and the head is very hot. All the tCme he 
is delirious, he complains of ^reat pain of the head, and, on opening the skull, we 
find a portion of the brain softened; and around the softened spot, and even run- 
ring through it, are seen red vessels. There can be no doubt, in such a case as 
this, that the disease is the result of inflammation. I, as well as others, have fre- 
quently noticed, that after paralysis has begun, although there may previously 
have been no great aflfection of the head, the latter will sometimes become affected. 
Patients gradually complain of more and more pain; gradually have the head more 
and more hot; gradually become more and more delirious; and then they die. It 
appears as though, at first, there had only been softening enough to produce para- 
lysis;— ronly enough to produce inflammation; and the latter has then gone on to a 
far greater extent. It is said, by Dr. Hooper and others, that when there is soft- 
ness of the brain, it is analogous to the gangrene of other parts; but whether it 
really is the case, I do not know. A part may be softened, without there having 
been symptoms to lead us to conclude the existence of gangrene. There can be 
no question that this softening of the brain is, sometimes, not inflammatory; for it 
is accompanied by paleness, not only in one spot, but all around. If there be in- 
flammation, it shows itself in a very odd way; for the part is white all around. I 
can suppose that the brain may be broken up, without inflammation; — just as the 
coats of the stomach may sometimes be found perfectly pulpy, and perfectly pale. 

Sometimes caused by a Coagulum. — Occasionally the paralysis, in hemiplegia, 
has been induced by a coagulutn of blood; and this coagulum may be of all sizes. 
When paralysis comes on in a moment, without any previous inflammation, I 
imagine that in general there is an effusion of blood. Apoplexy may be the result 
of the eff"usion of blood; but when the apoplexy is over, — when, I presume, that 
general state of congestion of the blood-vessels, which was sufficient to produce 
apoplexy, has gone ofl", — then there remains a clot, just sufficient to produce hemi- 
plegia. The blood becomes absorbed; — sometimes leaving a cavity, and some- 
times not; the parts then all become contracted together; and a cicatrix is formed. 
Around this spot, the brain is generally softened. I mentioned this circumstance, 
as taking place in apoplexy;* and it also occurs in paralysis. The paralysis arises, 
I believe, from what remains after the clot has been absorbed. The brown, dark- 
coloured substance, which is sometimes taken from the brain of a hemiplegic 
patient, I should imagine to be the remains of blood. The blood was nearly all 
absorbed; but the brown softened part left behind, was quite sufficient to produce 
paralysis. 

Dr. Abercrombie says, a cyst will form round a clot of this kind, even in a fort- 
night. Whether extravasated blood can be absorbed from a ventricle, if etfused in 
any quantity, I do not know; but I should think not. In most cases of that descrip- 
tion, the blood has lacerated the brain, and forced its way from the substance of the 
hemisphere, into the ventricle. Four ounces of blood have been found, after para- 
lysis, in a cavity formed in the brain. When the brain has been softened, and has 
produced hemiplegia, or fatuity, or only an aberration of the mental faculties, the 
vessels will sometimes suddenly give way: and then tliere is apoplexy; — an eflfu- 
sion of blood suddenly taking place into the softened part. Softening is supposed, 
by some, to resemble "gangrena senilis;''^ — that gangrene which takes place in 
the toes of old people, from ossification'' of the small vessels. Some will have it, 

» See Page 516. ^ From " os, ossis," a bone; and " facio," to make. 



PARALYSIS. ^67 

that it is not the result of inflammation; but of disease of the vessels, affecting the 
circulation. I should imagine the truth to be, that (like most other diseases) it is 
the effect of different circumstances. That inflammation will soften the brain, 
there can be no doubt; and if the vessels be obstructed, so that the part is not 
nourished perfectly, then also it will become soft. 

Pressure from various Tumours. — Pressure from an abscess, or from various 
tumours formed upon the surface of the brain, (whether they be encysted, carcino- 
matous, melanotic, or of any other kind,) may have this effect. White tumours, 
reddish tumours, scrofulous tumours, tumours of all descriptions, and hydatids, 
have been seen (in this disease) pressing upon the brain, in different parts. It 
has sometimes been occasioned by the pressure of an exostosis; — from the bone 
growing too much in one particular spot, so as to compress the brain. Excessive 
thickening of the membranes has given rise to the disease. 

The Cause is on the opposite side. — It is a well established fact, I think, that 
the disease occurs on the opposite side to that in which the cause of it resides. 
The observation of this fact is so general, — so many persons, who have extensive 
opportunities of examining patients, assert that they never met with any exception 
to it, that I cannot but think the few exceptions on record must have been mistakes. 
Serres says, that he opened one hundred and seventy cases of apoplexy united 
with hemiplegia; and that, in all those cases, the affection was on the opposite 
side. He opened forty-seven cases of mere hemiplegia; and there the affection 
was on the opposite side; and in about one hundred and fifty cases of paralysis 
detailed to him, the results were the same. I never saw an exception to it; and 
many authors say the same. There are a few instances to the contrary on record; 
some of which I have looked over; and to me they are any thing but satisfactory. 
In some of these, there could be no doubt, other morbid appearances were found at 
the same time; so that, in all probability, sufficient attention was not paid to the 
opposite side. In general, the brain is sliced very rapidly; and morbid appear- 
ances in the brain, I know, are every day passed over. On the other hand, when 
the spinal marrow suffers compression, or any cause sufficient to induce paralysis, 
the disease occurs on the same side. 

Cause generally in the Substance of the Brain. — The cause of hemiplegia is 
generally within the substance of the brain; and pressure of the brain usually pro- 
duces apoplexy; so that, I conceive, we have a reason for apoplexy occurring so 
often first, and leaving hemiplegia behind. Apoplexy generally arises from a mere 
temporary fulness of the vessels of the head. It goes off; and then some injury 
occurs at one particular spot, and is sufficient to produce hemiplegia. Local pres- 
sure on the surface of tlie brain, however, may likewise produce hemiplegia; and 
local pressure on any part of the brain, if it be very intense, will produce apoplexy, 
because pressure in any one spot of the brain, if it be intense, will necessarily 
compress the whole. 

Loss of Verbal Memory. — A very curious symptom, sometimes observed in 
hemiplegia, is a loss of verbal memory. This is quite distinct from a loss of the 
power of utterance. In general, persons in this disease do not speak well; because 
they have not full power over the voluntary muscles of articulation;* but, some- 
times, if they can speak well, they have not a proper word in their mind; and they 
cannot make themselves understood. Some forget entirely the meaning of words; 
some forget entirely the meaning only of names;^ and some do not forget these 

» See Page 665. 

*> A singular instance has been related to me, of a gentleman who could not be made to 
understand the name of an object if it was spoken to him, but understood it perfectly when 
it was written. His mental laculties were so entire, thai he was engaged in most extensive 
agricultural concerns; and he managed them with perfect correctness, by means of a remark- 
able contrivance. He kept before him, in the room where he transacted business, a list of 
the words which were most apt to occur in his intercourse with his workmen. When one 
of these wished to communicate wiih him on any subject, he first heard what the workmerx 
had to say, but without understanding him further than simply to catch the words. He thea 
turned to the words in his wriitea list, and whenever ihey met his eye, ho un.lorstood ihea^ 



668 PARALYSIS. 

entirely; for the moment the proper word is mentioned, they say — "Right, thank 
you!" They know it directly. This affection of the mind occurs, sometimes, without 
any hemiplegia; and sometimes it lasts for a period, and then hemiplegia super- 
venes. Some have an abundance of ivords; but do not know their proper mean- 
ing. They distribute them about very incorrecdy; so as not to express their 
wishes. Others have only a few words; and with these they endeavour to say 
every thing. 

Dr. Prichard, in his work on Diseases of the Nervous System (to which I have 
so often referred),* mentions the case of a lady, who forgot the names of all per- 
sons; and of another who forgot the names of some things;" and who likewise for- 
got that she had ever been married. Dr. Currie mentions the case of a man, who 
forgot the Hebrew language alone, out of several with which he was acquainted. ° 
Mr. Aberneihy used to mention the case of a man who, after an injury of the head, 
though he knew English very well, could speak nothing but French. He had been 
equally acquainted with, both languages; but, after the injury he had sustained, he 
could only speak French. He also thought he was only sixteen years of age. 
Dr. Rush mentions the case of a lady, who forgot her English, and spoke nothing 
but French for a month. 

A writer on hemiplegia, named Wepfer, mentions a case of this disease, in which, 
after the stupor ushering it in went off, the patient recollected neither persons nor 
words; and when he recovered the words again, he forgot their meaning. He lost 
all his language; — could not utter a single word; and at last, when he could, he 
forgot their meaning; and he preferred Latin to his own native language, which 
was German. He could read any thing, a few words at a lime; and he wrote both 
Latin and English in elegant characters; but without knowing the meaning of a 
word. The end of the case was, that he died apoplectic. "^ 

Some persons, however, forget only proper names.® Sir Alexander Crichton 

perfectly. These particulars I heard from his son; — a gentleman of high intelligence. 
Another frequent modification consists in putting one name for another, but always using 
ihe words in the same sense. An example of this also occurred in. the gentleman last men- 
tioned. He uniformly called his snufF-box a "hogshead;" and the association which led to 
this appeared to be obvious. In the early part of his life, he had been in Virginia, and con- 
nected with the trade in tobacco; so that the transition from snuff to tobacco, and from to- 
bacco to a hogshead, seemed to be natural. Another gentleman, affected in this manner, 
when he wanted coals put upon his fire, always called for paper; and when he wanted 
paper, called for coals; and these words he always used in the same. manner. In other cases, 
the patient seems to invent names; — using words which, to a stranger, are quite unintelligi- 
ble; but he always uses them in the same sense, and his immediate attendants come to 
understand what he means by them. — Dr. Abercrombie's ''InqvAries concerning the Intellect- 
ual Ptmersf' Part 3; Section I; Subsection 5. {Ninth Edition; Page 152.) 

« See Page 599. 

*> The late Dr. Gregory used to mention a lady, who, after an apoplectic attack, recovered 
correctly her ideas of things, but could not name them. In giving directions concerning 
family matters, she was quite distinct as to what she wished to be done; but could make 
herself understood only by going through the house, and pointing to the various articles. — 
Dr. Abercrombie's ^^ Inquiries concerning the Intellectual Powers;" Part 3; Section 1; Subsec- 
tion 5. (Ninth Edition; Page IbO.) 

« Dr. Beattie mentions a gentleman who, after a blow on the head, lost his knowledge of 
Greek; and did not appear to have lost any thing else. — "/>r. Abercrombie on the Intellectual 
Powers;" Part 3; Section i; Subsection 5. {Ninth Edition; Po.ge 155.) 

"* After several weeks he began to know his friends, to remember words, to repeat "the 
Lord's prayer," and to read a few words of Latin, rather than German, which was his own 
language. When urged to read more than a few words at a time, he yaid that he formerly 
understood these things, but now did not. After some time, he began to pay more attention 
to what was passing around him; but, while thus making slight and gradual progress, he 
was (after a few months) suddenly cut off by an attack of apoplexy. — Dr. Abercrombie's ^^In- 
quiries concerning the Intellectual Powersf Part 3; Section 1; Subsection b. {Ninth Edition; 
Page HI.) 

e A gentleman whom I attended some years ago, after recovering from an apoplectic 
attack, knew his friends perfectly, but could not name them. Walking one day in the street, 
he met a gentleman to whom he was very anxious to communicate something concerning a 
mutual friend. After various ineffectual attempts to make him understand whom he meant, 
fee at last g&iz&<i him by the arm, and dragged him through several streets, to the house of 



PARALYSIS. 669* 

nientions the case of Jin nttorney who, in his seventieth year, married a young 
lady; and, being very excitable, he also every evening saw his mistress. Under all 
this, as a consequence, from the excitement of his brain, he was seized with vertigo 
and insensibility; and these symptoms were followed by a loss of memory; — so 
that, instead of asking for bread, he asked for his boots^ and if they were brought 
to him, he was very angry, because he wanted something lo eat; but still he kept 
asking for boots or shoes, instead of for bread. Instead of asking for a tumbler, he 
inquired for a chamber-pot; and when he wanted a chamber-pot, he asked for a 
tumbler ot dish: and yet he was conscious he was wrong; and recognized the right 
words when they were spoken by others, and then pronounced them by imitation.* 
Dr. Abercrombie mentions having seen a case, in which the same wrong word 
was always used in the same wrong way. Whenever the patient missed the 
name of a particular object, he applied the same incorrect word (whatever it was) 
to the same thing. In the " Psychological Magazine," which is quoted by Sir 
Alexander Crichton (in his work on Disorders of the Mind), a case is mentioned 
where a person, after much tiresome business, on attempting to write a receipt one 
morning, could not write more than the two first words. He wrote on slowly, 
letter after letter, in the most deliberate manner. He found that he spoke words 
different from what he meant. He saw that he was wrong; but he could not set 
himself right; but, instead of writing — " Received fifty dollars for half a year's 
rent," he wrote — "Received fifty dollars through the salvation of the Bible." 
This state lasted an hour or two, and then nothing of it remained. 

I have seen two instances of this description. The one occurred in a lady, who 
was not hemiplegic, but who said she had a violent pain above each eye; and as 
long as that lasted, she could not tell the name of any thing; but when the name 
was mentioned, she knew it. This continued for some hours; and then the pain 
went off, and she knew every thing as well as before. After a short time, a second 
attack occurred. She had been taking digitalis. I know an instance of a medical 
man, who makes a dead pause, and says — "I cannot tell the word; I want to tell 
you what is the name of such a thing." It will occur every thirty or forty words. 
Dr. Currie (formerly of Guy's Hospital) says that he knew a person who, during 
an attack of this description, began his words m English, and ended them in Latin. 
At St. Thomas's Hospital (before the time of my connection with that institution), 
there was a Welchman who had forgotten his native language; but, while suffering 
from an injury of the head, he spoke nothing but Welch." When he recovered, 
he forgot it entirely; and talked only English." Dr. Rush mentions an instance 
of a student who, in consequence of a fever, lost his Latin, and began to learn it 
again; when, one day, it suddenly returned; — just as the power over paralyzed 
parts of the body will occasionally do. He also mentions, that a French countess, 
during the excitement of fever, spoke the language of Lower Brittany, which she 
had learned when young.*^ Dr. Abercrombie (one of the most recent writers on 

the gentleman of whom he was speaking, and pointed to the name-plate on the door. — Dr. 
Abercrombie's ^'Inquiries concerning the Intellectual Powers;'^ Part 3; Section 1; Subsection 5. 
{Mntk Edition; Page 150.) 

» This genileman was cured of the complaint, by large doses of valerian, and other car- 
diacs.— Dr. JJfasr>7i Good's '• Study of Medicine;" Classi; Order I; Genusd; Species!) VarietT/2. 
•> A few years ago, a man wuh brain fever was laken into St. Thomas's Hospital; and, 
as he grew better, spoke to his attendants, but in a language they did not understand. A 
Welch milk-woman, going by accident into the ward, heard him, answered him, and con- 
versed with him. li was iheti found, that the patient was by birth a Welchman; but had 
left his native land in his youih, forgotten his native dialect, and used English for the last 
thirty years. Yet, in consequence of this fever, he had now forgotten the" English tongue, 
and suddenly recovered the Welch.— Dr. Mason Good's "Study of Medlcinef Class 4; Or- 
der I; Genus 6; Species 1; Variety 2. 

<= Sir Asiley Cooper mentions "this case, as having occurred in Guy's Hospital. It is re- 
corded in his "Treatise on Dislocations and Fractures of the Joiiiis (abridged"). With 
important Additions, from the VVorks of the most distinguished modern Snr;?eons. Edited 
by Alexander Cooper Lee." Published by Butler, Medical Bookseller, St. Thomas's Street, 
Southwark. Page 536. 

^ A lady, mentioned by Dr. Prichard, when in a state of delirium, spoke a language which 



670 PARALYSIS. 

the subject) mentions the case of an American student; who, after fever, forgot all 
names;* ary:l, after learning the names, he was taught to read, and began his Latin. 
After a little progress, he had suddenly a strong sensation in his head. He applied 
his hand to it; and said, that he found all he had been learning he knew some 
time before, 

[Dr. Rush mentions an Italian gentleman, who died of the yellow fever in New 
York; and who, in the beginning of his illness spoke English, in the middle of it 
French, but on the day of his death only Italian. 

A Lutheran clergyman, of Philadelphia, informed Dr. Rush, that Germans and 
Swedes, of whom he had a considerable number in his congregation, when near 
death, always prayed in their native languages; though some of them, he was con- 
fident, had not spoken these languages for fifty or sixty years. 

A case has been related to me" of a boy who, at the age of four, received a frac- 
ture of the skull, for which he underwent the operation of trepan. He was, at the 
time, in a state of perfect stupor; and, after his recovery, retained no recollection 
either of the accident or the operation. At the age of fifteen, during the delirium 
of a fever, he gave his mother an account of the operation, and the persons who 
were present at it; with a correct description of their dress, and other minute par- 
ticulars. He had never been observed to allude to it before; and no means were 
known by which he could have acquired the circumstances which he mentioned. 
An eminent medical friend informs me," that, during fever, without any delirium, 
he on one occasion repeated long passages from Homer, which he could not do 
when in health; and another friend has mentioned to me, that, in a similar situa- 
tion, there were represented to his mind, in a most vivid manner, the circumstances 
of a journey to the Highlands, which he had performed long before; — including 
many minute particulars, which he had entirely forgotten. A gentleman, who was 
under the care of Dr. Johnston, of Kirkaldy, when in a state of slight delirium, 
connected with erysipelas of the head, sang with great precision some Gaelic songs. 
In health he had no kind of taste for music; and though in his youth he had some 
knowledge of the Gaelic language, he had been for many years entirely unaccus- 
tomed to it, and his knowledge of the language was supposed to be nearly or 
altogether lost. An ignorant servant girl, mentioned by Coleridge, during the 
delirium of fever, repeated passages from theological works in Latin, Greek, and 
Rabbinical Hebrew; which, being taken down and traced to the works from which 
they were derived, were found to be repeated with perfect accuracy. It turned out, 
that she had been servant to a clergyman, — a man of much learning and peculiar 
habits; who was in the practice of v^ralking backwards and forwards, along a pass- 
age in his house which led to the kitchen, and there reading aloud his favourite 
authors. The late Dr. Gregory"' was accustomed to mention, in his lectures, the 

nobody about her understood; but which also was discovered to be Welch. None of her 
friends could form any conception of the manner in which she had become acquainted with 
that language; but (after much inquiry) it was discovered that in her childhood she had a 
nurse, who was a native of a district on the coast of Brittany; the dialect of which is closely 
analogous to Welch. The lady had at that time learnt a good deal of this dialect; but had 
entirely forgotten it for many years before this attack of fever. — Dr. Abercrombie's ^^In- 
quiries concerning the Intellectual Powers;" Part 3; Section 1] Subsectionb; Head 4. {Ninth 
Edition; Page 141.) 

* The late Bishop of LlandafF, Dr. Watson, gives a singular case of partial amnesia in 
his father;— the result of an apoplectic attack. " I have heard him ask twenty times a day," 
says Dr. Watson, — " ' What is the name of the lad that is at college?' (my elder brother); 
and yet he was able to repeal, without a blunder, hundreds of lines out of classic authors." 
Hence, there is no reason for discrediting the story of a German statesman, a Mr. Von B., 
related in the seventh volume of the "Psychological Magazine;" who, having called at a 
gentleman's house, the servants of which did not know him, was under the necessity of 
giving his name; but unfortunately at that moment, he had forgotten it; and excited no small 
degree of laughter, by turning round to a friend who accompanied him, and saying, with 
great earnestness,— "Pray tell me who I am; for I cannot recollect!" — Dr. Mason Good's 
"Study of Medicine;''^ Class 4^; Order I; Genus 6; Species l; Variety 2. 

»> Dr. Abercrombie. « See Note to Page 239. 



PARALYSIS. 671 

case of a clergyman who, while labouring under a disease of the brain, spoke no- 
thing but Hebrew; which was ascertained to be the last language he had acquired. 
An English lady, mentioned by Dr. Prichard, on recovering from an apoplectic 
attack, always spoke to her attendants in French; and had actually lost the know- 
ledge of the English language. This continued about a month. A gentleman, 
whom I* attended in a state- of perfect apoplexy (from which he did not recover), 
was frequently observed to adjust his nightcap with the utmost care, when it got 
into an uncomfortable state; — first pulling it down over his eyes, and then turning 
up the front of it, in the most exact manner. Another, whom P saw in a state of 
profound apoplexy (from which he recovered), had a perfect recollection of what 
took place during the attack; and mentioned many things which had been said in 
his hearing, when he was supposed to be in a stale of unconsciousness. A lady, 
on recovering from a similar stale, said she had been asleep and dreaming. 

A man, mentioned by Willis, on recovering from a putrid fever, was found to 
have so entirely lost his mental faculties, that he knew nobody, remembered no- 
thing, and understood nothing. He continued in this state for two months, and 
then gradually recovered. Some years ago P attended a young man who, on re- 
covering from a tedious fever, was found to be in a state bordering upon idiotism; 
and this continued even after his bodily health was restored. In this state he was 
taken into the country; when, after several months, he gradually recovered. 

Some years ago, P saw a boy who had fallen from a wall, and struck his head 
against a stone which lay at the foot of it. He was carried home in a state of 
insensibility, from which he soon recovered, but without any recollection of the 
accident. He felt that his head was hurt; but he had no idea how he had received 
the injury. After a short time, he recollected that he had struck his head against 
a stone; but had no recollection how he had come to do so. After another inter- 
val, he recollected that he had been on the top of a wall, and had fallen from it, 
and struck against the stone; but could not remember where that wall was. After 
some time longer, he recovered the recollection of all the circumstances. Dr. 
Prichard mentions a gentleman, who suffered a severe injury by a fall from his 
horse, and on his recovery had no recollection of any thing of the accident, or for 
some time before it. A considerable time elapsed before his recollection of it 
began to return; and it was only as he repeatedly rode over the country where the 
accident had happened, that the sight of the various objects gradually recalled the 
circumstances of the journey in which it occurred, and the accident itself. A. lady, 
whose case has been communicated to me,* was seized with an apoplectic attack 
while engaged at cards. The seizure look place on a Thursday evening. She lay 
in a state of stupor on Friday and Saturday; and recovered her consciousness, 
rather suddenly, on Sunday. The first words she then uttered were — " What is 
trump?" A respectable surgeon was thrown from his horse, while riding in the 
country; and was carried into an adjoining house, in a state of insensibility. From 
this he very soon recovered, described the accident distinctly, and gave minute 
directions with regard to his own treatment. In particular, he requested that he 
might be immediately bled; the bleeding was repeated, at his own desire, after two 
hours; and he conversed correctly, regarding his feelings, and the state of his pulse, 
with the medical man who visited him. In the evening, he was so much recovered 
as to be able to be removed to his own house; and a medical friend accompanied 
him in the carriage. As they drew near home, the latler made some observation, 
respecting precautions jcalculated to prevent unnecessary alarm to the wife and 
family of the patient; when, lo his astonishment, he discovered that his friend had 
lost all idea of having either wife or children. This continued during the follow- 
ing day; and it was only on the third day, and after further bleeding, that the cir- 
cumstances of his past life began lo recur to his mind. 

A younoc clergyman, when on the point of beinsr married, suffered an injury of 
the head, by which his understanding was entirely and permanently deranged. 

* Dr. Abercrombie. 



672 PAftALTSIS. 

He lived in this condition to eighty; and, to the last, talked of nothing but his 
approaching wedding, and expressed impatience for the arrival of the happy day/] 

[Many persons can catch hold of an entire song, an entire sermon, or a series 
of speeches in parliament; and can recite them almost, if not altogether, verbatim 
immediately afterwards; but who lose all recollection of them in a day or two: 
while there are others, who are obliged to pause over the subject submitted to them, 
or have it repeated several times before they can get it by heart; yet who, when 
they have once fixed it in the memory, retain it as long as they live. Mr. W. 
Woodfall, the celebrated reporter of the parliamentary debates, was an instance of 
the former of these talents, with regard to his powers of apprehension; the well 
known Jedediah Buxton was an example of the latter: though it may be mentioned, 
that Mr. Woodfall retained with as much ease, as he first fixed speeches in his 
memory. 

Failure of memory takes place in a variety of ways. It is sometimes general, 
and extends to every subject; but it is frequently far more manifest on some sub- 
jects than on others. Salmuth mentions a case, in which the affected person had 
forgotten to pronounce words, but could nevertheless write them. Mr. J. Hunter 
was suddenly attacked with a singular affection of this kind in December, 1789, 
when on a visit at the house of a friend in town. He did not know in what part 
of the house he was, nor even the name of the street when told it, nor where his 
own house was: he had not a conception of any thing existing beyond the room 
he was in; yet was perfecUy conscious of the loss of memory. He was sensible 
of impressions of all kinds from the senses; and therefore looked out of the window, 
although rather dark, to see if he could be made sensible of the situation of the 
house. The loss of memory gradually went off; and, in less than half an hour, 
his memory was perfectly recovered. This might possibly be connected with a 
gouty habit, to which Mr. Hunter was subject; though not at this time labouring 
under a paroxysm. 

Boerhaave, however, gives a still more extraordinary instance of oblivion; — in 
the case of a Spanish tragic author, who had composed many excellent pieces, but 
so completely lost his memory (in consequence of an acute fever), that he forgot, 
not only the languages he had formerly learned, but even the alphabet; and was 
hence under the necessity of beginning to read again. His own poems and com- 
positions were shown him; but he could not be persuaded that they were his 
productions. Afterwards, however, he began once more to compose verses; which 
had so striking a resemblance to his former writings,. that he at length became con- 
vinced of his being the author of them.''] 

These things are very curious. They occur in different circumstances; but 
they are, no doubt, of the nature of paralysis; and very frequently they are united 
with it. 

SECTION II.— PARAPLEGIA. 

Symptoms. — In paraplegia (so called from nia^a, badly, and TtTir^aao), to strike), 
or that form of palsy which affects one-half of the body horizontally divided, both 
sense and motion are generally lost. There is, very frequently, constipation and 
retention of urine. At last, however, the sphincters become paralyzed; and there 
is neither retention of urine nor costiveness; but both faeces and urine pass invo- 
luntarily. In this form of paralysis, it is very common for the affected parts to 
experience spasmodic twitches and catches. This is an occurrence comparatively 
rare in kemiplegia. Very frequently, too, there is violent pain. In hemiplegia 
there is sometimes pain; but by no means so frequently as in paraplegia. The 
urine, in this disease, is sometimes altered in quality. It is not sufficiently acid. 

» Dr. Abercrombie's " Inquiries concerning the Intellectual Powers;" Part 3; Section 1; 
Subsection 5. (Ninth Edition; Pages 142 to 150.) 

b Dr. Mason Good's " Sltady of Medicinej" Class 4; Order 1; Genus 6; Species Ij Va- 
riety 2. 



PARALYSIS. 673 

It is perhaps alkalescent; but when it is not, still there is a deficiency of acid; and, 
soon after it is passed, it becomes strongly alkalescent. This is more particularly 
the case, when the paralysis has arisen from an injury to the spine. 

Progress. — When paraplegia does not come on suddenly, it usually commences 
in the lowest part, — the toes; and extends upwards. Its extent is various; but it 
generally reaches a little higher than the hips. 

Causes. — It is very frequently produced by a fracture of the vertebrae; and the 
higher the vertebrje in which the fracture takes place, the higher is the paralysis; 
and the sooner does death take place, — if death do occur. Caries of the vertebrae, 
also, frequently produces this afiection. Any disease of the spinal marrow, and 
many diseases of the membranes, produce paraplegia. In some instances, the 
spinal marrow is softened into a pulp, at one particular spot. Sometimes it is ex- 
ceedingly hardened; and sometimes the membranes, also, are exceedingly diseased. 
Sometimes there is suppuration,— producing compression; and sometimes an efTu- 
sion of serum, or of blood. 

All the diseases which I mentioned on the subject as occurring in the brain, and 
producing hemiplegia, and other forms of paralysis,* may occur in the spinal mar- 
row, and produce paraplegia. Sometimes a clot of blood has been found; some- 
times considerable haemorrhage, — compressing the spinal marrow; — tumours of 
various descriptions; — exostosis of bone; as well as a mechanically altered position 
of the parts, diminishing the canal locally. I had a very striking case of this, in a 
boy who died of peritoneal disease. His peritoneum was filled with tubercles; 
and, besides symptoms of mesenteric'' disease, he had lost the use of the lower 
extremities. The paraplegia was at once explained, by finding a scrofulous tuber- 
cle, as large as a nut, in the centre of the spinal marrow. The disease has fre- 
quently arisen from mechanical injury, when the bones appear to have sustained 
no violence, and in such instances I have seen recovery take place. In all proba- 
bility, an effusion of blood had occurred, which was afterwards absorbed; or the 
parts received such a shock, as was equivalent to concussion of the brain. I can 
conceive that, — as an affection of the brain may be induced by mere concussion, 
and may last for a day, or a month, or months, — so a mere concussion of the spinal 
marrow may unfit it for its functions for a time; and the person may eventually re- 
cover; — at least, patients frequently recover from paraplegia, produced by a fall or 
a blow upon the spine. The softening which we observe, is sometimes the result 
of acute or chronic inflammation; and sometimes it is not the result of inflammation 
at all; but a morbid change not well understood.*" 

Sometimes arises from Cold. — Paraplegia sometimes arises from cold. I had 
under my care a man, who had lost the use of his lower extremities from working 
in cold water in a ditch; — digging the foundation of a wall, or something of that 
description. He was continually hard at work in damp, cold places. We rarely 
see hemiplegia produced in this way; the reason of which is evident. Cold is con- 
tinually applied to the lower extremities horizontally^ but it is very seldom indeed 
applied to the upper extremities vertically. The lower extremities are frequently 
in water, while the upper are not. 

Can it arise from Cerebral Affection? — But besides all these causes in the spinal 
marrow, there can be no doubt that paraplegia arises, sometimes, from an afl!*ection 
of the head; because, occasionally, we find no uneasiness whatever in the spinal 
marrow; but there are symptoms of great uneasiness in the head; such as giddi- 
ness and drowsiness. Dr. Baillie wrote a paper in the "Transactions of the Col- 
lege of Physicians,"* to show that, in the greater number of cases of paraplegia 
occurring in adults, the cause was situated in the head. However, he did not 
prove the point at all. He gave but one dissection;*' and that was not seen by hira- 

» See Pages 665 to 667. * From jue<rec, the middle; and tm^oy, an intestine. 

« See Page 516. a Volume 6; Page 16. 

e The bones of the skull, more especially at the sutures, were more vascular than usual. 
The '■'-dura mater" presented nearly its natural appearance, but the vessels of the ''pia 
mater" were very much loaded with blood; and there were effusions of serum between 
VOL. I. — 43 



674 PARALYSIS. 

self.^. Whoever reflects on all the cases which he has seen of this kind, will find 
that, in the greater numher of instances, the cause was evidently siniated in the spinal 
marrow. He will arrive at this conclusion, from the cause having been applied to 
that pari; from the uneasiness being felt there; or from the morbid appearances pre- 
sented there on dissection; but occasionally there can be no question, that the ilis- 
ease arises, from an affection of the head. 1 have seen a case of this description. 
The gentleman was a little poorly, and confined to his bed; but he had no great 
ailment. It was discovered, one day, that lie had lost the use of his lower ex- 
tremities; though no cause whatever could be assigned for it. He could not stand 
on his lower extremities. His urine had not passed; nor his faeces. No violence, 
that he was aware of, had been applied to the spine, or to any other part; and he 
bore striking all down the spine. Pressure of the most violent kind gave him no 
pain. He told me, however, that he had had symptoms of giddiness a day or two 
after he was first seized; and delirium came on. The cause in this case was evi- 
dendy situated in the head; but I am satisfied, that for one case where the cause of 
paraplegia is situated i)i the head, there are eight, or ten, or perhaps a dozen, where 
it is situated in the spinal marrow. 

Morbid .Appearances. — Sometimes, after paraplegia, no morbid appearance is 
to be found; — exacUy as is the case after apoplexy and hemiplegia. In the two 
latter diseases, I stated, frequently nothing wrong is found in the brain;^ and in the 
former, occasionally, nothing wrong is found in the spinal marrow. 

Cause of the Spasms. — The reason why we have spasms, twitchings, and con- 
siderable pain in this disease, is that it is so frequendy produced by a certain degree 
of inflammation of the spinal marrow^; — an inflammation that softens it; or by 
somethinor pressing on the spinal marrow, or at any rate producing great irrita- 
bility. The cause which compresses the spinal marrow, also irritates it at the 
same time; and the irritation produces such an affection of the roots of the nerves, 
that a sense of pain is felt; and if it be a nerve of motion, a spasm occurs. When 
the part is found compressed by a bone, and this compression is only partially 
established, then we have considerable twitchings. 



SECTION HI.— GENERAL TREATiMENT OF PARALYSIS. 

Surgical Treatment. — I will now consider the treatment of paralysis in general; 
or, at least, the treatment of hemiplegia and y^araplegia. If there be a local cause 
evident and removable, our first plan is to attempt its removal. If the cause be a 
fracture of the cranial bones, of course surgical means should be immediately 
adopted, for removing such a source of irritation. If there be suppuration from a 
carious bone, or injury of a bone, measures should be taken (so far as accordant 
with the best surgical discoveries) for letting out the pus. I have seen pus let out 
by trephining the head, and opening the " dura mater;" but success, in such a 
case, must be very doubtful. The removal of a portion of fractured, or carious 
bone, is always to be attended to, when such serious effects take place as para- 
lysis. If the cause be any thing taken into the stomach, we should endeavour to 
remove it. 

Jintiphlo glstics . — Suppose the disease appear to be of an inflammatory nature; 
— if the head be hot, and there be violent pain; together with delirium, and things 

the clifTerent membranes of the brain, on boSh sides of it. The " lunica arachnoides" was 
opaque, and much thickened. The substance of the cerebrum was considerably firmer, and 
that of the cerebellum was considerably softer, than is natural. About four ounces of water 
were found in the lateral ventricles of the brain; and a considerable quantity of water was 
discharged from within the theca of the spinal marrow. — ''Medical Transactions, published 
bv the College of Physicians in Londoni'' Volume G; Page 22. 

"'a The account of this examination, was communicated to me [Dr. Baillie] by Mr. Pen- 
nington, of Montague Place; who had attended the patient fur many years.— ''M(?fiJico- 
Chirurgical Transactions;" Volume 6; Page 23. 
b See Page.s 615, 665, and 666. 



PARALYSIS. 675 

of that description; then, of conrse, common antiphlogistic treatment should be put 
in practice; — such as bleeding, pnrginof, leeching, mercnrializingas qnicldy as pos- 
sible, applying cold, and starving the patient. ' This is the proper treatment of 
many cases of" paralysis. In the first instance, we must treat the complaint accord- 
ing to the symptoms of congestion or fidness; but (as in the case of apoplexy) we 
must be on our guard not to go too far;* for if we do not attend carefully to the 
patient's pulse, every time we visit him, and do not visit him frequently, we may 
be surprised some day to find the pulse low, and the patient sunk irrecoverably. 

In the Chronic Stage. — It is possible that paralysis may remain long after the 
inflammation is over; when the effects of inflammation only continue; when there 
is mere effusion left, or suppuration; or when the brain is softened, and there is no 
inflammation or congestion. At any rate all the patient's strength is gone; so that 
we should not be justified in severe measures, even if inflammation or congestion 
did exist. Great care is necessary, in this disease, not to push matters too far; 
and when there appears no danger of life, but the disease still continues, we have, 
in general, to carry on a certain degree of antiphlogistic treatment; — to make the 
patient abstain from wine, and from distilled liquors, and frequently from animal 
food. But we must not starve the patient too much; nor bring him too low in this 
chronic treatment. 

Mercury and Iodine. — Mercury is very useful at first; but, after a time, it would 
only impair the powers of the patient; and after having given it a fair trial, it is a 
pity to have recourse to it again. Iodine has been strongly recommended, and will 
act as well as mercury; but it is only proper when rubbed in, in the f^irm of oint- 
ment; and given internally, in combination with potassa. It is said to do good, 
and I have occasionally seen it useful; but when we consider that the disease may 
arise from so many different causes, it cannot be expected that any one thing can 
be of general use. 

The plan most generally useful, is antiphlogistic treatment; because it removes 
congestion and inflammation; and prevents the parts from being pressed upon, by 
an excessive quantity of blood. If by chance any thing that ought to be absorbed 
supervene, antiphlogistic treatment will cause absorption, better than any thing 
else; and should there be some morbid growth, this may also be diminished by the 
same treatment. 

Local Applications. — Local means, and counter-irritation near the part affected, 
are very proper; — that is to say, counter-irritation in the nape of the neck, where 
the head IS affected; and down the sjome, where the cause is situated there (as in 
paraplegia). 

Iconics. — But, while adopting these measures, it is often very necessary 
(although we would not give tvine) to give good food; and occasionally even 
tonics, and, after a time, they are often to be given rather freely. If there be 
great debility, we must not be afraid of giving wine. Patients will sink without 
it; and it will do no harm. 

Opium. — To lessen the twitches and violent pain, opium is sometimes proper. 
If we keep the bowels open, and restrict the patient from improper stimuli, we 
may give opium; for it is a great advantage to lessen the pain and spasms. I have 
often administered opium, and never saw it do any harm; but, of course, I have 
always given it very cautiously. Though I am not habitually fearful with respect 
to medicine, — when I know my way, and know what the medicine is, — yet I am, 
at the same lime, very careful in watching the effect of every dose; that I may stop 
before any harm lakes place. There is no occasion to be rash, because we are bold. 
Strychnine. — Where there are no signs of inflammation left, and the patient is 
languid, then stimulants may be given. On this account, strychnine has been par- 
ticularly recommended; for although it is a narcotic, that will destroy life, it is a 
powerful stimulant to the nervous system. It will cause parts to twitch; and, 
while it stimulates the nerves of sensation, and the central parts of the nervous 

» See Page 524. 



676 PARALYSIS. 

system connected with them, it at the same time stimulates \hose o^ motion; — pro- 
ducing spasm, twitching, and a tingling sensation. It must, however, be obvious, 
that strychnia cannot be of universal, or even general use. If a part of the nervous 
system be softened, and disease is induced by it, how can strychnine, or all the 
stimulants in the world, cure the affection? We cannot, by such means, make a 
soft part hard. We may stimulate the part for a time; but that will not cure the 
disease. If the disease arise from pressure, how can any stimulant whatever 
remove it? It cannot have the effect of removing an exostosis, or a tumour. I 
cannot say that I ever saw a case cured by it, unless the disease arose from mere 
torpor. Where it arose from cold, then we may suppose, beforehand, that stimuli 
will do good, and I think I have seen strychnine serviceable in such cases. In 
common cases of paralysis, — arising (as they often do) from disease of the brain, 
where the parts have been softened in consequence, — we might give strychnine 
till the patient jumped out of bed; but it would only be to lie on the iloor. I have 
given it freely; but I am not satisfied with it. 

Other Stimulants. — Nux vomica, camphor, cayenne pepper, musk, and ammo- 
nia, have been had recourse to; and have failed. Electricity and galvanism, I 
should say, stand upon the same level, in point of utility, with strychnine and 
other stimulants. They may do good if the disease arise from mere torpor; but 
if the disease arise from an organic cause, or from compression, or obstruction, or 
alteration of structure, it cannot be supposed they will do good; — according to 
the extravagant idea which some persons have formed of them. There can be no 
doubt of the occasional efficacy of strychnine; but if we look at the pathological 
state of the disease, we must perceive how futile it must often be. 

Sometimes ceases spontaneously. — Paralysis will sometimes cease spontane- 
ously when the cause is in the brain. If it arise from effusion, the fluid may be 
absorbed; and by proper treatment we may expedite the absorption; but after a 
time, if we do nothing, it will be absorbed; — just as congestion will cease after a 
time. A clot of blood may be absorbed: and whatever had been used, — whether 
electricity or strychnine, — of course it would have the credit of it — but if we try 
a series of cases, and treat them with one particular remedy, we shall find the latter 
fail in a great number of instances. After all, the antiphlogistic treatment is evi- 
dently more successful than any other; only it is necessary to remember that, after 
a time, it must not be pushed too far. 



SECTION IV.— LOCAL PALSIES. 

I now proceed to more limited palsies than the foregoing; — to what are called 
" local palsies." The most common local palsies affect the four organs of sense; — 
the eyes, the ears, the nose, and the tongue; the side of the face as to motion only; 
the upper eyelid as to motion only; a leg or an arm as to sense or motion; and the 
hands as to motion only. The cause of these local palsies is more frequently situ- 
ated in the course of the nerves, after they have quitted the cerebral mass, or at the 
ends, than anywhere else. If the cause of palsy be in the brain itself, or in the 
spinal marrow, then we generally have more than local palsy; — either hemiplegia or 
paraplegia. But if the nerves be affected in their course, after leaving the brain* 
or only at their extremities, then we generally have local palsy. 

Amaurosis. — The first of these of which I will speak, is one of those affecting 
an organ of sense. It affects the optical nerves; and is called " amaurosis." 

Symptoms of Jlmaurosis. — In this affection (which is also denominated "gutta 
serena") there is dimness or loss of sight, without any fault of the humours, or 
the capsules, or the cornea, or the conjunctiva. Frequently, on looking into the 
eye, we see that, at the bottom, it is lighter coloured than it should be; or that it 
is rather greenish. The iris is sluggish or immovable; and generally the pupil 
is dilated. Sometimes, however, it is very much contracted; which arises from 



PARALYSIS. 677 

irritation of the third pair of nerves. Indeed, from an affection of the third pair, 
the iris is sometimes not obedient to the light. 

Causes. — The cause of this disease is in the expansion of the optic nerve, (ihe 
retina,) or in the course of the nerve itself; perhaps at the very origin (or termina- 
tion), — the "corpora qnadrigemina." Sometimes it arises from softness of the 
nerve; sometimes from extreme induration: sometimes from tumours pressing 
upon it. I knew a young lady who was amaurotic, from seven years of ajje till 
the time she died; which was between twenty and thirty. A tumour was found 
pressing on the optic nerve. Disease of the "corpora qnadrigemina" frequently 
produces this affection: and so also does disease of the "thalami nervorum optico- 
rum." The latter is often softened, however, without any affection of the eyes. 

In this disease, there is very frequenUy headache, vertigo, and evident signs of 
cerebral congestion; but a very curious point in this disease is, that it will some- 
times arise from an injury of another nerve than the optic. It has been known to 
arise from a wound of the supra-orbital nerve, and various nerves of the face. 
There are on record many cases, where amaurosis arose from an injury of some 
other nerve. Mr. Wardrop mentions several cases.* It there appears, that where 
the nerves of the face (the supra-orbital, for example) have been only half divided, 
the complete division of the nerve has restored the sight; so that imperfect divi- 
sion produced amaurosis, and cornplete division cured it. It happened to me, in 
1815, to see an instance of this description; — in the case of a woman, aged twen- 
ty-seven, who could only see one portion of objects. In her it had arisen from 
arteriotomy in the temple. There could be no doubt that, in performing the opera- 
tion, a twig of the nerve was injured; and, from that moment, she partially lost the 
sight of the corresponding eye. This is a very curious circumstance; — one with 
which I was not acquainted when I began practice; and one with which many 
persons, I believe, are still unacquainted. I presume it is from sympathy. Dis- 
eases will frequently arise from sympathy of the head with the stomach; and so I 
believe that, in this case, the circumstance arises from sympathy; and not from any 
connection of function between the parts. 

Hemeralopia} — Amaurosis is singular in another respect. It is very frequently 
a temporary or periodical paralysis. Some persons become amaurotic at night, 
though they can see well during the day; and this is called " night-blindness," or 
" hemeralopia" (from r^uf^a, day; and w4/, the eye);" or (incorrectly) " nyctalopia" 
(from vv|, night; and co4/, the eye)^ It is common in hot climates; and espe- 
cially occurs in new-comers. It is said to be produced there, in that particular 
instance, from the great glare of the sun; — ^just as sheep are sometimes amaurotic 
in the spring, from being exposed to the glare of snow during winter; for it is 
observed that, in some mountainous parts, the sheep do not see till the commence- 
ment of summer; — till the snow has disappeared for some time. None of us can 

* In his " Essay on che Morbid Anatomv of the Human Eye." Second Edition; Volume 
2; Page 192. 

'' Dr. Mason Good has proposed Paropsis (from rr^^x, bad. and Si^k, sight), as the generic 
name of this atfection; and P. Lucifuga (night-sight), and P. A'ccfzyi/o-a (day-sight), instead 
of Nyctalopia and Hemeralopia. The Greeks eiiVployed the term " Nyctalopia" in the 
literal seme, — nigkt-sight; "in consequence of the person labouring under it being only 
able to see at night, or in a deep shade; while it has been used by modern writers in the 
opposite sense o( night-sight-ache; — agreeably to \.\\e technical or implied meaning of "o/jia," 
when employed pathologically; in which case it always imports diseased vision, as though 
a contraction of the term "paropia" or "paropsi-^;" whence "nyctalopia" has necessarily 
been made to import "(/rt//-sight," instead of "?^//?A^^ight;" or that imperfection of vision in 
which the eye can only see in the day, or whenever there is a strong light. And hence 
"Ac?7iemZopia," the opposite to "/ji/cifiZopia," has been used, with the same confusion and con- 
tradiction of terms;— by the Greeks importing day-sight, being taken naturally or literally; 
by the moderns day-sight-ache, and consequently ninkt-sight, being taken technically or by 
imp\\C3.['wn.—^'- Study of Medicine;" Chapter A; Order '2; Genus I, Species I. 

<= A detect in the sight; consisting in being able to see in broad day-light, but not in the 
evening. — Dr. Hooper's ''Medical Dictionary." 

<i A defect in vision, by which the person sees HttJe oxnoihing in the day, but in the evening 
and nigkt sees tolerably well. — Dr. Hooper's '^Medical Dictionary.'^ 



678 PARALYSIS. 

see at first, when we enter from the light into a dark room; and that is the same 
occurrence, on a small scale, which takes place in sheep thai have been exposed 
to the glare of the snow. This has been observed, by some persons, to take place 
on board a ship. It has been noticed on the sea-coast, in the West Indies, in 
negroes, and in sailors near the equator. It is described by Mr. Bampfield, who 
wrote on Dysentery, as very common; and Sir Gilbert Blane mentions having 
seen it, in connection with scurvy. In general, it will yield with the other symp- 
toms of scurvy; and when it will not, Mr. Bampfield says that, in all cases, it 
yielded to blisters applied to the temples. Dr. Heberden mentions an instance of 
night-blindness, in a person who never had it except on board ship.* 

JSydalopia.^ — On the other hand, f/«?/-blindness is mentioned, by various 
writers, as occasioned by a dilated pupil, and occurring in Italian peasants. Regu- 
larly, at sun-set, persons in this situation become either perfectly blind, or very 
nearly so; — the light which occurs then not being sufficient for them. I had a 
case of this kind in a woman, who had been suckling four months: she said that 
she had always dimness of sight at five o'clock in the afternoon. This was in the 
neighbourhood of London. After lying down, and putting out the light, she gradu- 
ally saw more clearly as the night proceeded; but when midnight arrived it became 
duller; and remained so till nine the next morning. She had nausea in the morn- 
ing. I never saw her again. This woman was suckling; which might be too 
much for her. At five o'clock her sight began to be impaired; and she went to 
bed early. She had what is called "ptosis;'"" — a dropping of the upper eye-lid. 

DysecKa. — The hearing is often lost; but more frequently from other causes 
than paralysis. The affection is called "dysecoBa." 

But it is not uncommon for smell, hearing, and taste to be paralyzed, when there 
is paralysis of another kind. Sometimes in /temzplegia, sometimes in /j«r«plegia, 
we see a person lose smell and taste, or smell and hearing. It is rare that smell 
and taste are paralyzed; except in conjunction with other kinds of paralysis. When 
the cerebrum is diseased, several kinds of paralysis occur; as well as epilepsy, and 
other nervous diseases. 

Paralysis of the Portio Dura. — The most common partial paralysis, which 
affects motion only, is that of the face: and this chiefly arises from an affection of 
the "portio dura." When this partial paralysis occurs, it cannot be mistaken for 
a moment. The face is drawn to the opposite side; and the eye of the aflected 
side remains wide open, while the other is shut. The consequence of this is, that 
the tears are not directed towards the inner canthus of the eye, but fall over on to 
the cheek. There is an inability to laugh; so that if the patient attempt it, he 
laughs " on the wrong side of the mouth." There is an inability to distend the 
cheek; and an inability to whisUe or frown. If he frowns, he does it with only 
one " corrugator supercilii;" and as to whistling, he makes all sorts of noises out 
of the other corner of the mouth. Sensation is, in this case, unimpaired. The 
" portio dura" being a nerve oi motion^ and not o( sensation, motion only is para- 
lyzed. 

Causes. — This affection generally arises from cold, but not always. Very often 
the patient is deaf at the same lime; and he has a discharge from the ear. This 
may be conceived, from the situation of the "portio dura;" indeed, it often occurs 
in persons who have been exceedingly deaf. Sometimes it arises from caries of 
the bones; and sometimes it has appeared lo arise from an enlargement of the gland 
behind the ear, compressing the nerve. Sometimes this paralysis is evanescent; 
and if we apply a stimulating liniment, it soon disappears. It will disappear spon- 
taneously; but I dare say it disappears much sooner on stimulating the part. 
Occasionally, however, it is tedious and incurable. I have seen cases in which it 

* " Commentaries;" Chapter 60. 

*" " ]Nyciali)pia" and " hemeralupia" chanj^e meaning, in the hands of differenl authors; 
Nycialopia, if understood as "day-blindness," m;)y afise from dilated pupil, thin "pigmentum 
nigrum;" or a too sensible stale of the retina. The contrary of either of these slates causes 
hemeralopia. Nyctalopia is sometimes epidemic; especially if the ground be covered with 
snow. — Dr. Fletcher. 

e From WToa;, to fail. 



PARALYSIS. 679 

has been much improved; but I hardly recollect a case where the cure was quite 
perfect. It would be very wrong to suppose (as has been intimated too frequeuily) 
that this kind of paralysis has no connection wiih an ajfTection of the head. It may 
have no connection, because it may be external to the brain, — external to the " fo- 
ramen ovale;" but, in many cases, patients have fulness of the head, giddiness, 
sleepiness, 'and other symptoms; which clearly show that there is an afTeclion of 
the head, as well as of the nerves. The " porlio dura" may sufier compression, 
and become softened, within the head; as well as in the bones of the cranium, and 
after it has left those bones. It is by no means a trifling complaint; and very often 
is connected with a more serious affection. 

Treatment.— 'The proper mode of treatment would be, to ascertain how far there 
is an internal affection or not. If we find symptoms of drowsiness, they must be 
treated the same way as in other cases; but even if we find noticing of that de- 
scription, still there may be a propriety in applying leeches over the " portio dura" 
(about the mastoid proces.*), rubbing in mercury and iodine, stimulating the parts 
well, and applying blisters. I have done all this, and with a certain degree of suc- 
cess; but (as I just now said) I hardly recollect a case which, after continuing some 
time, was perfectly cured. Repeated leeches, blisters, mercury, stimulating appli- 
cations, and frictions, I believe, are the best things we can employ. 

Some have thoughtlessly proposed to divide the "portio dura" of the opposite 
side, — in order to paralyze the other muscle. This would do very well, if it 
were antagonized; but, unfortunately, the " orbicularis palpebrarum" is a distinct 
muscle; and therefore the effect of cutting it would be, to prevent the patient from 
shutting either eye. It would prevent the affected muscles from being drawn to 
the healthy side, but both eyes would remain staring wide open; and the patient 
would thenceforward be unable to make use of the muscles at all. He could 
neither whistle nor laugh. 

Paralysis of the Fifth Pair. — It sometimes happens, that the nerve of sensa- 
tion of the face is affected. The "portio dura" is a nerve only of motion; but 
there is another nerve which gives sensation; and not only to the face, but (as it 
would appear) to the nose and the other organs of sensation in the head. Paralysis, 
in this case, is much more rare than in the other. 

A very interesting case is recorded by Sir C. Bell, in which the following ap- 
pearances were presented: — " The left side of his face is relaxed, and the natural 
balance of the features is gone, — so that the countenance has a distorted, wry 
appearance. The left eye stares widely and unnaturally open, while the right is 
only moderately disclosed. When he makes an attempt to close the eyelids, the 
left remains unmoved; but the eyeball is elevated upwards; and it is raised to so 
great an extent, that the pupil is quite concealed beneath the upper lid; — the white 
of the eye only being exposed. He is unconscious of the eyeball thus revolving 
upwards; the objects around him in the ward, are not seen while it takes place. 
He was told to direct his eyes, so as to look as straight above him at the ceiling as 
he could; when he did this, it was observed that he could not raise the pupil by 
his utmost efforts so high, by some degrees, as during the involuntary act. When 
turned up in the effort to wink, the cornea rose so as to be presented towards the 
roof of the bony orbit, and so as to be quite concealed by the eyelid; and, on the 
other hand, when he looked upwards at the ceiling, more than one half of the pupil 
was disclosed. During sleep, the eyelids remain wide open; and the pupil is con- 
cealed;— just as is observed at the time he winks. It is remarked, that the globe 
of the eye protrudes considerably more than the other; the conjunctiva is inflamed, 
and is loaded with numerous blood-vessels. He says, that he suffers pain from his 
eye being constantly open; especially when he is sitting before the fire, at night. 
Wheti he is told to frown, there is no motion perceived on the left side of his fore- 
liead; but all the expression seems drawn to the right side. When maile to laugh, 
the features are curled up, in the expression of laughter, only on the right side of 
tlie face; which presents a singular contrast with the sad, or rather lifeless appear- 
ance of the left or paralyzed side. When a spoon was put into the left angle of 
his mouth, he could not grasp it: he said that, in eating, he put the morsel into 



680 PARALYSIS. 

the right side. The left nostril is not dihited in a corresponding- degree with the 
right; and the difference between them was most distinctly seen, when he attempted 
to snuff lip the air, or to breathe hard; for then, while the right nostril expanded 
more widely, this one became quite collapsed, and shut up against the air. The 
sensibility of the skin, over the whole of the head, is perfect; and the muscles of 
the jaws act powerfully. He can move his tongue about in all directions. There 
is a greater fulness over the left temple and jugum, than over the right; ther^is 
also a blueness of the integuments, consequent on the injury he had received; but 
he does not even wince if this part be pressed severely. There is an enlarged 
gland in the hollow under the left angle of the jaw; and it gives him pain when 
pressed. The whole chain of the ' glandulae concatenatae' on the left side of the 
neck, are enlarged and tender. His hearing is not affected, and there has been no 
discharge from the ear. He says that, for some days, his head has been drawn 
towards the right side; but this is now gone, and he can hold his head erect."" 

In an affection of the " portio dura," the patient yee/s as before; but as, in this 
case, there was disease of the fifth pair, there was no sensation in the face. It 
might be pinched and scorched, the eye might be rubbed, and the internal part of 
the nose might have substances introduced; but yet no sensation was experienced. 
There was, however, no distortion of the face, — no want of power over the muscles 
of the face; which clearly showed the distinct uses of the " portio dura," and of 
the fifth pair. I must mention, however, that the "temporalis" and *' masseter" 
muscles were paralyzed; because the fifth pair is not altogether a nerve of sensa- 
tion; — there are branches in it of motion likewise. This particular case arose 
from mechanical injury. 

If this particular nerve be divided intentionally within the cranium (which may 
be done by practice and dexterity), the external parts which it supplies lose their 
sensation; and, after a time, the eye becomes muddy, and the cornea opaque. 
This result I saw, when Magendie made his experiments; and many others have 
witnessed it. 

The treatment of a case of this kind, can only be conducted on the general treat- 
ment of paralysis; — icxactly as in the case of disease of the '* portio dura." 

Anaesthesia. — Paralysis of the sense of touch, which is called " anaesthesia," 
is also very rare. It is common enough for persons to lose sensation and motion 
in hemiplegia; but to lose the sense of feeling only is very rare. A case, which 
arose from cold, is described in the third volume of the " Medico-Chirurgical 
Transactions," by Dr. Yelloly. 

[[The following are the principal circumstances which P have had occasion to 
observe relative to this case. The hands, up to the wrists, and the feet, half way 
up the leg, are perfectly insensible to any species of injury; as cutting, pinching, 
scratching, or burning. The insensibility, however, does not suddenly terminate; 
but it exists (to a certain degree), nearly up to the elbow, and for some distance 
above the knee. He accidentally put one of his feet, some time ago, into boiling 
water; but was no otherwise aware of the high temperature, than by finding the 
whole surface a complete blister on removing it. No species of injury to a vesi- 
cated part of either hands or feet, is felt by him. The extremities are insensible 
to electrical sparks taken in every variety of mode. The cubital nerve, where it 
passes the elbow, communicates the sensation produced by pressure or a blow only 
half way down the forearm. He perspires much on the left side, just about the 
hip; but nowliere else. He is generally rather chilly; and the extremities are cold, 
except when he is in a comfortable room; in which case they are of the usual tem- 
perature of the body. The thermometer, however, rises to 101' in the mouth. 
The hands are somewhat of a purple colour. If he wishes to ascertain the tem- 
perature of any body, he is under the necessity of putting it to his face or neck, or 
the upper part of his arm. His skin seems to be more than usually sensible to the 

a Extracted from a Clinical Lecture by Sir Charles Bell; published in the " London Me- 
dical Gazette;" Volume 3; Page 341. (No. G3j February 14, 1829.) 
»• Dr. Yelloly. 



PARALYSIS. 681 

effects of heat. On putting his hand, at the desire of a friend, into a pail of hot 
grains, — which his friend assured him were not too hot, and (to convince him of it) 
previously ihrust his hand and arm into them, — there was a very extensive vesica- 
tion produced. His hands are never free from blisters, which he gets by inadvert- 
ently putting them too near the fire; and he has met with several severe burns, 
without being aware of them; no degree of pressure is felt by him, but a blow 
produces a slight degree of tingling. He has a general uneasy sensation in the 
extremities, which warmth rather relieves. His skin, in general, heals very readily, 
after being burnt or scalded in the most severe way; and there is no fever; (as far 
as he has been able to determine,) nor any increased heat or throbbing during the 
process of healing. This seems to be also the case with some other parts of the 
body, which are not altogether insensible; for, a litde time ago, he got burnt in the 
front of the patella; and, though there was a considerable slough separated in con- 
sequence, he suffered no pain, and little inconvenience during the cure. If the 
heat to which the insensible parts are exposed is moderate, vesication is not imme- 
diately produced. The part becomes red; and in a few minutes, but sometimes not 
till the lapse of an hour or two, is blistered. That a smaller than ordinary tem- 
perature produces vesication in this individual, seems to be ascertained by the 
circumstance, that exposure to the heat of a common fire gave rise to a blister on 
the knee, which was followed by the slough above mentioned; though the clothes 
which covered the part were not at all injured. Immersion in water at 120,° pro- 
duces no change in the affected parts; but exposure to the same temperature, at a 
common fire, speedily blisters. That degree of heat, is (as far as I can judge by 
myself) about the utmost which can be long borne by the hand, in ordinary cir- 
cumstances, without pain. 

Cold water, and warm water of every temperature, invariably appear lukewarm 
to him. Water at the freezing point produces no degree of sensation whatever; 
but when his hand is kept in it for some time, he feels a slight coldness at the end 
of the thumb. After his hand had been immersed in water of the common tem- 
perature, and was introduced into water of 32°, he had some sensation of warmth. 
The cold produced by means of a mixture of snow, or ice and salt, communicates 
no sensation, except a slight chilliness in the thumb; and when this freezing mix- 
ture follows the use of water of the common temperature, it produces a slight 
degree of warmth. A solid body produces no sensation, whatever the temperature 
may be. The power of motion exists in the muscles of both hands and feet. 
AVith the former he can grasp pretty firmly; but, in holding any thing, he is apt 
to drop it, if his attention is called away. There has been of late a slight loss of 
substance in the hands. He can lift a chair; but cannot raise himself from the 
ground, by taking hold of any thing placed above him. The susceptibility of 
impression generally, as well as the muscular power, appear to be somewhat di- 
minished. The functions are natural, and the pulse regular and moderate. 

In the treatment of these symptoms, no advantage has been derived from any 
plan which has been adopted either by others or myself. The warm bath, elec- 
tricity, galvanism, tonics, the rhus toxicodendron, and mercury (given with a view 
to its action on the bowels, and on the system at large), have been equally una- 
vailing; though it must be owned, that the patient has never shown a sufficient 
degree of perseverance, in the prosecution of any means which have been adopted 
for his relief.*] 

A case is recorded in the fourth volume of the "American Repository,** where 
the hands and feet were affected in the same way. The man was looking another 
way, and cut off his thumb without knowing it; and when he looked at his hand 
again, it was gone. This man frequently met with accidents, from treading on 
things which he ought to have avoided. He had burns and wounds in his hands 
and feet. He continued in this state for two years. There is an instance men- 
tioned by Laennec, in his second volume, where the right arm was broken; but 

a " Medico-Chirurgical Transactions;" Volume 3; Pages 92 to 95. 



682 PARALYSIS. 

the patient knew nothing- aboiit it, till he found he could not use it as before. All 
these persons were in the middle period of life, between forty and sixty years of 
age. I have never seen an instance of it. 

Paralysis of a Limb. — There are some interesting and curious cases of partial 
paralysis of sense and motion, which occur rather suddenly, and in only one ex- 
tremity. It is well to know these cases. I have never seen one; but they occur 
from time to lime. The extremity has been the arm, in almost every case. It 
has become suddenly cold, motionless, and senseless; and it has then mortified. 
This has not been from itifiammaiion; but, becoming paralytic first, the limb has 
presently mortified; so that frequently the whole case has not lasted more than a 
few days. One of the earliest instances with which I am acquainted, is mentioned 
b)^ Dr. Wells.* In that case it took place in the left arm; but the arm was not 
examined. Another case occurred in the right arm; and was followed by death 
in a few hours. It was observed, before death, that the arm was only pale; and it 
is said that nothing morbid was seen at the aiitopsy. There is another case men- 
tioned, where both the arm and leg, iti hemiplegia, lost the pulse entirely; and. 
there death look place in five days. But the nature of such cases has now been 
pretty well cleared up. It appears that some have taken place after external vio- 
lence. The external violence has lacerated the inner coat of the artery, and an 
effusion of lymph has blocked up the vessel; — so that the part has been deprived, 
almost immediately, of all blood; and the consequence of it, in the first place, was 
a loss of sensation and motion, and afterwards mortification. In the "Edinburgh 
Medico-Chiriirgical Transactions,'"' there is a paper well worth reading, commu- 
nicated by Mr. Turner, a suigeon; who found a laceration of the internal coats, 
and complete obstruction. In other cases there appears to have been no external 
violence; butr the artery has been previously diseased, and has suddenly given way 
in the inner coal; so that inflammation has been set up, lymph efi'used, and ob- 
struction produced in that way. Occasionally the obstruction takes place from an 
accumulation of pus. These cases were mysterious before the arteries were 
examined. 

These, I believe, are almost the only cases of partial paralysis, in which the 
pulse is lost in the paralyzed part. In most paralyzed limbs, it is weaker than in 
other parts of the body; but where it ceases altogetlier, it arises from a disease of 
the artery; — such as I have now mentioned. Magendie mentions a case of dis- 
eased nerves, producing such symptoms as I have stated; and, after death, the fifth 
pair was found swollen, with a ijrayish yellow-coloured matter. 

Diseases of the Nerves, a Cause of Local Paralysis. — The diseases of the 
nerves which give rise to this partial paralysis, are precisely the same, though 
different in situation, as those which give rise to hemiplegia and paraplegia.*^ In 
some instances it is entirely mechanical compression. Hemiplegia may arise from 
the compression caused by a tumour on the brain; paraplegia from the compres- 
sion caused by a tumour in the spinal canal; or the pressure of a bone that is 
fractured; and so may amaurosis (which is a partial paralysis) arise from the 
pressure of a tumour on the optic nerve. Any cause that will produce paraplegia 
or hemiplegia, will produce local paralysis when diflerenlly situated. Occasionally 
this local paralysis arises from local inflammation of a particular nerve; and the 
inflammation may be of so intense a character, as to be seen after death; and, in- 
deed, we may see ecchymoses. Sometimes there is sofiening of a particular nerve, 
-r—even ulceration of it; and a decided efi'usion into its sheath. These are precisely 
the same things that I mentioned, as causes of hemiplegia and paraplegia.*" Tu- 
mours have frequently been found resting on particular nerves; and when there 
ari6 these circumstances (inflammation, softening, ulceration, and tumours), there 
are often paralysis, violent pain, and spasmodic convulsive action of the muscles 
which these nerves supply. 

* In the " Transactions of a Society for the Improvement of Medical and Chirurgical 
Knowledge;" — a work which only C(jnsisis of a few volumes; but which contains papers of 
the highest, imporance by Dr. Bailiie, John Hunter, and others. 

^ Volume 3j1E%rt 1. ^ wy <= See Pages 665 and 672. 

...'.Kv'-'-' I 



BOOK III. 

DISEASES OF THE llESPIMTOEY ORGANS. 



CHAPTER T. 
BRONCHOCELE.^ 



Definition. — The disease to which I shall next direct your attention, is situated 
in the neck, outside the air-tubes; — in the gland called "thyroid." This disease is 
called "bronchocele;" from ^fioyxo^, the loindpipe; and the substantive of which we 
make so much use, — x»7?w>7, a tumour. The French call it "goitre;" and it is sup- 
posed that this is a corruption of the Latin word "guttur," the throat. 

Characters of the Tumour. — The disease occasions a sweUing in the front of 
the neck, in the situation of the thyroid gland; — a swelling produced, in fact, by an 
enlargement of that gland. No disease would be called "bronchocele," although 
a swelling in the neck, unless it were the result of an enlargement of the thyroid 
gland. This tumour is, for the most part, soft; and neither painful when left to 
itself, nor when touched; and therefore it is not tender. Although it is usually 
soft in almost every part, yet occasionally we find it hard in some one part; — of a 
cartilaginous, and (indeed) sometimes of a bony hardness. It may attain a large 
size, or it may be very small; — it may, in fact, be merely a general fulness of the 
gland, or a slight general enlargement. Very frequently it is enlarged chiefly, or 
almost entirely, in the centre, or on one side; and from being,- at the beginning, a 
slight fulness of only one lobe of the thyroid gland, it may attain so enormous a 
size, as to hang down to the knees. Fodere, in his treatise on the disease, men- 
lions an instance of a tumour which weighed seven or eight pounds; and Alibert 
mentions a tumour, occurring in a man thirty-eight years of age, which reached to 
the middle of the chest, was as large as a pumpkin, and looked like a pelican's 
pouch. There is also one mentioned, as existing in a female upwards of sixty 
years of age. It extended from ear to ear; descended below the mammcs; im- 
peded deglutition and respiration; and pressed on the "meatus auditorius," so as 
to close it up. A German author mentions an instance of a goitre descending to 
the knees. 

Internal Structure. — Its external appearance is sometimes uniform and some- 
times knotty; and on cutting into the tumour, we find cells of all sizes, widi con- 
tents of various consistency. Sometimes the contents are found gelatinous, and 
sometimes soft. Sometimes one particular part is cartilaginous, or even ossified; 
containing a quantity of calcareous matter. A variety of appearances are pre- 
sented in various parts of the same tumour. Occasionally the tumour suppurates; 

a In conformity with Dr. Elliotson's plan,— to liesciibe the diseases as they occur, a capilc 
ad caLcem (Paii^e 70), — bronchocele, and certain afFcciions of the nioiuh, stand next upon ihe 
list. And althous:h some of them scarcely admit of being- classed among- disenses of the 
respiratory organs; yet their proximity to those parts will probably seive as a butlicicut apo- 
logy for their introduction under this head. 



6S4 BRONCHOCELE. 

and sometimes disappears spontaneously. The blood-vessels of the part are found 
very much enlarged.* 

FrogTCss and Effects. — When the disease has begun, it usually increases; but 
occasionally it makes a stop; — does not, at a certain period of life, increase any 
more; and I have fancied that it has sometimes appeared to shrink in old affe. 
Broncliocele may destroy life, by pressure on the neighbouring parts; and Dr. 
Baillie says he saw one or two cases, in which death took place from pressure on 
the cesophagus and trachea. I have frequently seen it affect the voice; so that a 
person spoke in a hoarse, croaking tone, and with a sort of hissing sound; — such 
as is produced when the trachea is pressed. The disease is not entirely confined 
to the human subjecrt; but caitle, also, and dogs have it. It is very common for it 
to be less during the winter, and to increase again during the summer. It is said 
usually to begin in one lobe only of the thyroid gland. 

Influence of Jlge and Sex. — This disease affects females more frequently than 
males; and usually it does not begin before the individual has attained eight or ten 
years of age. There are, however, exceptions to this. In the *' London Medi- 
cal Repository," a physician mentions a child (in Derbyshire) who was born with 
a goitre of considerable size. At different times, when in Switzerland, I have 
made inquiry of the country people and of my guides; and one old peasant told 
me, that he knew an infant who was born with a goitre; and I saw one myself in 
a little boy only four years of age. However, the answer I usually received was, 
that the disease seldom appeared before six years of age; — nearly agreeing with 
what is usually stated by authors; who say that, in general, it does not begin before 
the eighth or tenth year. Indeed, I was told that not only bronchocele, but even 
cretinism (the idiocy of the country, which I formerly spoke of") did not begin 
in early childhood. Some of these people have a notion that a child has a goitre, 
or is a cretin, if either of the parents was drunk at the time of conception. They 
ascribe these diseases to that cause; though not in every case. 
■ Hereditary in its Nature. — As the disease is certainly seen in children, and 
they are sometimes born with it, and frequently the parents have goitres, it may 
be hereditary;" but although both parents may have goitres, yet (just as we ob- 
serve with respect to other diseases) it does not follow that the progeny must have 
them too. A case has been mentioned to me of a goitrous father and mother, who 
had produced five children, all of whom were goitrous, and cretins; and of another 
pair (both goitrous) who had four children with goitre; and one, twenty-two years 
of age, who was neither goitrous nor idiotic. In fact, she was said to be *' tall 
and genteel." 

Frequently accompanies Cretinism. — This disease frequently accompanies cre- 
tinism. When we see an individual with a large head, an "ace-of-spades" nose,'' 
the eyes a mere slit, perhaps deaf and dumb, and imbecile, it is very common to 
find the thyroid gland enlarged; and it is asserted that if people, both having goitres, 
marry, and one of their children (having a goitre) marry another with a goitre, that 
their offspring (constituting the third generation) are sure to be something worse 
than goitrous, — to be cretins, — to be idiotic. This is asserted; but I do not know 
its truth from any observations of my own. 

Occurs in various parts of the Globe. — We meet with this disease in various 
parts of the globe; and in all latitudes, — hot and cold. It is seen in England, 
France, Spain, Switzerland, Germany, China, Tartary, Bengal, the Island of Su- 
matra, Spanish America, and North America. Mungo Park says, that he saw it 
in the negroes of Barbary.* Some have ascribed it to the cold; but as it occurs 

» There is a representation of the disease in Dr. Baillie's work. 

^ See Page 545. *= See Page 54f>. 

<» The negroes attribute this disease [the "Guinea-worm"] to bad waier; and allege, that 
the people who drink from wells are more subject to it than those who drink from streams. 
To the same cause they attribute the swelling of the glands of the neck, ("goitre,") which 
is very common in some parts of Bambarra. — " Travels in the Interior of Africa; by Mungo 
Park.''^ Chapter 21. {^Page 59 of Chambers's " People's Edition.'") 



BRONCHOCELE. 685 

among the negroes in Barbary, and also at Bengal, it cannot be owing to the cold. 
Some have ascribed it to snow-water; but there is no snow either in Barbary 
or Bengal; and, on the other hand, the disease is unknown in Greenland and 
Lapland, where there is little else than snow-water, and where the weather is very 
sharp. 

Dependent on the Quality of the Water. — It appears, however, to be dependent 
in some measure upon the water; for the waters in the rivers and lakes of Swit- 
zerland are always bad, and are drunk only by the poor and ignorant; and those 
who drink them heanily are, for the most part, sure to have the disease. Those 
who are above the very lowest, — the most abject class, do not drink the waters 
either of the rivers or lakes; but the most ignorant people do. I have seen them 
drinking water the colour of ink, in Switzerland, in 1826. I had an intelligent 
guide, who told me that, beyond all doubt, this water produced it; but those who 
drank spring or snow-water, which did not run along a bed of lime, escaped; and 
nearly all escaped who drank cascade-water. He said, that the bad water usually 
took about a year to produce the disease; but the instant the bad water in his 
neighbourhood was drunk by those unaccustomed to it, they found unpleasant 
effects. Sometimes, he said, these effects were prevented by putting a bit of ice 
or snow into it. 

Dr. Richardson, in Captain Franklin's "Journal of a Voyage to the Polar Sea," 
makes an observation perfectly agreeing with the account which this man gave me. 
The captain says, that at Edmonton, on the banks of the Saskatchawan river, goitre 
is very common; that it is certain goitre affects only the drinkers of this water; 
and th.at, in its worst state, the disease is confined almost entirely to the half-bred 
women and children, who are always resident in the Fort, and make use of the 
river water; which is drawn, in the winter, through a hole made in the ice; whereas 
the men, from being often from home on journeys, and using snow-water, are less 
affected vviih goitre; and when they are at home in the winter, if signs of goitre 
come on, their annual summer visit to the coast presently cures them. He says 
the natives, who confine themselves to snow-water in the winter, or some of the 
small rivulets which flow through the plains in the summer, are exempt from the 
disease. A residence of one year at Edmonton, where the water is so bad, is suffi- 
cient to render a family bronchocelous. He says, that many of the goitres acquire 
a large size; and that burnt sponge has been tried, and found to remove the dis- 
ease; but that drinking the water again, renews it. A great proportion of the 
children who have goitres (he says) are born idiots, with large heads and other dis- 
tinguishing marks of cretins;* but he could not learn whether it was necessary that 
both parents should have goitres, in order to produce cretin children.* 

Another year that I was in Switzerland, passing along a valley near the lake of 
Valteline, the guide told me that, in one of the populous villages, there was no 
spring; and the inhabitants are therefore obliged to drink the water of the river; 
which is so bad, that goitre is very prevalent there. But, in another village, there 
are plenty of springs; and nobody there drinks any water, except that from the 
springs: and no one has goitre. He also added, that where there is much goitre, 
they are all Catholics; whereas in the village where there are plenty of springs, 
the inhabitants are Protestants. This is rather an important remark; because it is 
a very striking circumstance that, on many parts of the Continent, the Protestant 
districts are much cleaner and more healthy than the Catholic districts. More 
frequenUy than otherwise we can tell the Catholic districts, by merely looking 
round, and observing the state of the peasantry, without asking a single question. 
The Catholics spend so very much time in praying, that they are dirty in their 
persons, and not at all industrious; whereas the Protestants are very clean; — not 
spending so much time in church-exercises; and they are better off altogether. No 
one who has travelled, can doubt the truth of this remark; and it is important to be 

* See Page 545. 

^ "Narrative of a Journey to the Shores of the Polar Sea; in the vears 1810 to 18-22. By 
John Franklin." Chapter 4. (Third Ediiionj Volume Ij Pages 183 to 18tj.) 



6S6 BRONCHOCELE. 

aware of the fact; because (as T shall have to mention*) the worse people are off, 
the more subject are they to the disease, when the causes of it are apphed. 

[These facts seem to ifavour the notion (which is a popular one in goitrous dis- 
tricts), that bronchocele originates in some deleterious quality of the water. In- 
deed, It is impossible to examine the filthy beverage of some of these districts, 
without being convinced that pernicious consequences must ensue from its habitual 
use. Bally''— a native of a district in Switzerland, where bronchocele is endemic 
— states that, in his country, those M'ho drink the waters of certain fountains are 
almost always attacked; whilst others of the same village who avoid these waters 
are not liable to the complaint. Rambuteau, also, considers that water impreg- 
nated with calcareous salts contributes to its development. Dr. Coindet observed, 
that almost every individual of a regiment who drank the calcareous water of the 
pumps at Geneva, was attacked with goitre; which disappeared rapidly upon their 
removal to other quarters. Its prevalence in Nottingham is ascribed, by Dr. 
Manson, to the same cause."' 

Mr. M'Clelland has lately made extensive researches into the causes of bron- 
chocele among the Himalaya mountains. His inquiries extended over one thou- 
sand square miles; and he invariably found limestone-rocks in the immediate 
neighbourhood of goitrous districts; while in villages where this stratification was 
not observed, the disease was rarely met with. When it was found in the latter 
places, Mr. M'Clelland could generally trace it to the use of water having its 
source in the limestone-rocks; and where these waters were avoided, the com- 
plaint seldom appeared. Unfortunately, however, there are facts which prevent 
the universal application of this theory respecting the origin of the disease: — 
1. Bronchocele is met with abundantly in districts where there are no limestone- 
rocks; as, for instance, in the Vallais. 2. It is absent in many places abounding 
in limestone formations. 3. It prevails in districts where the water is pure, ami 
free from calcareous impregnations. •* 4. A strict adherence to distilled water, is 
not sufficient to ward off the disease in affected places.*] 

Nature of the Water. — The nature of the water which produces this disease, is 
not well known; but, in all probability, it is mineral. I presume it to be so, as the 
water contains so much lime; but I will not assert it. Captain Franklin states, 
that those inhabitants who reside sixty miles nearer the source of the river^ than 
Edmonton, are said to be more severely affected than those at Edmonton; and he 
says goitre is unknown at a distance from the river, where nothing but snow-water 
is drunk for nine months in the year. He adds that, still farther from the source 
than Edmonton, where the water is still turbid, the disease is unknown. It cer- 
tainly appears to be connected with the water; and seems to arise from some im- 
pregnation which the water has near its source, and which it loses as it goes along-. 
At Edmonton, Captain Franklin tells us, the river is clear, except from the month 
of May to that of July; and that the distance from the Rocky Mountains is one 
hundred and thirty miles. The neighbouring plain is alluvial, and the soil calca- 
reous; with many fragments of limestone. ^ In Switzerland the cause of the dis- 
ease would not appear to be in the water at its source; for the springs and cascades 
do not produce it. On the contrary, it is the water that runs along beds, and is 
found in lakes, that appears to give rise to it. Persons on the mountains are rarelv 
affected; and those who remove from the valleys and places where it prevails, to 
the mountains, find the tumour in some degree alleviated; and, after a great leno-ih 
of time, the disease has been known to cease altogether. The disease prevails 
much more in valleys with high mountains around them (such as abound in 
Switzerland) than elsewhere; and perhaps in those which are most exposed to the 
east and south winds. 

a See Paj^e 687. " " Dictionnaire des Sciences M6dicale,s." 

e " On the Etrects of Iodine." ^ Humboldt. 

e" Library of Medicine;' Volume 5; Pasre 18G. ^Saskatchawan, 

s Franklin's "Journey to the Polar Sea;" Chapter 4. (Third Edition; Volume 1; Pages 
184 and 185.) 



BRONCHOCELE. 6S7 

General Chnracfer of Goitrous Distrkts. — Whatever may be the cause of the 
afTection, it is found to prevail most where the air is worst; — where the mountains 
cause the air to be pent up, and where the persons are badlv off.'' It prevails in a 
particular valley in Switzerland (the Vallais) most friglitfujly; and there the peo- 
ple are worst off; for tliere more poverty and wretchechiess exist, than in almost 
any other part. The inhabitants are dirty, and badly fed. In the countries where 
it is prevalent, the people have a dirty brown look, and appear withered; — as if 
they were in premature old age. It seems that the causes which produce the dis- 
ease, are those which poison the habit generally, and render it more liable to be 
affected by the causes of this particular disease. They have an aguish, or malaria' 
kind of look; yet we sometimes have it where there is no ague; and we have ague 
where this disease does not exist. Any circumstance which throws the body out 
of health, may predispose to this disease. The particular circumstance of the 
patient having a withered look, may not be immediately connected with bron- 
chocele; but the causes of the withered look may impair the constitution, and 
render the person constantly liable to become goitrous. My own guide told me, 
that whrre the inhabitants were dirtiest, and the worst fed, they were most subject 
to the disease. Dr. Good says that, in Deibyshire, "He found a much larger 
number of the poor affected with this disease than he had ever seen before, while 
the rich escaped; he found also that by far the greater part of those who were 
labourino; under it, were not only exposed to all the ordinary evils of poverty, but 
derived their chief diet from that indigestible and innutritive substance, the Derby- 
shire oaten cake; which is probably the chief cause of all the glandular and para- 
bysmic> enlaraements which are so common to that quarter."*' But this oat-cake 
is eaten in other parts of England, with no such effect. 

Diagnosis. — [x^lthough the tumour of bronchocele is in general sufficiently cha- 
racteristic, it may sometimes be confounded with other affections. .The thyroid 
gland is liable to inflammation; but this disease may be distinguished from goitre, 
by the hard unyielding character of tho swelling; by its being accompanied with 
redness of surface, increased heat, and pain on pressure; by the suddenness of its 
appearance; by its not attaining the size of a goitrous tumour; and by its tendency 
to suppurate, 'j'he gland is sometimes affected with scirrhus.^ In this case, how- 
ever, only a small portion is usually affected; and differs from bronchocele in its 
extreme hardness, and in being generally the seat of severe lancinating pain. In 
scirrhus, also, the swelling seldom attains a large size. Encysted tumours some- 
times form in the course of the trachea; and may be distinguished from broncho- 
cele by their situation, by their compact form, and by their giving a sense of 
fluctuation. Aneurism of the thyroid arteries may be known from goitre by the 
pulsation which accompanies the former affection, by the situation of the swelling, 
and by its diminishing or disappearing under firm pressure,®] 

Treatment. — The patient should certainly desist from drinking any water which 
may be suspected to be the cause of it. Burnt sponge is nnquestionablv useful in 
it; and many practitioners say that they have seen cases cured by it. It has been 
supposed that the good effects of burnt sponge, are to be ascribed to the iodine 
which sponge contains. I presume there can be no doubt, that it possesses a 
remedial power over the disease; and some unite it with sulphur. 

Iodine. — By far the most efficient remedy, however, is iodine;^ and it may be 
employed externally or internally. I have cured many cases of bronchocele,— 
some of them where the tumour was rather large, — with this remedv. It may be 
employed in the form of iodine itself; or it may be united with hydriodate of po- 
tassa; and that, perhaps, is the best way of administering it. With regard to the 
quantity, there is no rule for the dose; for it produces two effects, — constitutional 
and local. The constitutional effects are emaciation, morbid irritability of body, 

« See Page 545. *> Congestive. 

c Dr. iVhiSon Good's " Study of Medicine;" Class 6: Order 1; Genus '2; Species I. 

d From 5-KP'^o», to harden. « " Library of Medicine;" Volume 5; Page 187. 

f From iflD^f, a violet-colour. 



688 BRONCHOCELE. 

quickness of pulse, pal pillion, and absorption of particular parts; more especially, 
it is said, the rnammae of women, and the testes of men. It likewise takes away 
the appetite; and is more or less injurious to the body at large. But besides that, 
it is a very acrid substance; and therefore, like any other acrid substance taken into 
the stomach, it will produce vomiting and gastritis, and even ulceration; and when 
it passes the stomach, it may produce diarrhoea, and more or less inflammation of 
the mucous membrane of the intestines. It affects the stomach and intestines im- 
mediately, — simply as a corrosive agent; and this may arise in one person from a 
small quantity, though it will not occur in another from a large quantity. We 
never know, beforehand, the disposition of the patient with regard to it; and there- 
fore it is always best to begin with a small dose. There can be no impropriety, as 
the disease is chronic, in delaying an efficient dose for some time. We may there- 
fore begin with five minims of the saturated tincture; and if no unpleasant eff'ect be 
produced, it may be increased a drop every dose, or every other dose. I have gone 
so far as to give one hundred minims for every dose; but a greatnumber of persons 
will not bear above twenty or thirty minims. Patients complain of heat of the sto- 
mach; but if we begin gradually, and inquire of the patient whether there is any 
burning sensation, or heat of the stomach, or any griping, we never need run the 
risk of doing mischief from its local effects. When a person begins to feel a dose 
(such as fifteen or twenty minims), I have been told that diarrhoea took place even 
with griping and bleeding; — owing to its being such a corrosive substance; and if a 
large quantity be taken into the stomach, the mucous membrane will soon be in a 
state of erosion. 

Hydriodate of Potassa.^-^As to the hydriodate of potassa, there is scarcely any 
rule for the dose; but it may be given in larger doses than the tincture of iodine. 
If we dissolve a drachm in an ounce of distilled water, we may begin with ten or 
fifteen minims, and increase the dose to a great amount. There were two or three 
men whom some gendemen of my class saw at St. Thomas's Hospital, and who 
took two drachms of the salt at a time. There can be no doubt that the medicine 
was good; for Dr. Burton* analyzed it very carefully. The article is often adul- 
terated; and lime has been found in it; but care was taken to have a good article; 
and that which these men took was known to be a pure salt. I also recollect a 
woman, who took one drachm for a dose, three times a day, diluted with ten or 
fifteen ounces of distilled water. There is no rule for any medicine, as to the dose 
applicable to all cases. Some persons always find fault with others who are ener- 
getic, or employ remedies in an efficient manner; but it does not follow, because 
we are energetic, and employ medicines efficiently ^ that we should employ them 
rashly. There is no occasion to do a patient harm; and no occasion to run any 
risk. It has been thought by some, that it would be better to give iodine and this 
salt together. 

With respect to the length of time during which the remedy may be taken, I 
have been obliged, in bronchocele, to give iodine a whole year, before the disease 
was cured. Seeing the disease was lessened, I persevered; and have gone on for 
twelve months; and, indeed, for more than that time. I think, in one case, I con- 
tinued the remedy fourteen or sixteen months, before the disease went away. That 
was the longest case of bronchocele I ever cured. I never saw any unpleasant con- 
stitutional effect; though no doubt such efl^ects will occur, for they have been men- 
tioned by authors; but I think if we see the patient frequently, and make proper 
inquiries at every visit, such unpleasant effects can hardly take place. Now and 
then, it may take us by surprise; as is the case with every remedy. It may act 
suddenly. But in general, when a remedy appears to act suddenly, it has been 
continued some time after its effects have begun; and if it had been watched care- 
fully, and left off" the moment it commenced its action on the body, no such effects 
would have ensued. In cases where a remedy has seemed to act suddenly, I can- 
not but think that, with the exception of digitalis, it has generally begun to act mo- 

» At that time, the Lecturer on Chemistry at St. Thomas's Hospital. 



BRONCHOCELE. 6S9 

derately, and has then been continued without diminution. Had it been omitted 
the moment the effect began, the slight effect would gradually have ceased. 1 am 
not aware of ever having done mischief with iodine. 

External Use of Iodine, — It is well to apply the remedy externally^ as well as 
internally. We make an ointment by putting a drachm, or even two drachms of 
the hydriodate of potassa, to an ounce of lard. The skin differs like the mucous 
membrane, and the constitution at large; and what produces merely an irritation in 
one part, will produce a diffused rash in another. It is well to use half a drachm, 
or a drachm at first, if the person have a fine skin; and then, if no ill effect be 
produced, we can increase it. It is absurd to apply it so as to irritate the skin. 
The patient cannot bear rubbing then; and if inflammation begin, it must cease 
before we can apply it again; and we lose so much time. We shall see, when I 
speak of diseases of the abdomen, how much good is effected in the same way as 
in bronchocele, by the exhibition of this medicine. 

Other Remedies. — Besides burnt sponge and iodine, some recommend carbonate 
of soda: some, conium; and some, leeches. If the part fall into an inflammatory 
state, leeches may be useful; and if inflammation occur, the iodine should be sus- 
pended, and common antiphlogistic remedies resorted to, till the effect has ceased; 
and then it should be had recourse to again. Mercury, internally and externally, 
has been useful; and the two may be combined. I have seen the disease give way 
to the two; but I can hardly say how mucli good was ascribable to each. Pressure 
has been said to be useful; but it is awkward to make pressure, on account of the 
trachea and oesophagus. There can be no doubt that a seton, in this disease, is 
an efficient remedy. There are on record, very many cases of this disease, which 
have yielded to a seton placed in the skin over the tumour. 

Ligatures on the Vessels. — The disease has been treated surgically^ as well as 
medically. Some surgeons have tied the vessels of the tumour, with good effect; 
but this IS a point on which I must not dwell. I have only to do with this disease 
as it is treated by medicine; but I may mention, that Sir William Blizzard (formerly 
an able surgeon at the London Hospital) tied the vessels; but death took place from 
secondary haemorrhage. However, in one week the tumour decreased in size one- 
third. Walther tied the left inferior thyroideal artery; and the tumour diminished 
so much, that at the end of fourteen days he took up the right superior thyroideal 
artery. No inconvenience was felt; and the tumour speedily disappeared almost 
entirely. A surgeon in this country (Mr. Coates) tied the artery on the left side 
only; and cured the complaint. 

Extirpation of the Gland. — Some surgeons have been bolder still. Dr. Hedenus, 
of Dresden, (with whose son I was acquainted,) extirpated the gland in six cases; 
in one of which it was as large as a skiltle-ball. The whole of the cases were 
succe.ssful. Fodere mentions the case of a barber, who cut one away from his 
wife. This was a lucky hit; for he would probably kill the next\woman on whom 
he operated. Two unsuccessful cases of extirpation, are said to* have occurred to 
Mr. Gooch. Dupuytren (the celebrated French surgeon) removed a tumour, after 
having first tied the arteries. Only a few spoonfuls of blood were lost; but the 
operation was very long. Much suffering took place; and the patient died in thirty 
hours. In several cases, the operation has been found so hazardous, and altogether 
so difficult, that the surgeon has been obliged to desist in the midst. Desault is 
said to have removed half the gland with success. I find a note in " Frazer's 
Journal," stating, that in no part of the world has the whole tumour been extir- 
pated. There can, however, be no doubt of the fact; for persons have shown that 
the tumour has been extirpated, by the scars in tiie neck left after the operation. 

The chief treatment, however, is by means of iodine internally, and a seton. 
Neither of these will cure every case. I have seen the tumour so hard, that it was 
quite absurd to suppose any thing was capable of removing it. When it is carti- 
laginous, or ossified to a great extent, I should think it vain to give iodine, or apply 
a seton. 

VOL. I. — 44 



690 AFFECTIONS OF THE MOUTH AND THROAT. 



CHAPTER 11. 

AFFECTIONS OF THE MOUTH AND THROAT. 

SECTION I.— PAROTITIS. 

The next disease which I shall describe, is an affection of one of the glands in 
the neighbourhood of the thyroid; but a little higher. This is entirely a medical 
disease; and I believe the surgeon never applies his art to it. The last-mentioned 
disease is disputed territory; — surgeons take it, and physicians take it; but this 
("the mumps") is, I believe, strictly medical. 

Definition. — As this is an inflammation of the parotid glands, it is called *' paro- 
titis;" or, in the language of CuUen, "cynanche/?«ro^zf/e«." Dr. Cullen describes 
five kinds of cynanche.* The definition of the vi^hole is — '* ])yrexia, frequently of 
the typhoid type; redness and pain of tiie fauces; deglutition and respiration diffi- 
cult, with a sense of constriction; narrowness in the throat." The first of the 
five kinds here mentioned, is inflammation of the parotid glands. I think it better 
to drop the word " cynanche;'"' and not consider the different species of cynanche 
as varieties of one general affection; but I shall speak particularly of inflammation 
of the parotids ^ inflammation of the tonsils, and so on; and I presume that, in a 
few years, the word '^ cynanche'^ will be discontinued; and that we shall speak 
only of diseases o( one part, or o^ another. 

Symptoms. — Parotitis, or (in plain language) "the mumps," is a swelling of 
one or both parotid glands: attended with an increase of heat in the part; extending 
to the submaxillary and sublingual glands; and afl^ecting the rest of the salivary 
glands. The disease is attended by slight feverishness; and lasts, in general, three 
or four days; — sometimes longer. It is sometimes followed by inflammation of 
the testicles, or breasts; and sometimes by phrenitis. When a testicle has been 
so inflamed, it frequently becomes atrophied; and nothing is left but the mem- 
branes; — the " tunica albuginea," and " tunica vaginalis." 

75 it Contagious? — Parotitis occurs, usually, but once during life; and is said, 
I know not how truly, to be contagious. It certainly is sometimes sporadic; but 
frequently it is epidemic. It prevails, in a boy's school, all at once throughout; 
and it prevails in several schools in the same neighbourhood. I really do not know 
whether it is so or not. 

Jige at which it occurs. — It occurs most frequently from seven to fifteen years 
of age; — sometimes later. Now and then, we see it in young men; but most fre- 
querUly it occurs at the time I have stated. 

Treatment. — There is nothing particular required for it. We ought to apply 
moderate warmth, keep the patient quiet, make him abstain from ordinary nourish- 
ment and stimuli, give him a mild aperient; and the disease, for the most part, goes 
away after a time. It is very rarely that suppuration takes place. I have seen 
suppuration; but I presume it was an accidental circumstance, — from the inflam- 
mation extending to the cellular membrane. I should not recommend cold to be 
applied; because the disease has a tendency to metastasis. At least, when it ceases, 
the testicles and breasts are apt to be afl^ecled; and one would suppose that if we 
cause it to cease suddenly, there is a greater probability of such inflammation oc- 
curring. As to inflammation of a testicle, that is not in itself dangerous. It is only 
sharp and painful; yet it is thought to be a serious matter. I believe, that if one 
testicle should be lost, the other will do double work. But there is somethino- 

o 

» Dr. Cullen's five species are:— 1. Tonsillaris. 2. Maligna. 3. Trachealis. 4. Pha- 
ryngea. 5. Parolidea. 



ArPECTIONS or THE MOUTH AND THROAT. 691 

more danjrerous; and that is the liability to phrenitis. Phrenitis sometimes takes 
place, when inflammation of the testicle ceases. Sometimes the inflammation in 
the brain may occnr at once, when the mumps cease; but, more frequently than 
not, inflammation of the breast or testicle occurs^rs^, and then phrenitis supervenes. 
If the case be severe, we must treat it still more actively, — by means of leeches 
and purgatives. 



SECTION II.— TONSILLITIS. 

- We now enter the air-passages; and the first disease I shall describe, is inflam- 
mation of the tonsils; called by Cullen *' cynanche tonsillaris^'''' but frequently 
called by others *' tonsillitis."* 

Symptoms. — The disease to which these names are given, is not an inflamma- 
tion of the tonsils simply; for the surrounding parts are more or less aff'ected. 
The "velum pendulum palati" and the uvula, as well as the tonsils, — one or both, 
—are red and swollen. The uvula is elongated, and its margins are translucent; — 
it becomes (Edematous and swollen. If both tonsils be inflamed, on opening the 
patient's mouth two large red balls are seen, one on each side of the throat; which 
impede deglutition and speech. They may also be felt externally. When the 
tonsils are enlarged, people say "the almonds of the ears are down;" for the tonsils 
are called, in common language, " the almonds of the ears." Besides this swellino- 
and redness, the secretion of the parts is altered; so that the mucus of the mouth 
is very tenacious, — slimy, as people say. There is frequently very great pain; 
for the inflammation affecting the tonsils is of a phlegmonous character; and the 
pain is sometimes very severe, — stabbing and shooting to the ear. Besides the 
shooting pain, there is necessarily great tenderness felt — particularly on swallow- 
ing. Even the efTort to swallow the saliva — that is to say, the mere effort of 
swallowing, without the presence of any firm substance to swallow — gives pain; 
the motion of the part is painful. The disease sometimes occurs on one side only; 
and it is said that the disease will shift from one tonsil to the other; — as in inflam- 
mation of the eye. When one eye gets better, the other may become inflamed; 
and a similar occurrence often takes place in the case of the tonsils; when one 
ceases to be inflamed, the other becomes so. 

Sometimes, in addition to the redness, heat, swelling, and hardness, there are 
specks of ulceration. Some persons, as soon as they have a sore throat, have 
specks of ulceration here and there, on the tonsils and uvula; wnth very little sub- 
jacent inflammation. Some persons have the mucous membrane inflamed alone; 
without any inflammation of the subjacent cellular membrane, hardness, or enlarge- 
ment. If the case be severe, there is a good deal of pyrexia. The pulse will 
become very quick in this disease, (as it sometimes will in acute rheumatism,) 
without any danger whatever; and the tongue is frequently excessively foul; — I 
presume from the inflammation afl^ecting it, as well as other parts. The foulness 
of the tongue is not at all in proportion to the danger of the disease; but I presume 
it arises, in a great measure, from the irritation being situated in that quarter of the 
body. 

Terminations. — The disease may terminate in " resolution," as it is called; or 
it may terminate in suppuration. It is decidedly phlegmonous inflammation, so 
far as the parts are concerned; and they very frequently suppurate; and when they 
do, the matter is found to be very offensive; — as offensive as if it were coming from 
a diseased bone. 

Causes. — The 'predisposing causes of the disease are, in the first place, a 
peculiar constitution, and disposition to it. IMiere are some people who, in what- 
ever way they may be exposed to the general causes of inflammation, continually 
get a sore-throat. Whenever they are exposed to the vicissitudes of temperature, 

» From *' tonsillae," the tonsils; and " itis," infiammaiion. 



692 AFFECTIONS OF THE MOUTH AND THROAT. 

coldness, and moisture, they are sure to have inflammation of the throat; and this 
will run in families, — so as to be constitutional. It certainly is predisposed to by 
mercury. When j)ersons have been much under the influence of mercury, they 
are very liable (as I mentioned when speaking of inflammation in general*) to take 
cold from the vicissitudes of temperature; and the throat is certainly particularly 
liable to inflammation from this cause. The youthful period of life appears more 
liable to tonsillitis than old age; for we see far more cases of inflammatory sore- 
throat in the young, than in the old. Perhaps, among the predisposing causes, I 
might mention the season of the year; — Spring. Cases of this description certainly 
occur (from cold and wet) more frequently in the Spring, than at any other period. 

The exciting causes of the disease are, especially, cold and wet; — whether 
applied to the body at large, or to the feet only. Cold applied in any way, is suf- 
ficient to produce the disease. 

Treatment. — It is rarely necessary to take blood from the arm; but leeches 
around the throat are particularly useful. I do not know that it is necessary to 
apply them internally to the fauces. I think that, applied externally^ they answer 
every purpose they can eff'ect; and that a free application of leeches, is far superior 
to blistering. As a general rule, in the treatment of inflammation, we must be upon 
our guard never to let blistering take the place of the removal of blood. If the 
inflammation be at all severe, and requires the abstraction of blood, we only harass 
a patient (in any disease whatever) by blistering; which, in this di.^ease, is a very 
painful remedy, and does not, by any means, answer so good a purpose as the 
frequent application of leeches externally, under the lower jaw, followed by poul- 
tices. The latter not only tend to encourage the bleeding, but act as a constant 
fomentation; — relaxing the parts, and causing perspiration there. If the patient 
be too weak for the application of leeches, a blister then will be proper; or, if we 
have applied leeches as far as it appears advisable, and still it is requisite to do 
more before the disease can be controlled, then blisters may be used with advan- 
tage. It must be remembered, however, that when a patient can bear leeches, they 
are the most useful remedy. 

Incision of the Tonsils. — I have found great benefit, in this disease, from a mode 
of treatment perfectly analogous to what is practised, with so much success, in 
gome cases of inflammation of the surface of the body, and subjacent cellular mem- 
brane. In "erysipelas phlegmonodes," or any kind of erysipelas where there is 
extreme tension and hardness of the surface, incisions do great good. They set 
the surface at liberty; so that the tension is removed, and great benefit always 
ensues.'' Now I have adopted similar treatment, frequenfly, in inflammation of the 
tonsils; and with very great efl"ect. It is sometimes very diflScult to know, in the 
case of the tonsils, whether matter is formed or not; and I dare say many practi- 
tioners (I am sure it has occurred to me) have plunged a lancet into the tonsils, in 
the expectation of finding matter, when there was none. They sometimes become 
so exceedingly large, that it warrants a person in trying whether there is any mat- 
ter or not. Sometimes, when there is matter, instead of being softened, the parts 
are so tense that we do not find any fluctuation; and sometimes they are swollen 
so much, that we might fancy there was fluid when there is not. Thus mistakes 
are made on both sides. But whether matter comes or not, great relief is expe- 
rienced by plunging a lancet into one or two places. The part is always very 
tense, and if incised by a lancet, gapes; and when there is a little bleeding, the 
patient (in most cases) is better for it. 1 have seen it afl^ord far more relief than 
leeches: and I know, therefore, that it is a very good practice. If there be any 
matter there, its escape is desirable; but even if there be none, we generally find 
very great benefit. It is wrong to delay this operation; for it is quite harmless, 
and productive only of momentary pain. 

Purging and Vomiting. — For the purpose of purging, there is nothing so good 
as a large dose of calomel; because it may be mixed with sugar, and put on the 

« See Page 112. >> See Page 401. 



AFFECTIONS OF THE MOUTH AND THROAT. 693 

tongue; when it slips down easily. It is wrong to give acrid purgatives, such as 
salts, which stimulate the parts as they i]fo down; and it is wrong to give any thing 
bulky. Castor oil easily slips down. Some persons recommend vomiting, in this 
disease; and it certainly causes a great discharge of mucus from the pharynx and 
larynx, and all the surrounding parts; and frequently does good; but, frequently, 
it is a severe remedy. 

Gargles. — Gargles are pleasant to the patient, on account of the tenacity of the 
mucus. A. sour gargle is very grateful; and so, sometimes, is the inhalation of the 
steam of hot water. This relaxes the parts, and is found very agreeable; but I 
have often seen j)atients derive the greatest comfort from ices. 

I believe the free application of leeches externally, an incision or two in the ton- 
sils, and a good dose of calomel will, for the most pait, cure the disease. As to 
starving and low diet, we need not inculcate that; for the patient cannot swallow 
any thing. 

Tonsillitis ivith Dehilify. — Although the above described form of the disease is 
that which we see every day, yet we occasionally find this affection occurring with 
debility. It is chiefly in old people that it occurs in this latter form; and chiefly 
in people who have had frequent sore-throats. When the throat has been sore 
very often, the inflammation is not of an active kind, but follows the course of 
gonorrhcea. When people have had the latter afl*ection very often, the active 
symptoms are less severe; and so it is in the throat. When persons have had 
many attacks of tonsillitis, the inflammation is generally less active; the parts are 
not of so bright a red; they are of a more dingy red; there is less pain; and the 
swelling is greater in proportion to the other symptoms. In such a case as this,-— • 
with such debility of constitution, the shortest way is to give stimulating gargles; 
— for instance, the decoction of seneka, with Cayenne pepper and brandy in it. If 
the patient be weak, we must give good food; and sometimes allow a little wine 
The case may be (like any other inflammation) active, and to be treated as first 
pointed out; or it may be passive, and require only local astringents and stimii^ 
lants. But sometimes the whole constitution is weak; and we have to support the 
patient with good food, and perhaps even wine.* 

Ulceration and Gangrene. — Sometimes, when the disease occurs with ulcera- 
tion, there is a great tendency to mortification. This is a case that must be treated 
on the principles I before mentioned;'' — good food, more wine, and perhaps qui- 
nine. But good food and wine, are among the best things; and we must also em- 
ploy stimulating applications, together with stimulating gargles. In this case, too, 
the chlorides of soda and lime answer very well; — that is., when the patient simply 
requires a stimulating gargle. 

We are not, however, in every case of inflammation, to jjresume the existence 
of ulceration; but (as I mentioned when speaking of ulceration of other parts of 
the body) where there is ulceration, we must adopt the antiphlogistic regimen. I*, 
Many cases of ulcers of the leg yield to antiphlogistic treatment, after all other 
means have failed; and so it is in ulceration of other parts of the body. The parts 
are red, and there are signs of strength; and the shortest way to cure the ulceration 
is to bleed locally and generally, and put the antiphlogistic plan in force. Ulcera- 
tion occurring in tlie throat, however, is most frequently of an opposite character. 
This ulceration of the throat is most frequently seen in scarlet-fever; where it is 
called "cynanche maligna;''''^ but ulceration of the throat frequently occurs without 
scarlet-fever at all. In these circumstances, it is frequently necessary to inject 
stimulating gargles, several times a-day. 7'here are many good applications, but 
one of the best is the acetate of copper, made into a gargle. 

Chronic Ulceration. — Chronic ulceration of the tonsils is also very common; 
being one of the common efl'ects of syphilis. 

Enlargement of the Tonsils. — Inflammation of the tonsils is sometimes chronic; 
and is then attended with permanent enlargement of the tonsils. This is more 

• See Page 131. t See Pages 130 and 131, and 134. « See Page 131. ^ See Page 390. 



694 



AFFECTIONS OF THE MOUTH AND THROAT. 



frequently seen in children than others. The tonsils, after they have been inflametl, 
remain hard, — fall into a state of chronic inflammation, induration, and enlarge- 
ment; — from lymph, I presume, having been effused into the cellular membrane. 
There is no difficulty, in cases of this description, in making a diagnosis. If we 
fail to make it externally, we have only to make the patient open his mouth, and 
the disease is apparent. The best treatment is the moderate exhibition of calomel, 
so as slightly to affect the mouth; the use of iodine, internally or externally; and 
of hydriodate of potassa. Iodine, in both forms, has great power in dissolving and 
dissipating induration and enlargement. There can be no impropriety in combin- 
ing both plans. If there be much tenderness, leeches are very proper. 

Occasionally this enlargement is not the result of active inflammation, but takes 
place slowly; and friction with iodine, or hydriodate of potassa, or both, is a very 
good thing. Sometimes there are cases, in which it is judged right to have recourse 
to surgery; to extirpate the tonsils, or tie a ligature; but the greater number of 
cases do not require this, provided they are treated early and perseveringly by mer- 
cury, or iodine and hydriodate of potassa, both internally and externally. 

Pharyngitis. — Cullen also speaks of inflammation, very far back in the throat; 
and I therefore legitimately touch upon it. I allude to " pharyngitis," — inflamma- 
tion of the pharynx; or, as it is called by Cullen, '•' cy n2.nc\\Q pharyngeal 

Symptoms. — Pharyngitis usually takes place from the mere spread of inflam- 
mation from the tonsils. When the tonsils are inflamed, it is very common for the 
inflammation to go farther back. Inflammation knows nothing of our artificial 
division of organs, and division of diseases; but spreads along the mucous mem- 
brane; and the pharynx is continually becoming inflamed. Now and then, how- 
ever, it occurs in an idiopathic form; — that is to say, it occurs as a distinct separate 
disease. I have seen one or two instances of it. When this inflammation exists, 
there is redness at the back of the throat. On looking into the mouth, we see the 
posterior part exceedingly red. Deglutition is very much impeded; but respiration 
is not at all difficult. At any rate, if there be any difficulty of respiration, it is 
slight. The voice is not affected, any more than respiration. It is the gullet that 
is affected; and therefore persons can speak and respire very well. 

The treatment of this affection is the same as that for inflammation of the ton- 
sils;* and therefore I shall not dwell upon it. 

SECTION III.— STRICTURE OF THE (ESOPHAGUS. 



We are frequently consulted upon a disease, which occurs rather lower down 
than the pharynx. I refer to stricture in the oesophagus, — producing obstruction. 

Symptoms. — In this disease there is, as in inflammation, a difficulty of degluti- 
tion; but then there is no sensation of heat in the part, — no soreness; — and, for 
the most part, no pain. The difficulty of deglutition is chronic; and, for the 
most part, has come on very slowly. It is easily ascertained by the applica- 
tion of a bougie or probang; and this, I may say, is the only remedy; for medi- 
cine can do no good in stricture of the oesophagus. When patients come to us 
with a difficulty of swallowing, if we ascertain it is not in the throat, but a little 
lower down, and that stricture has come on slowly, it is right to pass an instru- 
ment down a certain distance. This being the case, we employ surgery, and 
surgery only. 

Spasmodic Stricture. — But this disease appears sometimes in a different form; 
and it is then entirely of a spasmodic nature. Frequently, when persons have not 
2i permanent stricture of the oesophagus, they have occasionally a spasmodic stric- 
ture in the part; — just as tfiey have in the urethra; so that it will be much worse 
at oyie time, than ai another. This occurs uiore frequenily in women, than in 
other persons; and frecjuently it is connected with hysterical symptoms. 

Treatment, — The best mode of treating it, is to use the shower-bath; to purge 

• See Page 692. 



AFFECTIONS OF THE MOUTH AND THROAT. 695 

the patient well; and to use oil of turpentine, and other remedies of that kind. I 
have read of cases where it appeared to give way to mercury; but I have not seen 
them myself. It has always appeared to me, that they would do better wiiii the 
common remedies of hysteria; — by purging, on the one hand; and by lessening the 
irritability of the body at large, (by means of the shower-bath, the administration 
of iron, and putting the health generally into good order,) on the other. We must 
carefully remember this form of tiie disease, and iis freedom from danger. 

SECTION IV.— INFLAMMATION OF THE MOUTH (STOMATITIS). 
a. Pustules of the Mouth, 

Characters. — Repeatedly are children brought to us by their mothers, with pus- 
tules on the tongue and lips, and inside the cheeks. I do not know that the disease 
has any specific name; but the parts I have mentioned, are elevated in consequence 
of the pustules; and the tongue is frequently much swollen, and just the colour 
that it is when persons are much under the influence of mercury. From the swell- 
ing of the tongue, the quantity of mucus secreted, the saliva running out of the 
mouth, and the fetid state of the breath, one would imagine, at first sight, that 
the child had taken mercury; but if we give calomel in such a state, it does not 
increase the mischief, but answers well as a purgative. It is one of the best to give 
children. 

Treatment. — I have found great benefit, in these cases, from the use of washes 
containing some astringent; but the mode of giving it to the child, is to put a grain 
or two of sulphate of zinc (for example) into an ounce of syrup. The child has 
no objection to it; and it exercises a beneficial influence. The disease sometimes 
occurs to many children in one family; but whether it is contagious I do not know. 
The disease is described as common ulcers in the mouths of children; and they 
may last some time without any danger; but purgatives and local astringents are 
very useful. Whenever we have to apply an astringent to the mouth of a child, it 
is better to give it in syrup, instead of water. 

b. Aphthss. 

There is a disease that frequently affects the mouth, and neighbouring parts; 
and usually in the period of infancy. It is called the '* thrush;" or, in medical 
language, '' aphthas.^^^ It is always mentioned under diseases of the skin; but as 
it occurs in the mouth and throat, it is perhaps hardly right to call it ^^ 3. cutaneous 
disease;" — it is a disease of the mucous membrane. 

Characters. — It consists in the formation of vesicles within the mouth and lips, 
and all the way along the cheeks, the jLongue, and the velum pendulum palati; and 
even on the mucous membrane of the hard palate, the tonsils, and pharynx. On 
opening the mouth, it presents an appearance just as if the patient had been taking 
milk, curds and whey, or some chalk mixture; — all the vesicles are exceedingly 
white. This is produced by innumerable elevations of the cuticle, by a fluid, and 
a large number of minute vesicles. There is sometimes a good deal of inflamma- 
tion with it; and sometimes there is scarcely any thing more than this white appear- 
ance, — as if the parts were filled with curd. 

Age at lohicli it occurs. — This disease is certainly most common in infants; 
but we shall frequently see it in adults, at the end of chronic diseases; — at the 
end of phthisis, for instance. It is very common then for persons to complain much 
of the throat; — to complain of a difficulty of swallowing; and even when persons 
die of diseases of the abdomen, of various sorts, it is very usual indeed to see 
apiith33 before death. It will occur in old people from very trifling causes. 

' From avrx, to set on fire. 



696 



AFFECTIONS OF THE MOUTH AND THROAT. 



Not necessarily fatal in Old Jige. — It is supposed to be a fatal disease, when it 
occurs in old people; or in those in whom a chronic disease has existed for a long 
time; but it is not an invariable rule. I recollect an old lady of ninety, who at 
that advanced age, suffered an attack of bronchitis, and got well; — and afterwards 
attained the age of one hundred; — how much more I cannot tell; but I know she 
lived ten years after the attack, notwithstanding it was united with aphthae; and 
therefore aphthae is not necessarily a fatal sign in old people. We see the disease 
every day, however, in persons who are dying of chronic diseases. I believe old 
women say, that if we do not have it when we are youngs we must have it when 
we are old, I only mention this to show how common the disease is. 

Treatment. — When the disease occurs in infants, it may be so slight as to re- 
quire scarcely any treatment; but if it do, we find it useful to employ the warm 
bath, and attend to the bowels. There is frequently irritation of the mucous mem- 
brane lower down in the alimentary canal; frequently sickness and diarrhoea; and 
therefore it is sometimes useful, besides the warm bath, to have recourse to pur- 
gatives; and besides that, it is sometimes necessary to employ Hydrargyrum cum 
Creta, and opium. There is often tenderness on pressure; and then it is neces- 
sary to apply poultices over the abdomen, as a constant warm bath; and to apply 
a leech or two; but often a mustard poultice answers best. A small portion of 
ipecacuanha or camphor, is often serviceable; but nothing is better than a mild 
astringent in syrup; — such as I have mentioned already* (made with a minute 
quantity of sulphate of zinc). Many people employ borax and honey; and inju- 
dicious nurses tie a rag to a stick, and mop out the child's mouth; and thus make 
things worse. They had better use a camel's-hair pencil; or leave the disease to 
pursue its course. I have no doubt hat the chlorides are useful; but in the case 
of children, they must be given very much diluted. In adults, I do not know any 
means so useful as the chlorides. They will frequently change the appearance 
of the month almost immediately; but the common solution must be diluted with 
six or eight times its weight of water. When the intestines have been in a state 
of irritation only, a few specks will appear at the rectum; and then old women 
consider that the disease has had a long journey, and has shown itself at the other 
end. If, however, we examine the intestines, we find no inflammation, — only 
specks; and it is only towards the anus that these specks appear. Nevertheless, 
the irritation which produced the vesicles, certainly does frequently extend all 
through the alimentary canal. 

c. Stomatitis Mercurialis. 

[The inflammation of the mouth excited by the specific action of mercury, is a 
serious adjunct to the ptyalism produced by this metal. " Ptyalism" strictly 
signifies increased secretion from the salivary glands; and it may occur quite inde- 
pendently of mercurial action, as an accompaniment of hysteria, hypochondriasis, 
and dyspepsia; but it is then very rarely attended with stomatitis. 

Symptoms. — The affection is generally preceded by an unpleasant taste, com- 
pared to that of copper or brass; soon after which the patient complains that his 
teeth feel soft and tender when brought together, and he fancies they are loosened 
in their sockets. Soon after this, shooting pains are felt in the face, and a stiffness 
in the movement of the lower jaw, caused by tumefaction of the submaxillary and 
parotid glands. The gums are of a deep red colour, and their margins projected 
(as it were) from the teeth. Here and there we may perceive spots of a dull white- 
ness, caused by opacity of the epithelium. The tongue is swollen, indented at the 
edges by the pressure of the teeth, and coated witli a thick yellow or brownish fur: 
the breath has a peculiar fcetor, and often before the stomatitis is very manifest. In 
severe cases there is ulceration of the gums; commencing at the margins, and ex- 
tending to the interior of the cheeks. Occasionally the tumefaction of the salivary 



AFFECTIONS OF THE MOUTH AND THROAT. 697 

glands is so great, as to prevent the mouth from being opened: this, together with 
the engorgement of the tongne, may become so considerable as to induce suffoca- 
tion. But wiihout attaining so serious a degree, the stomaliiis is productive of great 
distress, by tlie impediment to speaking, mastication, and deglutition, as well as 
by the profuse secretion of saliva. The patient often complains of it more bitterly 
than of the internal inflammation, for the removal of which the mercury was ad- 
ministered; and he can scarcely refrain from inveigliing against his physician, for 
substituting so loathsome an aff'ection even for a malady which threatened his 
existence. The local symptoms are generally accompanied by feverishness, and 
general irritation. 

Duration. — The duration of ptyalism varies with the extent and severity of the 
inflammation. If ulceration has taken place, the parts seldom recover themselves 
till several weeks have elapsed; and even without this, it may be almost as long 
before the spongy state of the gums, and the increased flow of saliva, entirely sub- 
side. Ordinarily, however, when there has been only turgescence and soreness of 
the gums, the affection disappears in a {e\Y days. 

Modifying Circumstances. — The severity of stomatitis holds no direct ratio 
with the amount of the mercury introduced into the system. The enormous quan- 
tities requisite for inducing the specific effects of this metal in some subjects, are 
no less surprising than the sudden appearance of the affection, when only the most 
trifling doses have been taken. Some persons have, by idiosyncrasy, a remarkable 
susceptibility of mercurial influence; while others are as strikingly capable of re- 
sisting it. The constitutional liability, however, cannot be fairly estimated when 
inflammatory disease is present; for the most general fact with which we are ac- 
quainted as to the specific action of mercury, is, that the readiness with which it 
takes place is in an inverse ratio with the intensity of the existing disease. Other 
circumstances, also, very materially affect the result; such as the mode of adminis- 
tration, the state of the bowels, and of the function of the skin, previous blood- 
letting, &c.; but this is not the place for their consideration. 

Treatment. — In slight cases, very little more is necessary than to enjoin frequent 
ablution of the mouth, at first with tepid water, and afterwards with a mild astrin- 
gent gargle; and to secure a free action of the bowels by saline aperients, and of 
the skin by warm clothing. When the inflammation is more severe, — as indicated 
by a white line of suppuration along the edges of the gums, — we must, in addition 
to the measures just mentioned, employ others of greater activity. If the tume- 
faction is general, leeches applied under the lower jaw, with fomentations, will 
afford relief. The best local application (in our experience**) is the nitrate of silver, 
either in substance, or in a strong sohition (two scruples to an ounce of distdled 
water), by means of a small sponge fastened to a proper handle, or a camel-hair 
pencil. A lotion of chloride of soda will be very useful for correcting the fcetor, 
as well as for its stimulant property. An alum-gargle containing laudanum, is of 
service, when the active period of inflammation has passed by. We" have very 
little confidence in internal medicines exhibited as antidotes; such as sulphur and 
iodine. The supposed efficacy of the former depends, we*" believe, on its laxative 
operation. Opium in repeated doses has proved useful by quieting the erethism;" 
and also, perhaps, by lessening the secretion from the salivary glands. But it must 
be confessed, that the affection is very slighdy amenable to treatment, excepting as 
to the progress of ulceration; which may be arrested, with tolerably certainty, by 
the nitrate of silver. The practitioner should never neglect to enjoin free ventila- 
tion of the patient's apartment; which, indeed, ought to be kept not only airy, but 
cool. 

d. Stomatitis Ulcerosa, 

Symptoms. — Under this term we shall notice a form of inflammation of the 
a That of Dr. Syraonds. ^ Dr. Sy mends. « From jf»9»^ai, to excite. 



698 



AFFECTIONS OF THE MOUTH AND THROAT. 



gums, which appears in children between the first and second dentition. It is 
sometimes called "cancrum oris," or a milder variety of that frightful disease 
which we shall describe presently, under the appellation — '■^gangrasna oris." 
It would be better to confine both these terms to the latter disease; which is not 
merely more intense in degree, but distinct in its pathological nature, from " stoma- 
titis ulcerosa." This aff*ection begins with inflammation of the outer surface of 
the gum, and more commonly in the lower jaw; sometimes limited to one side, but 
more frequently extending to both sides. The inflanjed part is extremely swollen, 
and soon surmounted by a line of ulceration at the margin adjoining the teeth. 
The cheeks and lips became hard and (Edematous, — so as to impede the opening 
of the mouth; and this, together with the quantity of mucus and saliva collected 
between the gum and the cheek, renders it difficult to procure a satisfactory inspec- 
tion of the diseased parts. The breath has a peculiar foetor, allied to the state 
called "brassy" or "coppery," and quite distinguishable from the odour of gan- 
grene.* There is often considerable flushing of the face and conjunctivae, with 
heat and tenderness; and the glands below the jaw are enlarged and painful. If 
the disease be not speedily checked, the ulceration may proceed so far as to lay 
bare the alveolar processes; but, occasionally, we have known it continue in an 
indolent state for several days, neither advancing nor disposed to heal. In some 
subjects, the ulcerated surface is very prone to bleed. More or less fever, for the 
most part, accompanies the affection; but is sometimes absent. The bowels are' 
costive, and there is no inclination to food. 

Causes. — The disease prevails chiefly among the poorer classes of the com- 
munity; and indicates debility of habit, as a predisposing cause. The attack may 
be often referred to the immediate agency of cold, damp, or disorder of the stomach 
and bowels. When seen early, the prognosis is favourable; unless the disease has 
supervened upon some other acute malady; — such as fever or scarlatina. 

Treatment. — Though the disease is inflammatory, it is not to be combated by 
the ordinary antiphlogistic measures. Leeches and cold lotions may be useful in 
reducing the glandular enlargements; but they cannot be depended upon for stopping 
the internal ulceration. The best applications for this purpose, are of the same 
kind as we have recommended in the other species of stomatitis;'' — such as the 
strong solution of nitrate of silver, and the mixture of syrup and sulphate of zinc. 
A linctus made with a drachm of strong muriatic acid, added to an ounce of honey, 
is an excellent reinedy. We can also speak highly of a gargle composed of alum, 
decoction of cinchona, and tincture of myrrh. The only objection to this (as to 
certain other gargles) is, that the age of the child often prevents it from being used 
in sufficient quantity, or with sufficient frequency, to render it efficient. 

The internal treatment may be commenced by an emetic; unless the lips and 
cheeks are so swollen and tender, as to render vomiting too distressing an action. 
After the emetic, a brisk purgative of scammony or jalap, with calomel or Hydrar- 
gyrum cum Creta, should be administered. If there is much fever, we may exhibit 
salines and antimonials; but it is seldom necessary to continue them longer than a 
day or two. The action of the bowels may be maintained by castor oil, or rhubarb 
and soda. Should the ulceration, after the above treatment, show a tendency to 
spread, we must exhibit the sulphate of quinina, or decoction of bark, in doses 
suited to the age of the patient; — continuing, at the same time, the local treatment 
with undiminished energy. 



SECTION v.— GANGRtENA ORIS. 



Synonymes. — Gangrene of the mouth may be the consequence of any of the 
forms of stomatitis; but the disease we are about to consider is idiopathic, or gan- 
grene proper; — beginning with that loss of vitality which, in inflammatory mortifi- 



AFFECTIONS OF THE MOUTH AND THROAT. 699 

cation, is the last of a series of morbid changes. The synonymes of "gangraena 
oris" are — '^cancrum oris,^^ ^ ^ sloughing p ha gedsena of the moidhj^^ ^^ivater-ccm- 
ker,''^ '"■stomacace maligna,''^ '''-normal'' ^'necrosis infantilis.'''' 

Symptoms. — The existence of this disease is generally first intimated by an 
indolent swelling of one cheek, without heat or redness. It is hard to the touch; 
and so little tender or painful, that the patient seems all but unconscious of it; and, 
but for the enlargement being obvious to the eye, the mischief would probably- 
escape notice altogether in its early stage. Indeed, as it is, the tumefaction is occa- 
sionally mistaken for affections of a much less serious description. The skin of 
the cheek has a peculiar glossy or waxy appearance. On examination of the 
mouth, we detect a whitish or ash-coloured eschar, without any inflammatory red- 
ness of the surrounding membrane; generally in the centre of the cheek, or in the 
commissure of this part and the lower jaw. The gums look pale and spongy. 
There may be a certain degree of languor, dulness, or slight feverishness; but, not 
less frequently, there is nothing to call particular atlention to the general health. 
Such are the principal phenomena of the first stage of the disease. As it advances, 
the slough spreads rapidly over the interior of the clieek and lip, and invades the 
gums. Saliva escapes in great quantity; at first clear, afterwards mixed with a 
dirty sanious matter, which has a horrible fcetor. About the same time, the outside 
of the cheek presents a pale ashy spot; which soon becomes livid, and sphacelates. 
The extension of the disease to the bony structures, is evidenced by the loosening 
of the teeth; which are soon thrown off, with portions of the alveolar processes. 
The fluid discharged appears to have a corrosive quality; for the angles of the 
mouth and the lower lip sometimes become new centres of mortification. We* have 
known both sides of the face attacked in the same individual; and there are cases 
on record in which all parts of the face, as well as the upper maxillary bones, the 
palatal, the nasal, and even the ethmoid, were involved in the destruction. Usually, 
however, death prevents the lesion from extending so widely. 

The constitutional disturbance is, in many cases, far from being proportionate to 
the severity of the local affection. The pulse is frequent, but weak; the bowels, 
at first confined, become, towards the close of the malady, extremely relaxed; and 
the heat of the extremities is much depressed. 

Causes. — The subjects of "gangrasna oris" are children, usually between two 
and five years of age; but we* once met with it in a girl who had attained her 
eighth year. It is confined to children of debilitated habit, and is very rarely- 
observed among the richer classes; low marshy situations, and rainy seasons, 
appear to increase the predisposition. Not nnfrequently, "gangrcena oris" is one 
of the sequelae of exanthematous fevers. There is no good reason for attributing 
the disease to the specific action of mercury; though it may have sometimes super- 
vened upon the latter; which, like any other cause of derangement, may have 
given the first impulse to the morbid process. It has often occurred when not a 
particle of mercury had been administered. 

Pathology. — As to the pathology, we* have already expressed our belief,'' that 
the disease is gangrenous ab origine. Any inflammation that may be found about 
the part is secondary only; — bearing no causative relation to the gangrene. It has 
been stated, that the commencement is often unattended by pain, heat, or redness. 
The swelling is the effect of the retarded circulation in the capillaries, and the infil- 
tration of the tissues with serum, or "liquor sanguinis." The pressure thus pro- 
duced, is sufficient to explain why the vitality of the central portion is destroyed. 
The mortification extends by contiguity; because the capillary circulation in the adja- 
cent parts, is necessarily affected by the pressure of the diseased tissue. If they have 
sufficient vital action, they may only suffer inflammation and suppuration; but it too 
often happens, that the lesion assumes the same character as in the neighbouring 
part; — being influenced by the same state of the general habit. It can scarcely be 
doubted, that this depraved habit consists mainly in deficient plasticity of tlie blood. 
The worst case that ever fell under our* notice, occurred in a girl recovering from 

» Dr. Syraonds. »> See Page 698. 



700 



AFFECTIONS OF THE MOUTH AND THROAT. 



milvl fever, who had been leeched on the forehead. There had been extreme diffi- 
culty in restraininjr the haemorrhage from the leech-biies; — in consequence of the 
incoagulable quality of the blood. 

Prognosis. — The prognosis is, from the first, unfavourable. Though the child 
may escape wiih life, it cannot he saved from disfiguration, when the gangrene is 
once established. If however cedema has been discovered very early, and a vigor- 
ous treatment adopted, the danger may sometimes be warded off. 

Treatment. — On the first appearance of the swelling, the cheek should be fre- 
quently rubbed with a stimulating embrocation, consisting of camphorated oil and 
ammonia; and in li\e intervals should be kept moist with a tepid lotion, containing 
muriate of ammonia and spirit of wine. A careful examination of the interior 
should be made; so that, on the detection of the slightest appearance of an eschax, 
the part may be touched with the solid nitrate of silver, or strong muriatic acid. If 
sloughing has already commenced, the lotion of nitrate of silver* will be the best 
application. The mouth should be frequently washed out, or syringed, with a 
solution of chloride of soda; — if only to moderate the foetor. M. Billard recom- 
mends, that as soon as the livid spot on the exterior of the cheek shows itself, a 
crucial incision siiould be made into the centre of the swelling, and butter of anti- 
mony introduced, or (still better) the actual cautery at a white heat.* This remedy 
had been previously much insisted on by M. Baron. When the gangrene is com- 
plete, we must endeavour to stop its extension by fermenting poultices. 

The medicines to be exhibited are tonics and stimulants; of which carbonate of 
ammonia in decoction of bark, or quinina combined with camphor, are the most effi- 
cient. Wine or brandy may be liberally administered, with beef-tea. Opium is 
strongly indicated; — not merely for allaying general irritation, but for the sake of 
the stimulating influence which it is known to exercise upon diseases of the capillary 
system characterized by debility. Constipation or diarrhosa must be met by the 
remedies appropriate to either slate. The patient should, if possible, be placed in 
a large airy apartment.*'] 



SECTION VI.— FETID BREATH. 

I may mention that persons sometimes consult us, on account of having a fetid 
breath; called, in vulgar language, "a smoky chimney." It must be very annoying 
if people are married, or in the way of being married, and I have no doubt that it 
has frequently prevented that interesting ceremony from taking place. 

Causes. — Fetid breath may arise from many causes. It may be accidental, 
from a person eating something disagreeable; which enters into the blood, and is 
poured forth from the vessels of the bronchia, till the blood gets rid of it all. If a 
person eat onions, it is not while they are in the stomach that the breath is fetid; 
but when the odorous principle of the onions gets into the blood, it is poured 
forth from the bronchial membrane. The bronchial membrane is found, by phy- 
siological experiment, to be one of the great outlets by which the body gets rid of 
things foreign to the blood. Carious teeth, or a diseased bone, is likewise a cause 
of fetid breath; but one very common cause is a depraved secretion of the tonsils. 
On looking into the mouths of these patients, we frequently see the tonsils enlarged, 
or at any rate containing a cheesy matter. If this be pressed out with the handle 
of a spoon, the person's breath (for the time) is rendered less offensive. I should 
imagine, that stimulating the follicles to secrete more abundantly, would favour the 
escape of this disagreeable matter; and not allow it to accumulate there, and form 
these nauseous concretions; but the individual's breath itself may be fetid, inde- 
pendently of this offensive secretion. 



a See Page 697. 



e "Library of Medicine;" Volume 4j Pages 36 to 40. 



^ "Maladies des Enfans." Page 247. 



DIAGNOSIS OF PULMONARY DISEASES. 701 



SECTION VII.— EARACHE. 

Before I quit these parts, as we are so near the ear, (which communicates with 
them by the eustachian tube,) it may be well to notice what is commonly called 
"earache." It is not, in general, an important disease; but sometimes it is of very 
crreat consequence. I mentioned, when speaking of inflammation of the brain, that 
the latter will spread from the ears and eyes.* I have seen several cases of phrenitis, 
which have spread from the ear. Common earache is not a thing so free from danger 
as toothache. We see earache very frequently, and are apt to disregard it; but, in 
any case, it may be dangerous. 

Earache always arises from more or less inflammation in the "meatus audi- 
torius;" and ought always to be attended to. Leeches should be applied exter- 
nally, and blisters; and, in some cases, the patient should be bled in the arm. 
After it has lasted a long time, the bones frequently become carious; and, when 
the bones are carious within, inflammation of the "dura mater," lying upon the 
petrous portion of the temporal bone, is likely to come on; and then it is all over. 
After death, matter is found within the ear itself; but sometimes also upon the 
bone, under the "dura mater;" and perhaps above the "dura mater," — in the arach- 
noid, on the "pia mater," and on various other parts of the head. Encephaloid 
disease, and other aftections, take place; the patient becomes delirious, and is soon 
gone. Therefore, when intense earache occurs, and the patient complains of pain 
in some other part besides the ear, and there is a wandering of the eyes, it is well to 
tell the friends that he is in the greatest danger. 

Such a case (like other varieties of phrenitis) ought to be treated actively; but I be- 
lieve, in almost every case, treatment will be found unavailing. There is a local 
cause (that is to say, disease of the ear) keeping up inflammation of the part; and 
therefore we cannot expect to be successful.'' 



CHAPTER III. 
DIAGNOSIS OF PULMONARY DISEASES. 

I^A KNOWLEDGE of the Condition of the chest and its organs, in health and in 
disease, is to be obtained by the study of those properties which are signs or indi- 
cations of this condition. These properties are divided into tw^o classes: — the 
physical properties, which are those capable of directly impressing our senses; and 
the vital phenomena, or those which arise out of the vital endowments of the parts; 
and which, in combination wiUi physical structure, constitute function. The " phy- 
sical properties" are necessarily confined to the chest, its contents, and those parts 
mechanically related with it; but the vital properties" of the chest and its organs 
affect, and may become evident in, various other parts of the body, through the 
connecting vital influences of the nervous and vascular systems. 

Physical Exanunation of the Chest. — We examine the chest physically by 
those properties of form, size, proportions, relative position and density of its parts, 
at rest or in motion, which are within the reach of our senses. Thus we see and 
feel the shape and motions of the chest; we listen to the sounds which these mo- 
tions cause, or which may be otherwise produced in the chest, — as by the voice, 
percussion, <fec.; and we judge of the results of these examniations, by comparing 

^ See Page 492. 

^ Fall details of the nature and treatment of this and its kindred affections, -t^-jll be found 
in a work with which our medical literature has recenllv been enriched: — "The ISaiure 
and Treatment of Disease of the Ear. By Dr. WilliamKramer. Translated by James 
Risdon Bennett, M.D." 



702 



DIAGNOSIS OF PULMONARY DISEASES. 



them with healthy standards. Now it is obvious, that a good knowledge of the 
anatomy and physiology of the chest, must greatly assist us in this examination; 
and this knowledge should be especially topographic; — teaching where each organ 
lies and reaches, in relation to the exterior; so that when we view, feel, and listen 
to the chest, we may be able to map out the general outlines of the organs within. 
This knowledge is to be obtained, not only from the common study of anatomy, 
but also from the frequent comparison of the interior with the exterior, when bodies 
are opened in the dead-room of hospitals, and from the habit of physical examina- 
tion itself. 



SECTION I.— EXAMINATION BY SIGHT AND BY TOUCH. 

Mode of Examination. — The patient being in a standing, sitting, or lying pos- 
ture, with his arms, legs, and trunk symmetrically placed, and the chest, if possible, 
entirely uncovered and exposed to a good light, we view it in front, behind, and 
from above; — carefully marking its form and proportions, and the corresponding 
prominences and depressions of the two sides. The chest may be viewed from 
above, when the patient is seated on a low seat, with the head a little inclined 
forward; — the observer standing behind or beside him, and looking down on his 
shoulders. A view is thus obtained of the depth of the chest from front to back; 
and in this way may often be delected between the two sides a want of correspond- 
ence, that is not perceptible by the ordinary modes of inspection. If the patient's 
strength do not permit him to stand or sit, the chest may be inspected when he 
lies on his back, by the observer standing at the foot or at the head of the bed; 
from which points the corresponding parts of the two sides can be best seen. 

Symmetry of the Chest. — Most healthy chests are nearly symmetrical, the two 
sides corresponding in shape and size. There is, however, in almost all instances, 
a slight superiority in the measured dimensions of the right side; and this is not 
unfrequenUy perceptible to the eye, in the lower part of the chest, especially in the 
back. Y have also remarked, in a great many healthy chests, that the left side of 
the chest, at the upper ribs in front, is somewhat higher than the right. But in 
spite of the occasional and even frequent occurrence of these anomalous formations, 
there is sufficient general regularity in the shape and motions of the chest, to render 
the changes caused by disease available as signs. 

Indications afforded by Sight and Touch. — By inspection we judge, not only 
of the statical condition of the chest, but also of its motions. Feeling by the hands 
will assist the siglit; and when we inspect the chest, desiring the patient to breathe 
in various degrees, with our hands and eyes fixed on corresponding points of the 
two sides, we watch and feel the amount and equality of the motions. If the chest 
is healthy, the motions are as uniform as the chest is symmetrical. At each inspi- 
ration, the clavicles, scapulae, and upper ribs rise; the lower ribs rise and spread; 
and the abdomen swells, as the diaphragm descends. By attentively watching and 
feeling the chest, we may often likewise so trace the limits of some of the move- 
ments, as to indicate the boundaries of the chest. The intercostal spaces and tJse 
hollows above the clavicles, are also fit marks for comparison between the two 
sides. They are strongly marked during full inspiration; and are more than usually 
so, when the entry of air into the lungs is rendered difficult by obstruction of the 
tubes; and less than usually so, when the obstruction is more in the tissue of the 
lung, from internal effusion, or external pressure. 

There are some general varieties of disordered respiration, which may be dis- 
tinguished by watching and feeling the motions of the chest. Healthy or perfect 
respiration is diaphragmatic and costal; but disease may limit the motions to the 
ribs or to the diaphragm. Thus, when the diaphragm is prevented from descend- 
ing, — by acute pain in it or below it, or by pressure from below, — the respiration 



Dr. C. J. B. Williams. 



DIAGNOSIS or PULMONARY DISEASES. 703 

is wholly performed by the raising of the ribs; and is called " heaving," "tlioracic," 
or "costal." When, on the other hand, the ribs are immovable,— in consequence 
of pain, ossification of the cartilages and ligamenls, or paralysis of the intercostal 
muscles, — the breathing is wholly "diaphragmatic" or "abdominal." When one 
side of ihe chest moves much less than the otiier, or when a part of one side moves 
imperfecdy, the respiration is " partial;" and this partiality of movement may have 
its cause in the walls of the chest, or (as is more usual) it may proceed from 
impermeability of the corresponding portions of the lung, in consequence of various 
diseases. 

Mensuration of the Chest. — Mensuration of the chest is a more exact method 
of detecting inequalities between the two sides. It is generally practised by fixing 
(with the finger) the end of a piece of tape, or string, at the mesial line of the 
sternum; and passing the tape horizontally round the chest, to meet at the same 
spot; when, by taking it off at the point where it crosses the spinous process of 
the dorsal vertebra, th.e measure of the two sides may be at once compared. Great 
care must be taken to pass the tape horizontally around corresponding parts; and 
attention should also be paid to the degrees of the respiratory act. The most ac- 
curate mode is, to compare the measurements of the two sides on a full inspiration 
and expiration, as well as in the intermediate state; or, without the troublesome 
process of removing and' measuring the tape, it may be sufficient to remark how it 
is tightened and slackened on the two sides by the motions of respiration. These 
expedients, together with the practice of inspection downwards on the shoulders, 
for the antero-posterior diameter of the two sides, are generally sufficient to furnish 
the comparative dimensions of the sides of the chest. 

Mensuration of its Internal Capacity. — Besides external measurement, which 
is essentially comparative between the two sides, there have been various attempts 
to measure the internal capacity of the chest, by noting the quantity of air that can 
be exhaled or inhaled at a breath, into or from a glass jar over water. The great 
objection to these as means of diagnosis is, that they depend on the strength of the 
patient, as much as on the capacity of the chest; and a weak nervous person, with 
sound lungs, thus tested, would rank lower than a pleuritic or phthisical patient, 
whose muscular energies are still considerable. 

So much for the modes of examining the chest by sight, touch, and measurement. 
They may often discover to us extensive disease, but they will not inform us of its 
nature; and they cannot detect the slighter degrees and forms of disease. The chest 
may be motionless, distended, or contracted, in parts; but whether from diseased lung, 
obstructed air-tubes, liquid or air in the pleura, or other cause, sight and touch will 
rarely inform us.^] 



SECTION II.— PERCUSSION. 

History. — [The chest of a healthy person, when slightly struck, ought to 
yield over its whole extent, more particularly in its anterior and lateral parts, a 
clear and distinct sound; — owing to the presence of the air, which constantly fills 
the lungs, and consequently a great portion of the cavity of the thorax. This fact 
was, no doubt, known to the ancients; and, even in our own times, there are few- 
persons who have not seen the common people striking their chests, and concrratu- 
latiug themselves on possessing what they call "a good hollow or bass.^^ From 
tlie knowledge of this fact, to the conclusion that the same sound cannot exist in 
cases where the lung is obstructed, or the cavity of the pleura filled with fluid, 
seems but a step; and yet this reflection appears never to have been made, until 
made by Avenbrngger, about the middle of last century. After seven years' silent 
investigation, and (as he himself tells us) amid laborious and disgusting researches," 

^ Pallioloj^y and Diagnosis of Diseases of the Chest. By Charles J. B. Williams, M. D." 
Fonnh Edition; Pages 1 to 9. 
" "Inter labores et laedia." 



704 



DIAGNOSIS OP PULMONARY DISEASES. 



he gave his discovery to the world, in a small pamphlet. The only reward he 
seems to have obtained for his fine discovery, was a slight notice of it by Van 
Swieten and Stoll: this, however, failed to attract the attention of his contempo- 
raries; and he died, without ever perhaps dreaming of the celebrity, which his dis- 
covery was destined to obtain. Corvisart is entitled to the honour of withdrawing 
this method from the oblivion into which it had fallen, after a period of thirty years; 
and of making all Europe, and even the native country of its author, acquainted 
with its merits.* 

3^ode of Percussion. — The patient ought, if practicable, to be either seated or 
standing; if in bed, the mattrass, still more the pillows, and also thick curtains, 
always render the sound less. The chest ought to be covered with a thin dress; 
or the physician should have a glove on. This precaution, originally recommended 
by Avenbrugger, is particularly necessary; inasmuch as the contact of the naked 
hand and skin occasions a sort of clatter, which renders the pectoral sound less 
perfect and distinct.'' It is better that the chest should be covered, and the hand 
naked; since the glove necessarily diminishes the sensibility of the touch; and be- 
cause the sensation of elasticity perceived by the operator, frequently confirms his 
judgment, in cases where the difference of sound is only doubtful. In every case 
the perception of the sense of fulness or emptiness, conveyed by percussion, is 
much stronger to the operator than to the mere bystander. Percussion ought to be 
made with the four fingers united in one line; — the thumb being placed, in oppo- 
sition to them, at the junction of the second and third phalanges of the index; and 
used merely in maintaining the fingers in close and strong apposition. We must 
strike with the ends^ and not ihe face or pulpy portion of the fingers; not ob- 
liquely, but perpendicularly; gently, and quickly; — that is, raising the hand imme- 
diately from the skin. 

When we percuss comparatively the two sides of the chest, we must be careful 
not to strike successively on parts that are similar, with a like force, and under an 
equal angle. The omission of these precautions frequently leads to errors of con- 
sequence. We ought, in general, to apply percussion to the bones, and not to the 
intercostal spaces; and to strike the anterior and lateral parts of the chest, in a 
direction parallel to the ribs. If, however, the intercostal spaces are not very sen- 
sible, — as frequently happens in fat or phlegmatic persons, — it is better to strike 
across the ribs. In any point where the muscles covering the ribs are thick, flabby, 
or relaxed, we should endeavour to procure their tension. If the muscles are very 

* Leopold Auenbrug, or Auanbrugger. was born atGraetsin Styria, in 1722. He gradu- 
ated at Vienna; and afterwards became physician in ordinary to the Spanish Nation, in the 
imperial hospital in that city. In Ersh and Puchhelt's "Literatur der Medicin," besides the 
treatise on percussion, he is recorded as the author of two works on subjects relating to mad- 
ness; and in the "Biographic Medicale" he is farther said to be the author of a Drama, and 
to have published on Dysentery. The work on Percussion was first published in 1761, under 
the title of "Inventum Novum ex Percussione Thoracis Humani, ut Signo, Abstrusos In- 
terni Pectoris Morbos Detegendi" ("A New Discovery, for Detecting the Internal Diseases 
of the Chest, by Percussing the Thorax"); and the author is said to have died so late as 1809. 
For a complete view of the subject of Percussion, as introduced by Auenbrug and im- 
proved by Corvisart, I beg to refer to the translation of the treatise, in my work entitled — 
"Original Cases, illustrating the Use of the Stethoscope and Percussion." (Pages 3 to 64.) 
— Dr. Forbes. 

b This injunction of having the chest covered, so strongly insisted on by the original pro- 
poser of the practice and by our author, seems to me of inferior consequence, as far as the 
accuracy of diagnosis is concerned. In my own practice, I have often followed the inter- 
dicted method; and without any inconvenience, as far as I am aware. A much greater 
authority, Corvisart, did the same; and he gives it as his opinion; that percussion may be 
equally well performed in one way as the other. (See his "Translation of Avenbrugger;" 
Page 20.) He says, however, that it may be well for beginners to attend to the precaution 
recommended by Avenbrugger. I would further add, that if the operation can be equally 
well performed over a garment (as, no doubt, it can), there are very obvious reasons for 
giving this mode the preference. Our author omits to state the additional and very neces- 
sary precaution, given by Avenbrugger, of drawing the shirt or other covering, tight over 
the place.— Z?r. Forbes. 



DIAGNOSIS OF PULMONARY DISEASES. 705 

much relaxed, or if there is (Bdema or a flabby fatness, it is often useful to stretch 
and compress the integuments with two fingers of the left hand, and to strike be-' 
tween. In the case of children and lean persons, it is found sufficient to percuss 
with the extremity of one finger. 

When we obtain from percussion only a slight difference of sound on the two 
sides, — leaving the result doubtful, — it is advisable to repeat the operation; — 
changing our position to the other side of the patient: in this manner we frequently 
obtain a result entirely different; — the side most sonorous in the former trial, yield- 
ing now a sound inferior to the other. This precaution is never to be omitted in 
doubtful cases; for percussion yields exact results in the hands of those only who 
bring to its exercise experience, dexterity, and much attention. 

Character of the Sound derived from Percussion. — This is different in the dif- 
ferent parts of the chest: on which account I shall (Hvide its surface into fifteen 
"regions," twelve of which are double: — 1. Subclavian. This includes merely the 
portion of the chest covered by the clavicle. When struck about the middle or 
sternal extremity, this bone yields a very clear sound; its humeral extremity, on 
the contrary, yields a rather dull sound. A knowledge of the natural and morbid 
sound of the chest in this region is very important; inasmuch as from it is usually 
derived the first signs of the development of tubercles in the lungs. When the 
clavicle is more distant from, or closer to, the chest than usual, — in consequence 
of the more arched or straighter form of this bone, — the sound is less distinct: this 
is especially the case in the latter condition of the clavicle. 2. Anterior-superior. 
This is bounded by the clavicle above, and the fourth rib (inclusive) below. The 
sound is here naturally very clear; though somewhat less so than over the sternal 
end of the clavicle. 3. Mammary. This begins below the fourth rib, and termi- 
nates with the eighth. It can rarely be percussed in females; and in the male 
it seldom yields so good a sound as the anterior-superior region; — on account of 
the thickness of the inferior edge of the "pectoralis major." 4. Submammary, 
This extends from the eighth rib to the cartilaginous border of the false ribs. On 
the right side, it almost always yields a dull sound; — on account of the size of the 
liver: while, on the left side, it frequently yields a sound clearer than natural, and 
which may be called almost tympanitic; — owing to the presence of the stomach 
distended with gas. In very rare instances, the unusual size of the spleen may 
occasion the dull sound.* 5. Sternal — Superior, Middle, and Inferior. Over 
the whole extent of the sternum, the sound is as clear as on the sternal end of the 
clavicle. In certain cases, however, particularly in very fat persons, the lower por- 
tion of the sternum yields a duller sound; — on account of the great quantity of fat 
about the heart.'' 6. Axillary. This extends from the upper part of the axilla, 
to the fourth rib (inclusive): it yields naturally a clear sound. 7. Lateral. This 
is bounded superiorly by the fourth rib, and terminates with the eighth. The 
sound in this region is always good on the left side; on the right, it is frequently 
much less; — owing to the liver rising higher than usual; and thereby compressing 
the lung upwards, and rendering it more dense and less charged with air. The 
liver, when sound, never extends above the level of the sixth or fifth rib. 8. Infe- 
rior Lateral. This is bounded above by the eighth rib, and terminates with the 
border of the false ribs. For the reasons just mentioned, this region on the right 
side yields a completely dull sound, and is almost always much less sonorous than 
the left. This last, on the contrary, — for reasons already stated, — frequently yields 
a clearer sound than natural; and this even when the inferior portion of the lung is 

* Andral is of opinion that the dulness of this region on the left, owing to the presence of 
the spleen, is of more frequent occurrence than is commonly imagined. — (Tome 2: Page 
'33si-Dr. rorbes. y o k , ^ 

^ Avenbrugger considers this diminution of sound, under a part of the sternum, as gene- 
ral. He says that " the whole sternum, on percussion, sounds as clearly as the sides of the 
thorax; except at that part behind which lies a portion of the heart; for "there the sound is a 
little duller." The opinion of Corvisart coincides with that of our author. I have myself 
frequently found the sound dull in this point, when there was no reason to suspect disease 
of the heart. — Dr. Forbes. 
VOL. I. — 45 



706 DIAGNOSIS OF PULMONARY DISEASES. 

obstructed, or there exists an effusion of fluid in the pleura. 9. Acromion. This 
is comprehended between the clavicle, the upper edge of the "trapezius"'' muscle, 
the head of the humerus, and the lower part of the neck. Here there is no sound 
^vhatever; — the soft pans in this place yielding passively to the percussion. 10. 
Upper Scapular. This corresponds to the supra-spinal fossa of the scapula, and 
hardly yields any sound; — on account of the muscle that fills it. The spine of the 
scapula, which bounds this region below, sometimes yields a slight sound, but 
never considerable; and this only when the arms are very forcibly crossed. 11. 
Lower Scapular. This corresponds to the portion of the scapula below its spine; 
and, on account of its muscles, yields no sound. 12. Inter-scapular. This in- 
cludes the space between the inner margin of the scapula and the spine, when the 
arms are crossed on the breast. It is not easy to elicit any sound from it; on 
account of its muscles. Sometimes, however, it yields a middling but sufficiently 
distinct sound; especially in thin persons; and when the arms are strongly crossed, 
and the head bent; — so that the "rhomboid" and "trapezius" muscles are made 
quite tense. The spine in this region gives a good sound; as does also that por- 
tion of the chest included between the inner and upper angle of the scapula, and the 
first dorsal vertebra. 13. Inferior Dorsal. This begins at the level of the lower 
angle of the scapula, and terminates at the twelfth dorsal vertebra. To elicit from 
this region all the sound it is capable of yielding, we ought, especially in fat sub- 
jects, to endeavour to find the angle of the ribs, and to percuss on that point in a 
transverse direction. In the upper part of the region, the sound is pretty good; a 
little lower, it is often slight or none; and on the right side, it is almost always 
obscure; — on account of the presence of ihe liver. On the left side, it frequently 
yields the factitious sound so often mentioned as owing to the presence of the sto- 
mach. 

' Percussion of the chest has great advantages; because it enables ns to detect the 
existence of an obstruction of the lungs, or an effusion into the pleura, of moderate 
extent; but it cannot discriminate these from each other. Many causes, moreover, 
conspire to circumscribe the number of cases in which it is of use. We have just 
seen, that in many places of the chest it gives no satisfactory result; and its chief 
indication (that o{ fulness) is not obtained, in pulmonary diseases, until the organic 
change is already far advanced. Its indications are very equivocal when the disease 
occupies the centre, or roots of the lungs, or when both lungs are simultaneously 
affected; they are deceptive when the chest is deformed, even in a slight degree; 
and ihey are extremely uncertain, or cease entirely, when the integuments are cede- 
matous or loaded with fat; or when they become flabby, from the removal of this 
excessive degree of obesity.**] 

Mediate Percussion. — [As the walls of the chest give the sound which we hear 
on striking the chest, so it is plain that they must be sufficiently tense and elastic 
to vibrate on being struck. The chests of some persons are so loosely put toge- 
ther, and so flaccid, that they give but little sound; although the organs within are 
quite healthy. In others, again, there is such a mass of fat and loose integument 
on the chest, that the walls are completely muffled by it, and they sound but litde 
on percussion. The same difficulty occurs in other cases, in certain regions where 
muscles of considerable thickness, or the mammae in females, lie on the walls. In 
other instances, again, the walls of the chest are so drawn in by contracted adhe- 
sions of the pleura, that they are too tight to vibrate, and give a hard or dull sound; 
although the lungs within them may be comparatively healthy. In all these cases, 
we must give to the part struck the equal tension which is wanting, by pressing on 
it a small piece of some firmly elastic body; such as wood, ivory, wlialebone, stiff 
india-rubber, or some such substance. T.iis, when struck, gives sound enough; 
and if it be firmly applied to the chest, the density of the contents within will 
modify this sound;— just as it modifies that of percussion on the naked walls of 
the chest. The sound obtained by striking a little plats of ivory or wood thus 

= " A Treatise on the Diseases of the Chest; by R. T. H. Laennec, M. D. Translated by 
John Forbes, M. D." Third Edition. Pages 15 to 22. 



DIAGNOSIS OF PULMONARY DISEASES. 70^ 

pressed on the chest, is the same in character as that of striking the chest itself; 
but it is louder; and as percussion on it gives no pain, the stroke can be applied 
with such force, as to make the vibrations reach the interior throui^h any thickness 
of fat or muscle. By these means, we can test the sonorous qualities of the tho- 
racic viscera, through the scapulae and muscles of the back; and through fat or 
(Edematous integuments, of any thickness. In this way, too, we can try the reson- 
ance or sonorous quality of any part of the abdomen. 

We owe this method of mediate percussion to M. Piorry; who calls this per- 
cussion-plate " a pleximeter." Mediate percussion is so much better than the 
immediate kind, that it is now generally preferred. There is, however, an im- 
provement on it, which was (I believe) first proposed by Dr. Skerrelt; it is to 
substitute for a pleximeter the fingers of the left hand. This mode of percussion 
has the advantage of convenience, as well as of yielding distinct results. Its 
adaptations are soon found out by a little experience; — in fitting the fingers to the 
inequalities of the chest, sometimes single, sometimes together, sometimes with 
their palmer surface outwards; but generally with this surfiice applied to the chest, 
and the back to strike on; — with other varieties of manipulation. ^j 



SECTION III.— AUSCULTATION. 

For the purpose of listening to the chest, in order to hear these sounds, some 
employ the naked ear; but it appears to me that it would be better to employ the 
intervention of a foreign substance, — a piece of wood. I think if we only employ 
the ear, we cannot examine every part of the chest so frequently as may be de- 
sirable; and it is not so convenient. If the patient be a young lady, and the phy- 
sician a young gentleman, perhaps mamma will not be pleased at his laying his ear 
on her daughter's bosom; and if the patient be a greasy old fellow in the hospital, 
we shall not like it. Upon the whole, therefore, I think it much better to employ 
a piece of wood. I do not think that persons who use the ear only, do so well as 
others. I have known such persons give extraordinary opinions; and a great many 
of them are not capable of saying which instrument is the best. 

7%e Stethoscope. — [We want an instrument, then, to transfer the sounds from 
the chest to our ear. This instrument must be a good conductor of sounds; and 
as the power of bodies to conduct sounds depends on the strength and uniformity 
of their elasticity, and their capacity to vibrate like the body that produces the 
sound, we must have an elastic material, of density resembling that of sources of 
sound within the chest, and of the walls of the chest through which they are 
transmitted. But the sources of the pectoral sounds vary. Some, as the voice 
and respiration (or at least the hollower sounds of respiration), are produced in air; 
while, in others, — such as the sonorous rhonchus, the rubbing sound, and the 
sounds of the heart, — the solids are chiefly concerned. We shall, therefore, need 
a varied capacity in our instrument, to receive these sounds. 

To transmit the sounds originalinof in the solids within the chest, we must have 
a uniform solid; and the lighter it is the belter, provided it be thoroughly rigid. 
Nothing answers to this description so well as wood; and in the light kinds of 
wood, v/ith a stifi*, longitudinal fibre, — such as pine wood, deal, cedar, and the 
like, — we find these qualities in perfection. Through a cylinder of such wood, — 
about eight inches long, and an inch and a half in diameter, adapted to the ear at 
one end, — most of the pectoral sounds may be heard, but those best which origi- 
nate in solids; such as the sounds of the heart, of friction, and sonorous rhonchi. 
The sounds of respiration and of the voice are also heard through it; but not nearly 
so distinctly as with the naked ear. 

We need, therefore, an aerial conductor for these sounds; because they originate 
in air, and can best be transferred through air. By perforating the cylinder with 

« Dr. Williams, on " Diseases of the Chest;" Pages U and 15. 



. 708 DIAGNOSIS OP PULMONARY DISEASES. 

a bore, a quarter of an inch in diameter, it becomes a tube; through the columns 
of air in which, the respiration and voice may be heard witli increased distinctness. 
But as this cohimn of air is in contact with only a small spot of the chest, it can 
transmit only the sounds produced under or very near that spot; and the instrument 
thus prepared is better adapted to explore small parts of the chest, than the ear can 
be. But we want the instrument also to transfer the sounds of larger spaces. 
The sounds of so limited a space, are often too weak to be heard alone; and, be- 
sides, it would be very tedious to go over the whole chest, (lotting in this way a 
quarter of an inch at a time. Now, if the column of air be enlarged at the base, 
■where it is in contact with the chest, by hollowing out the wooden cylinder into a 
funnel-shape, it will conduct the sounds produced on this greater extent of surface; 
for they are reflected by the funnel into this central bore, and conveyed concen- 
trated to the ear. This also gives the instrument the power of concentrating or 
magnifying the sounds; which are thus heard as strong at the distance of several 
inches, or even a foot or two from the chest, as they are to the ear in close contact 
with it; nay, in some cases they are even stronger. The best shape for the exca- 
vated end, is that of a long funnel or cone, with its apex terminating in the central 
bore; for this directs the sound at once to the ear, without repealed reflections, 
which may modify it. As we still sometimes want to explore small spots of the 
chest, by means of a perforated plug the excavated end can be filled, and the in- 
strument reconverted into a simply perforated cylinder. To make the instrument 
more portable, the upper part of the cylinder may be reduced to a stem half an 
inch or less in diameter, leaving only at the top a sufficient width for the ear; or 
this top may be made of a harder wood. Wood is so excellent a conductor of 
sound, that when once the vibrations are in it, they can be conveyed by a very 
small body of fibres. 

Uses of the Stethoscope. — Thus the stethoscope, although a simple instrument, 
performs several offices in relation to sound; the chief of which may be enume- 
rated as follows: — 1. To conduct sound by its solid walls. 2. To conduct and 
concentrate sound by its closed column of air. 3. To transfer sounds from its 
column of air to its solid walls, or the converse, when circumstances impede their 
transmission by one of these ways. 4. To diminish this power of transfer, and 
contract the field of hearing when small spots are to be explored.*] 

Mode of Using the Stethoscope. — [The general precautions which the practice 
of auscultation requires, are the following: — 1. The stethoscope must be applied 
very exactly and perpendicularly' to the surface on which it rests; so as to leave no 
interval between the skin, and any part of the extremity applied. 2. We must be 
careful not to produce pain by too strong pressure: this precaution is most neces- 
sary when the instrument is used without the stopper, and when the person is lean. 
3. Although it is not necessary that the chest should be uncovered, — as all the 
positive stethoscopic signs, and frequently also the negative ones, may be perceived 
through clothes of considerable thickness, provided they are applied closely to the 
body, — still it is better that the clothing should only be light; — for example, a flan- 
nel waistcoat and shirt. Silks, and also woollen stuffs, are often inadmissible, on 
account of the noise occasioned by their friction against the instrument. The ex- 
aminer ought to be careful, above all things, not to place himself in an uncomforta- 
ble posture, or to stoop too much, or turn his head backwards by a forced extension 
of the neck. These positions determine the blood to the head, and thus obscure 
the sense of hearing: they may sometimes be properly avoided by kneeling on one 
knee. In examining the fore parts of the chest, we ought to place the patient on 
his back, in a recumbent position; or in a chair, and gently reclining backwards. 
When we examine the back, we cause the patient to lean forwards, and to keep 
his arms forcibly crossed in front; and when we examine the side, we cause him 
to lean gently to the opposite one, and to place the forearm on the head.*"] 

" Dr. C. J. B. Williams, on " Diseases nf the Chest;" Pages 39 to 41. 

^ Laennec on the Chest; translated by Fuibes. Third EcUtionj Pages 27 and 28. 



DIAGNOSIS OF PULMONARY DISEASES. 709 



a. Auscultation of the Bespiration. 

Respiratory Murmur. — The penelration of the air into the organs of respiration, 
is accompanied by a slight niiirmur, which is distinctly perceived by tlie aid of 
mediate auscultation, and is called " tlie respiratory murmur." This sound of ihe 
passag-e of the air in the pulmonary tissue, tlie larynx, the trachea, and the great 
bronchial branches, presents a different character in each locality. In the first 
case, the sound is somewhat soft and silky; and the ear recognizes the penetration 
of the air into a multitude of litde cells, which are dilated to receive it: this is the 
true pulmonic respiratory murmur, which is also called " vesicular respiration." 
In the other cases, the sound is more rough, and is deprived of that crepitation 
M'hich accompanies the expansion of the air-cells; the passage of air through tubes 
of various dimensions is thus perceived: this is the bronchial respiratory sound; or, 
more simply, " bronchial respiration." 

Pulmonary or Vesicular Respiration. — In health, the "vesicular respiration" is 
heard almost equally at all points of the chest; yet it is more plainly heard at those 
parts where the lungs are nearest to the surface; as at the arm-pits, the space 
between the clavicle and the " trapezius" muscle, and between the same bone and 
the mammae. The "respiratory murmur" is loud in proportion to the rapidity of 
the respirations: a slow and deep breathing scarcely, but a short breathing (though 
incomplete) plainly, developes the respiratory murmur. Hence the inspiration is 
louder than the expiration; which is not performed, in ordinary circumstances, so 
rapidly as inspiration; and ihe elasticity of the lungs assists the exit of the air. 
** Vesicular respiration" is more energetic and blustering in children than in adults; 
and still more so than in old persons. The younger the infant, the more marked 
is this energy; and it continues until, and a lilUe beyond, the age of puberty. 

The intensity of the " respiratory murmur," differs in different individuals. 
With some it is heard with difficulty, unless in a strong respiration; with some it 
is heard with facility, even though the breathing be gentle; while others retain, 
during their whole life, the energetic murmur of infantile vesicular respiration; and 
it is then called "/JwenVe respiration." This last species of breathing sound (the 
*' puerile") is, for the most part, heard in females and men of a very nervous con- 
stitution; and, with the exception of these two classes, respiration never becomes 
puerile in the adult, except when a considerable portion of the lungs becomes, from 
some cause or other, impermeable to the air. When " vesicular respiration" is 
heard with equal force in all points of the chest, the lungs are in a healihy state; 
when, on the contrary, this respiratory murmur is diminished or annihilated at any 
part of the thoracic surface, we may conclude that the corresponding pari of the 
lungs has become impermeable to the air, in a greater or lesser degree. 

Bronchial Respiration. — "Bronchial respiration," in a state of health, is only 
heard on the anterior and lateral parts of the neck. But in some very thin persons, 
it may be heard towards the upper extremity of the sternum, and in the inter- 
scapular space. In all other parts, the respiratory sound in the small bronchial 
branches, is confounded with the " vesicular respiration." When, from any cause, 
the pulmonary tissue becomes hardened or condensed, the " bronchial respiration" 
replaces the " vesicular;" and thus it becomes one of the first signs of hepatization 
of the lungs, of the accumulation of tubercles in this organ, of an effusion, &c. 
"Bronchial respiration" becomes a sign of greater importance, in proportion to the 
distance at which it is heard from the interscapular spaces; therefore, it is a matter 
of the highest necessity, to practise the ear in distinguishing "bronchial" from 
" vesicular" respiration. 

Cavernous Respiration. — [When, from any cause, an excavation is formed in 
the lungs, the penetration of air into such cavity produces a sound similar to 
"bronchial respiration," when heard at the anterior pari of the neck: this is 
^'■cavernous respiration." "Cavernous" and "bronchial" respiration are some- 
times so modified, that in inspiration the air seems as if drawn /ro?n the ear, and 



710 



DIAGNOSIS OF PULMONARY DISEASES. 



in expiration as if driven back into the ear, of the auscultator: this is the " blowing 
respiration;'' — a decidedly morbid phenomenon; demonstrating' the near approach 
of the excavation, or of the bronchia which pass into it, to the surface of the lungs. 
This " blowing respiration" sometimes resembles the agitation of a movable veil 
(or sail), placed between the ear of the auscultator and the pulmonary excavation. 
This veiled blowing appears to arise from an unequal density of the sides of the ex- 
cavation in which it takes place.*] 

Modified Breath-sounds: Rhonchi. — [We* have now to describe a class of 
novel sounds, which arise from partial obstructions to the passage of the air; — 
obstructions which permit the air to pass, but not without such a resistance as 
causes an increased and modified sound. Thus, if a bronchial tube be narrowed 
by the swelling of its membrane, or by mucus secreted by it, the air v/ill pass 
through the narrowed portion with increased velocity and increased resistance; and 
hence the sound is changed from a simple breathing or blowing, to a louder 
wheezing, bubbling, whistling, or snoring, — according to the nature of the obstruc- 
tion. These new sounds Laennec called rdles^ or rattles. If we must use a sepa- 
rate word, P should prefer the Latin term rhonchus, (which is from the Greek 
poyxoi,) as more expressive, and it has been adopted by many English writers. 
If there were one, it would be desirable to use an English word; for nothing in- 
jures the purity of a language more than the introduction of foreign words. The 
rhonchi may be produced in inspiration, in expiration, or in both. They may be 
divided into the " dry" and the " humid;" — according as the impediment that pro- 
duces them is solid or liquid. 

Dry Rhonchi: — 1. Sibilant. — Of the " dry" rhonchi, there is the "sibilant," 
or " whistling" rhonchus; which is sufficiently described by its name, and may 
generally be imitated by whistling between the teeth. It is produced by the pass- 
age of air through a small and somewhat circular aperture; and this aperture may 
be formed by a slight obstruction of a small tube, or by a greater obstruction in 
tubes of larger size. It generally occurs in tubes narrowed by swelling of their 
mucous and submucous coats; — such as occurs in the early stage of acute bronchi- 
tis; but it is heard also in asthma, where the tubes are congested and constricted 
by the spasmodic contraction of their circular fibres; and it may happen, also, 
when viscid mucus clings to and diminishes the calibre of the tubes. 

2. Sonorous. — The " sonorous" rhonchus is a snoring, humming, or droning 
sound; and may vary in loudness or key from an acute note, like the hum of a 
gnat, down to the grave tone of a violoncello or bassoon. It must be produced by 
an obstruction leaving a flattened aperture; the lips of which, or the moisture on 
them, yield to the passing air with a vibrating resistance. Partial swelling of the 
sides of a tube, particularly at its bifurcation, a pellet of tough mucus in it, or ex- 
ternal pressure on it, may cause such a flattened opening within the tube; and the 
sound in question, therefore, occurs in various forms of bronchitis, and often ac- 
companies tumours, which press on the bronchial tubes. When caused by tough 
phlegm, coughing generally changes or removes it; when from the other causes, it 
is generally more permanent. When quite permanent, it usually depends on the 
pressure of a tumour, or some deposit outside the tube. 

3. Dry Mucous. — There is another rhonchus, which may be called the ** dry 
mucous;" because it is produced by a pellet of tough mucus obstructing the tube, 
and yielding to the air only in successive jerks; which cause a ticking sound, like 
that of a click- wheel. When the air is driven very fast, these click-sounds pass 
into a continuous note, and constitute the "sonorous" rhonchus. Sometimes, 
again, particularly in inspiration, the click-sound suddenly stops; — the tough mucus 
being forced into a smaller tube, which it completely closes, and may not be disr 
lodged again but by dint of forcible cougliing. 

Humid Rhonchi. — The " humid" rhonchi depend on the passage of air, in 

a " A Manual of Auscultation and Percussion; compiled froniLaennec's Great Work." By 
James B. Sharpe. Second Edition. Fage 16. 
"Dr. C.J. B. Wilharas. 



DIAGNOSIS OF PULMONARY DISEASES. 711 

bubbles, through a liquid in the lungs; and their varieties are produced by differ^ 
ences in the size of the tubes, and in the nature and quantity of the liquid; which 
cause differences in the bubbhng sound. 

1. Mucous. — The "mucous" rhonchus may be heard in large and smaller 
bronchi, down to the size of a crow's quill; and, in these tubes, its gurgling or 
crackling presents different degrees of coarseness. It is an irregular and varying 
sound; composed of unequal bubbles, and often interspersed with some whistling, 
chirping, or hissing notes. Its most common cause is acute bronchitis; which, 
after its onset, is attended with a secretion of liquid mucus into the bronchial tubes; 
and the passing of the "sibilant" and "sonorous" rhonchi of the first or dry stage, 
into the " bubbling" of the second or secreting stage, is often marked by a curious 
combination of chirping and cooing notes, like those of birds in a bush. 

2. Cavernous. — When the bronchial tubes become enlarged by disease, or when 
morbid cavities are formed by the destruction of portions of the lung, the bubbling 
of air through liquid in these is of the coarsest kind. It is quite gurgling; and if 
the liquid be scanty, has a hollow character, and is called " cavernous" rhonchus. 

3. iSubmucous. — When there is a little liquid in the smaller bronchi, the bub- 
bling or crackling is more regular; although the sound is weak, and is sometimes 
only a roughness added to the ordinary respiratory murmur. This is the "sub- 
mucous" rhonchus. It may result from slight degrees of bronchitis; and owes its 
importance only to its being permanently present, when such slight inflammation 
is constandy kept up by the irritation of adjacent tubercles in an incipient state. 

4. Subcrepltant. — Wlien there is more liquid, not viscid, in the smallest tubes 
and terminal cells, the rhonchus has a still more crepitating character; and re- 
sembles that heard on applying the ear near the surface of a liquid slightly effer- 
vescing; — such as champagne, or bottled cider. This is the " subcrepital" rhon- 
chus; which is heard in oedema of the lungs, humid bronchitis, and other affections, 
in which liquid and air occupy the extreme tubes, and are forced through each, 
other in the motions of breathing. 

5. Crepitant, — But the most perfect and equal crackling, is that of peripneu- 
mony: it is therefore called the "crepitant" ("crackling") rhonchus. It exactly 
resembles the sound produced by rubbing slowly and firmly, between the finger 
and thumb, a lock of one's hair near the ear. P believe this sound to depend on 
the forcible passage of air through a little viscid mucus in the finest tubes, narrowed 
by congestion and deposit around them. 

All these different rhonchi may occupy the whole of the respiratory movements, 
or be confined to part of them. Thus, an obstruction which is sufiicient at the 
commencement of inspiration to cause a rhonchus, may be insufficient when the 
tubes are dilated by the distension of a full breath; or there may be the converse; 
— an obstruction which is total in low degrees of respiration, and stops all sound, 
occasions a rhonchus in forced or extensive efforts; as in coughing. This suggests 
to us the propriety of using these different degrees of respiration, to test the nature 
and extent of bronchial obstructions. It may also be inferred, from what has been 
said, that the different stages and degrees of force in respiration may change the 
note of the different rhonchi; and thus produce such a variety, as that which we 
hear in the chests of some catarrhal and asthmatic patients. Laennec used to call 
this combination of piping sounds — " rhonchus canorus,^^ It may be readily con- 
ceived, too, that these several rhonchi may be variously combined; or exist at the 
same time in different parts of the lungs; and give rise to numerous combinations, 
on which it is useless to dwell. The loudness of a "sonorous" or "sibilant'* 
rhonchus, is no proof of the severity of the disease; nor is the fact of its being 
audible over the whole chest, unless the natural breatli-sound be, at the same time, 
absent or very feeble in parts. But the presence of the " bubbling" rhonchi, does 
imply mischief proportioned to its extent; and if they are heard over a large space, 
and accompany the whole act of respiration, — diminishing or superseding the natu- 

• Dr. C. J. B. Williams. 



712 DIAGNOSIS OF PULMONARY DISEASES. 

ral breath-sound, — they denote disease of a very serious character; because, as our 
hearing' informs us, there is an obstructing liquid in the tubes where there ought 
to be only air, and the function of respiration must be injured in proportion.*] 

h, Auscultation of the Voice, 

Natural Voice Sounds. — When any one, in a healthy state, speaks or sings, 
the voice resounds through every part of the respiratory organs. If we seek by 
auscultation to discover the nature of this resonance, we shall find it to differ in 
the larynx, the trachea, the bronchia, and the pulmonary tissue. The voice resounds 
so forcibly in the larynx and the superior portion of the trachea, that when heard 
through the medium of the stethoscope applied over those parts, the other unas- 
sisted ear does not distinguish the sound of the voice proceeding from the speaker's 
lips. This resonance is not so loud at the inferior portion of the trachea; and is 
still less so when the stethoscope is applied to the upper portion of the sternum. 
This resonance is yet strong, though diffuse, in the great bronchial branches situated 
at the root of the lungs, and which we explore by applying the stethoscope to the 
interscapular spaces. The sound of the voice does not pass through the instru- 
ment, but sounds at its extremity: nevertheless, the resonance is heard more plainly 
than the voice itself. In the pulmonary tissiie, and in the expanded bronchial 
ramifications, this resonance is scarcely heard; and the stethoscope discovers nothing 
more than a slight trembling; — such as may be felt by the hand placed upon the 
chest of the speaker. But, in those who have a powerful and deep voice, this 
resonance is at all times to be heard, upon whatever point of the thoracic surface 
the stethoscope be applied, as powerfully as at the interscapular spaces of ordinary 
persons. 

Bronchophony. — [If from any cause the lungs become impermeable, the reso- 
nance of the voice becomes audible in the small bronchial branches; and it increases 
greatly in the larger branches, if the induration is in a part situated near the root of 
the lungs: such resonance is called "bronchophony." This effect also takes 
place when the small bronchial ramifications are dilated; so much so, that the reso- 
nance is heard almost as plainly as at the larynx. ^^ Accidental bronchophony," 
therefore, indicates either an induration of the pulmonary tissue, or a dilatation of 
the small bronchia, or both combined at the same time. "Bronchophony" may 
be heard at all points of the thoracic surface. But it is more frequently recognized 
at the interscapular spaces, and the subspinal fossae of the scapulae; — on account 
of the proximity of the great bronchial branches, and the frequency of the hepati- 
zation of the inferior lobes of the lungs. It also as often occurs at the arm-pits, 
and beneath the clavicles; — by reason of tuberculous indurations which are so very 
frequently developed at the summit of the lungs. 

Pectoriloquy. — When there is an excavation of the lungs, communicating with 
the bronchia, the resonance of the voice is heard over the place, just as upon the 
larynx. This is called "pectoriloquy;" which is either "perfect," "imperfect," 
or "doubtful." It is "perfect," when the voice appears to issue directly from 
the chest, and to pass entirely through the tube of the stethoscope. It is " imper- 
fect," when the transmission of the voice is not complete, notwithstanding the 
presence of every other local symptom of excavated lungs. It is " doubtful," 
when the resonance is very feeble, and only to be distinguished from bronchophony 
by signs drawn from the place where it is heard, and from the history of the dis- 
ease. " Perfect pectoriloquy" is the result of the complete vacuity of the excava- 
tion; the greater density of the pulmonary tissue surrounding the excavation; the 
communication of somewhat voluminous bronchia wqth the cavity, and the proxi- 
mity of the cavity to the parietes of the chest. It is generally the sign of an 
excavation of middling size. It is also very evident in small cavities; — provided 
they are surrounded by hardened lung, and are near the surface of the lungs; but 

• Dr. C. J. B. Williams, on " Diseases of the Chestj" Pages 27 to 31. 



DIAGNOSIS OF PULMONARY DISEASES. 713 

in very lar^e excavations, wherever their seat, pectoriloquy is almost always very 
slight. " Pectoriloquy" is suspended occasionally, during a greater or lesser time, 
if the bronchia which communicate with the excavation are obstructed by expec- 
toration. It is diminished, or ceases entirely, when the cavity communicates with 
a vast number of bronchia, or opens into the pleura. It may take place at any 
point of the thoracic surface; since excavations may be formed in any part of the 
lungs; but as excavation is generally the consequence of a resolution of tubercles, 
and as these tubercles are principally developed in the upper portions of the lungs, 
it follows that pectoriloquy is most frequently heard beneath the clavicles, and in 
the hollow of the arm-pits. Dr. Elliotson states, that pectoriloquy may often be 
easily detected, on making the patient speak in a strong whisper, although it be 
doubtful when he speaks aloud. He also recommends that, when there is any 
doubt as to pectoriloquy or bronchophony, the voice should be explored on eac-h 
side, for comparison, with the plug of the stethoscope removed."] 

t^gophony, — " ^^gophony" is a particular resonance of the voice, which is 
heard at nearly the same points as " bronchophony," and is often coincident with 
it; but it is the result of very different anatomical conditions. ^^ Simple fegophony" 
is characterized by a tremulous jerking voice, like that of the goat; with an acute 
silvery tone, not possessed by the natural voice of the patient, rarely heard as if 
within the stethoscope, and seldom if ever passing through it. In one case aego- 
phony is pectoriloquous, — passes distinctly through the tube, like pectoriloquy; 
and this is where the portion of lung, which has an effusion around it, (producing 
the aegophony,) is solidified. When it is heard with " bronchophony," this goat- 
like voice resembles that of a man speaking with a counter between his teeth and 
lips; or still more that o( Punch. The existence of effusion into the pleura, is 
the anatomical condition producing asgophony. But this effusion must not be very- 
abundant. For, if so, aegophony is no longer heard; it is again manifest when the 
effus'ion diminishes, and finally disappears with the fluid by degrees. It therefore 
coexists with pleurisy, and continues from the first to the third day: it exists only 
for a few days in acute pleurisy, but continues many months when this disease is 
chronic. In both cases it is a favourable symptom; since it proves the effusion to 
be of small extent, "^gophony" may not be present in pleurisy under three 
conditions:— 1. When the effusion of fluid is very rapid and very abundant. 2. 
When old adhesions obstruct the effusion of fluid into the pleura. .3. When there 
are false membranes without effusion. Those who have thought that "aegophony" 
was audible in this last case, have mistaken it for "bronchophony." When the 
patient stands or sits, "aegophony" is heard between the spinal column and the 
scapula, and along a zone of three fingers' breadth, drawn from the inferior angle 
of the scapula to the nipple, following the direction of the ribs. When he lies in 
a prone position, it is heard only at the side. The extent over which "asgophony" 
is heard, will hardly allow it to be confounded with "pectoriloquy." The latter 
is bounded by narrow limits; is rarely discoverable at the same place with " aego- 
phony;" has not the jerking character; and is moreover accompanied by "cavern- 
ous respiration," and other signs of excavation. "iEgophony" is distinguished 
from " bronchophony," with which it often coexists; inasmuch as the latter is con- 
stantly accompanied by "bronchial respiration," and is always heard at the same 
place, — whatever may be the position of the patient; while " aegophony" changes 
its place with a change of position, and is generally attended by a pure respiratory 
murmur, although it be but feeble. The distinction of " aegophony" and of " bron- 
chophony," as the one or the other may exist alone or predominate, determines 
whether the pleurisy is simple, or complicated with pneumonia; and which affec- 
tion is the more serious; or whether pneumonia alone exists. To hear distinctly 
that goat-like voice which forms the principal characteristic of "aegophony," the 
stethoscope should be firmly applied to the chest, and the e-ar placed lightly upon 
its auricular extremity. 

* Sharpe's " Manual of Auscultation^" Pages 18 to 21. 



714 DIAGNOSIS OP PULMONARY DISEASES. 

Metallic Tinkling. — By "metallic tinkling" is meant that sound which may be 
perfectly imitated by gently striking a piece of metal, glass, or china, with a pin; 
or by dropping grains of sand or pins into a glass. ''Metallic tinkling^'' is heard 
when the patient breathes, speaks, or coughs; but more feebly in the former than 
in the two latter cases; sometimes the reverse of this happens, but that is an ex- 
treme case. Vv^hen pectoriloquy exists at the same lime, this metallic tinkling and 
the voice traverse the tube of the stethoscope; but, when pectoriloquy is not 
present, a light acute sound is heard within the chest; — analogous to the vibration 
of a metalHc string struck with the finger. ^'-Metallic tinkling^'' can be heard in 
two cases only: — 1. In that of the coexistence of a serous or purulent discharge 
in the pleura with pneumato-thorax. 2. When a large tubercular excavation is 
partly filled with liquid pus. "Metallic tinkling," therefore, may be taken as a 
sign of a triple lesion, when pneumato-thorax is joined to empyema; since there 
must exist at the same time a fistulous communication between the pleura and the 
bronchia; — the result of a tuberculous vomica, of an abscess in the lungs, or of a 
gangrenous eschar. The magnitude of the fistulous opening, and the relative pro- 
portions of air and fluid poured out, may be ascertained by this sound; since, the 
more clearly the tinkling is heard, the greater is the fistulous opening; and the 
greater the extent of the vibrations, the larger is the space filled with air; but the 
maximum of sound is (perhaps) when the air and fluid occupy equal spaces. 
Thus this space may be estimated (with sufficient accuracy) by the stethoscope, 
and by percussion exercised at the same time at different points; when a resonance 
similar to that of an empty cask, mixed with the tinkling, will be heard. Some- 
times this sound passes into another, similar to that which is produced by blowing 
into an empty decanter: this is the "botfle-buzzing" or "amphoric" sound. Re- 
spiration, the voice, and cough equally display it. There are two circumstances 
which produce this "buzzing resonance" more frequenfly than the tinkling; although 
sometimes these sounds succeed one another, or are alternately produced for uncer- 
tain periods, or even heard simultaneously; — 1. When two or more fistulous open- 
ings exist between the cavity occupied with air and the bronchia. 2. When this 
cavity is extremely vast, and contains but a small quantity of fluid. "Metallic 
tinkling" may be evinced by a fact quite independent of the voice, cough, or re- 
spiration. Thus, when pneumato-thorax with an effusion of fluid has taken place, 
and the patient is made to sit up, sometimes a drop of the fluid which was retained 
above falls down at the moment of examination; — producing a sound similar to 
a drop of water let fall into a decanter three parts empty; and it is accompanied 
by an evident "metallic tinkling." The latter, and the "amphoric buzzing," are 
always heard after the operation for empyema; as long as there is a communica- 
tion between the cavity and the air, either by the external wound, or by a fistulous 
opening. 

There is a phenomenon of no value as a sign, but which might be mistaken by 
the inexperienced for the metallic tinkling: — it is produced by the friction of some 
hard parts upon one another, where the ribs allow much mobility of parts; and re- 
sembles the sounding of fire-arms in military exercises. 

c. Pleural Friction- Sound. 

[There is a heavy sound similar to that which is produced, under the stetho- 
-scope, by rubbing the finj^er against a bone: this is called "the ascending and 
descending friction sound." It is the result of interlobular emphysema; and, in 
conjunction with ihe "dry crepitant rattle, with great bubbles," becomes a sign of 
that disease. This "friction-sound" takes place in the following circumstances: — 
1. When the internal surface of the pleura becomes unequal or wrinkled. 2. In 
pleurisy, when there is litde or no effusion, and when the pleura is covered only 
with false membrane, more or less thick, 3. When there is moderate effusion; 
and old adhesions do not, in certain positions of the body obstruct the lungs; while 
rising above the level of the fluid, and rubbing against the sides of the chest, at a 



DIAGNOSIS OF PULMONARY DISEASES. 71 5 

point where the ear may be applied. This friction disappears when the efTusion is 
very abundant; and reappears as the fluid diminishes. It is sensible to llie hand, as 
well as to the stethoscope: it may sometimes be heard by a distant observer, and even 
perceived by the patient himself. The habitual friction between the two glistening 
surfaces of the pleura, gives out no appreciable sound; — owing to their extreme 
polish. It takes place only when the healthy surfaces are changed by disease, or 
other causes."] 

The subjoined tabular view of the chief phenomena of auscultation of the organs 
of respiration, is extracted from Dr. C. J. B. Williams's work on the Diseases of 
the Chest. 

SOUNDS PRODUCED BY THE PASSAGE OF AIR IN RESPIRATION. 

Sound of Respiration, or Breath-Sound. 

Natural; produced by collision of the air against the sides and angles of the air- 
tubes. 
Tracheal; heard in the neck and at the top of the sternum. 
Bronchial; near the vpper parts of the sternum, between the capsules, S^c. 
Vesicular; in most other parts of the chest. 
Morbid, modified in production or transmission. 

Bronchial, or whiffling; transmitted from the bronchi by condensed tissue 

of the lung. 
Cavernous ) produced in morbid cavities communicating with the bron- 
Amphoric S chi. 
Rhonchi, produced by increased resistance to the air moving through the lungs. 

Dry, iDilant J pj-Q^^^yggjj j^y viscid mucus in the bronchi, or by swelling of 

sonorous > j^ membranes, or by pressure upon them. 

Dry Mucous ) ' ^ r r 

Moisl; Mucous . . I ^'lt!::i, H J^ bubbling | ,i,„ia in .he bronchi. 

Submucous liquid in the finer bronchi. 

Subcrepiiant . . . ., liquid in the smallest bronchi. 

ri .. ^ ^ viscid liquid in compressed smallest 

C^^P^^^^t • [ bronchi. ^ 

Cavernous liquid in a morbid cavity. 

SOUNDS OF THE VOICE TRANSMITTED THROUGH THE CHEST. 

Natdral Sounds, heard in a healbhij chest. 

Tracheophony; in the neck and at the top of the sternum. 

Bronchophony; near the top of the sternum, between the scapula, in the axilliB, S^C, 
Pectoral voice-sound; in many parts of the chest. 
Morbid Sounds, transmitted or produced by a diseased chest. 

Bronchophony, transmitted by condensed pulmonary tissue. 
vEgophony, the same vibrating through a thin layer of liquid. 
Pectoriloquy, resounding in a cavity in the lung. 
Tinkling, a changed echo of the voice or cough in a large cavity, 

SOUNDS PRODUCED BY THE MOTIONS OF THE LUNGS. 

Sounds of friction, when the pleurae are dry, or rough from deposits. 
Emphysematous crackling, by the irregular passage of air between the lobules. 



SECTION IV.— GENERAL REMARKS ON THE DIAGNOSIS OF 
PULMONARY DISEASES. 

[Having given a short sketch of the sources of physical diagnosis, P shall 
announce the great principles that oovern their application to the detection of dis- 
ease. These may be stated as follows: — 1. The value of most of the preceding 
signs, or of their combinations, in the determination of the seat, nature, or extent of 
disease, is to be estimated more by comparison with the phenomena of other por- 
tions of the chest, than by their mere existence in a particular situation. 2. The 

a Sharpe's "Manual of Auscultation;" Pages 3G and 37. 
^ Dr. Stokes. 



716 DISEASES OF THE LARYNX AND TRACHEA. 

greater the number of physical signs which can be combined in any particular case, 
the more accurate will our conclusions be. But of these combinations, the most 
important and indispensable is that of the passive and active auscultatory pheno- 
mena. 3. The existing physical signs, are to be considered in relation to the 
period of duration of the disease, and the rapidity or slowness of their own changes. 
4. In all cases, the value of physical signs must be tested by the existing symp- 
toms and previous history; while, on the other hand, the observation of these 
physical signs, enables us to correct the conclusions to which the unaided study of 
symptoms would lead us. 

In the cases we are every day called to treat, the value of physical signs must be 
tested by the history and symptoms; and these, in their 4urn, must be corrected by 
the physical signs. Whoever neglects either source of information, will fall into 
the most fatal errors. We must have recourse to the assistance of each and every 
one of these means; and even still, with all this combined knowledge, we shall 
meet with cases, the real nature of which is involved in the greatest obscurity. 
Indeed, when we reflect on the infinite complications of disease, modified by cir- 
cumstances infinitely numerous, it would be strange if such did not arise; and there 
can be no doubt, that if our means of diagnosis were extended one hundred-fold 
beyond their present state, the same circumstances would still occur. Physical 
signs form an addition, — constitute an assistance to diagnosis, but nothing more; 
yet of their value every impartial mind must be convinced, who compares the state 
of our knowledge previous and subsequent to their discovery. It is on the disco- 
very, explanation, and connection of those signs with organic changes, and with 
the symptoms and history of the case, that Laennec's imperishable fame is founded. 
Time has shown, that his principles of diagnosis were not the bagatelle of a day, 
or the brain-born fancy of an enthusiast; the use of which, like the universal medi- 
cine, was to be soon forgotten, or remembered only to be ridiculed. It has shown, 
that the introduction of auscultation, and its subsidiary physical signs, has been 
one of the greatest boons ever conferred by the genius of man on the world. A 
new era in medicine has been marked by a new science, depending on the immu- 
table laws of physical phenomena, and — like other discoveries founded on such a 
basis — simple in its application, and easily understood. A gift of science to a 
favoured son: not, as was formerly supposed, a means of merely forming a useless 
diagnosis in incurable disease; but one by which the ear is converted into the eye; 
the hidden recesses of visceral disease opened to the view; a new guide in the 
treatment, and a new help in the early detection, prevention, and cure, of the most 
widely spread diseases which afflict mankind.^] 



CHAPTER IV. 

DISEASES OF THE LARYNX AND TRACHEA. 

SECTION I.— ACUTE LARYNGITIS. 

Not described by Cullen. — I shall now proceed to consider inflammation of 
the commencement of the air-passages, properly so called; — inflammation of the 
larynx, — "laryngitis." This disease is not mentioned by Cullen. He speaks of 
*'cynanche trachealis;''^ — he speaks of the windpipe, and of croup; but not of 
this particular inflammation situated in the larynx. Indeed, so litde was it formerly 
attended to, that when two or three physicians died of it, some years a^o, it was 
considered almost a new disease; but, on looking into old writers, we find it well 
described. 

*■ Dr. Stokes's "Treatise on Diseases of the Chest;" Section 1; Pages 24, 40, and 41. 



DISEASES OF THE LARYNX AND TRACHEA. 7l7 

Morgagni and others have described this disease; — proving that it is not new to 
medical men; — but, from there being no " outward and visible sign," in some cases, 
it was called " angina occulta;^' to distinguish it from common sore-throat, which 
they called "angina manifesta.^^ 

Symptoms. — In this affection, there is hoarseness or whispering; and, indeed, 
almost suppression of the voice. The breathing also is hoarse, loud, and rough. 
The inspirations are long. There is great dyspnosa; and, besides the constant 
difficulty of breathing, there are occasional paroxysms of dyspnoea, in which every 
muscle of the body comes into play; the eyes start; and the person looks as if he 
were being hanged. Such is the state of the parts, that there is also frequent 
orlhopnoea (from op9o?, erect; and rtvorj, breathing); — that is to say, the person 
cannot breathe unless he be erect. From the great difficulty of breathing, the face 
is pale and crhasily; the lips are pale and livid; and perhaps the face and throat are 
swollen. There is pain felt in the throat, exactly in the situation of the larynx; 
and on pressing the larynx, we are sure to find it tender. Sometimes, but not 
always, there is redness and swelling of the face. 

Sometimes there is swelling and redness of the fauces, of the " velum pendulum 
palati," and uvula; and, indeed, of the tongue. Occasionally, "cynanche ton- 
sillaris" coexists with laryngitis. Indeed, it frequently does so;— the inflamma- 
tion commencing in the tonsils, and spreading into the larynx. The epiglottis is 
very often swollen. The epiglottis is a part of the larynx; — so much a part that, 
in many anatomical books, it is enumerated with the cartilages of the larynx. 
Sometimes there is cough, — but not always. Sometimes, too, there is difficulty 
in swallowing. In the function of deglutition, the larynx is raised and brought 
forward; and if a part of the larynx so much pressed upon be inflamed, of course 
there is a difficulty of deglutition; — dysphagia, as it is called. There is also ex- 
pectoration of viscid mucus; for the inflammation, being seated in a mucous mem- 
brane, will (of course) affect the secretion of that membrane. The tongue, likewise, 
is very foul; — from the inflammation taking place in its neighbourhood. These are 
the local signs; and they are those of inflammation; — redness, swelling, heat, and 
pain. 

General Symptoms. — From the disturbed function, there are also general 
symptoms. There are thirst, heat, extreme restlessness, and great anxiety. The 
difficulty of breathing must occasion great resdessness, and extreme anxiety. The 
pulse is rapid; and there is at last a clammy sweat. The pupils, too, at last become 
dilated; and the patient keeps his mouth constantly open. The difficulty of breath- 
ing occasions, I presume, such an accumulation of blood in the head, that more or 
less compression exists; and the pupils consequendy become dilated; and the 
patient, from the want of breath, opens his mouth, gasps, and makes an eflbrt to 
take in all he can. 

Duration. — This disease, when acute, lasts only about three or four days: — 
not including the previous days, on which there may be "cynanche tonsillaris;" 
but reckoning from the time when the larynx becomes actively inflamed. Death 
sometimes occurs very suddenly. A violent spasm takes place; and the patient is 
quickly destroyed. 

Most Common in Adults. — This is a disease which occurs almost always in 
adults. Children have croup, — inflammation of the ivindpipe; but when inflam- 
mation of this violent kind attacks adults, it aff*ects the tube higher up; — it aflects 
the larynx; and it has, therefore, been called " the croup of adults.'" 

Morbid Appearances. — After death, we find the mucous membrane of the glottis, 
and of the posterior part of the epiglottis especially, — perhaps the mucous mem- 
brane of the whole of the larynx, — red, swollen, and osdematous; — swollen not 
merely as mucous membranes are when inflamed, but from effiision into the sub- 
jacent cellular membrane. The " rima glottidis" is found to be nearly closed: and 
this would appear to be the great source of dyspnoea; — the osilematous state of the 
parts, which produces nearly a closure of the " rima glottidis." Sometimes the 
disease proceeds so far as to cause an efli'usion of fibrin; — so that, notwithstanding 



718 DISEASES OF THE LARYNX AND TRACHEA. 

the disease is an affection of the mucous membrane, fibrin is poured forth, ^jiist 

as in a serous membrane; and sometimes we find a quantity of pus; — or, al least, 
of puriform fluid. Occasionally the tonsils are not merely red, as I stated, but 
even ulcerated; and occasionally the pharynx and the trachea below, and even the 
bronchia, are also inflamed. We are not, therefore, to expect one uniform appear- 
ance in the disease. 

Pathology of Laryngitis. — We find the essence of it, in all cases, to be a vio- 
lent inflammation of the larynx; and, in general, an oedematous state of the " rima 
glottidis" and the parts around; but frequently there is inflammation higher up, 
about the tonsils and the "velum pendulum palati;" — perhaps, also, inflammation 
of the pharynx. With respect to the quality of the fluids, they will vary from 
thick mucus to puriform fluid, and even up to fibrin; but that which we particularly 
notice, is an oedematous state of the submucous tissue. All these appearances are 
nothing more than we might expect. The oedematous state, which perhaps is 
fatal, is nothing more than what occurs when the cellular membrane is inflamed in 
any other part of the body. When inflammation is situated near cellular membrane, 
it secretes abundantly. In violent inflammation of the skin, the cellular membrane 
secretes to a great extent; so that there is more or less oedema; and the same thing 
occurs here; but from the circumstance of the parts being air-passages, and the 
inflammation being in the narrowest part of the passage, it is often dano-erous. The 
same occurrence, situated a little higher in the pharynx, produces only a trifling 
inconvenience. 

Causes. — The disease begins from a catarrh. The person has a common cold; 
and the latter generally arises from cold and wet. The application of cold alone 
will produce the disease; but it usually results from a union of the two, applied 
either to the throat or to the feet. A few days after exposure, the patient has great 
hoarseness; and then pain in the larynx comes on. Sometimes it does not arise 
from a common cold; but, as I have mentioned already, a pretty brisk inflamma- 
tion of the tonsils takes place, and it spreads from them. Occasionally, too, it 
takes place suddenly; but I have seen it in the middle of a chronic disease. There 
is no part of the body which can be inflamed chronically, that may not become 
the seat of acute inflammation; and therefore this occurrence may take place in the 
throat. When there is a syphilitic sore-throat, or a chronic afl^'ection of any kind, 
patients may suddenly experience great difficulty of breathing, and be in the great- 
est danger from active acute laryngitis. 

[Acute inflammation of the larynx has been brought on by swallowino- scalding 
or corrosive liquids. By the convulsive action which these excite in the throat, 
they are in part thrown on, and even into the glottis. Children accustomed to 
drink from the mouth of a tea-kettle or tea-pot, have often attempted to do this 
when these vessels contained scalding water; the result has been violent inflamma- 
tion of both pharynx and larynx. Instances of this accident were first recorded by 
Dr. Marshall Hall. Mr. Porter observes, that when a person attempts to drink 

(by mistake) a corrosive liquid, a similar convulsive action takes place; closino- 

the pharynx, and throwing the oflfending matter violently backwards through the 
mouth and nostrils, under the epiglottis; and thus this accident becomes a cause of 
acute inflammation of the larynx. Mr. Ryland has, with good reason, placed the 
inhalation of flame, or of very hot air, among the causes of acute inflammatory in- 
juries of the larynx. Persons who die from severe burns, if it be onlv about the 
head and face, generally suflfer from severe dyspnoea; and the moutl/and larvnx 
are found in a highly inflamed and congested state: these efl^ects he very rationally 
ascribes to the great heat of the air inhaled at the moment of the conflaoration. 
The inhalation of very acrid vapours, might possibly have the same efl^ect. As 
exciting causes of asthenic laryngitis, erysipelas, scarlatina, small-pox, and measles, 
may be mentioned; and we may add, that inflammation of the tongue from the ex- 
cessive use of mercury, and diffusive cellular inflammation from punctured wounds, 
have been known to extend to the cellular tissue of the larynx, and cause death. 



DISEASES OF THE LARYNX AND TRACHEA. 7l9 

M. Bavle and Dr. Tweedie have noticed, that cpdematous laryngitis sometimes 
suddenly supervenes, without any obvious cause, during and after typhoid fevers. 
It occurs, also, not unfrequenily, in the course of chronic disease of the larynx, 
and is sometimes the cause of death in these cases. We"* have known it to come 
on, and hazard life, in a patient with aneurism of the arch of the aorta; before the 
tumour had well shown itself outwardly. 

Habitual intemperance, long courses of mercury, and frequent and long-continued 
exertions of the voice, are supposed to predispose persons to attacks of laryngitis. 
Except in cases of scarlatina, measles, and small-pox, and of the accidents before 
alluded to, laryngitis never attacks children: and, of those advanced in life. Dr. 
Cheyne states that it most frequendy occurs in such as are liable to indigestion 
connected with a disordered state of the liver. In most instances, the subjects of 
it had previously been liable to sore-throat. 

Diagnosis. — The symptoms of acute laryngitis, are generally sufficiently cha- 
racteristic to separate it from other diseases affecting the breathing. The stridu- 
lous or hissing inspiration, heard most distinctly at the larynx (which is drawn 
down at each act), the seat of the sensation of pain or constriction at that part, 
often the visible condition of the epiglottis, and the absence of pectoral signs, suffice 
to distinguish it from diseases of the chest. Abscesses external to the larynx, and 
compressing it, may cause difficulty of breathing and swallowing: sixteen years 
32:0 we'^ saw a fatal case of this kind, which w^as mistaken for laryngitis; until the 
first incision of the throat after death gave issue to a quantity of pus, which had 
formed among the numerous muscles of the tongue and larynx. Careful examina- 
tion will generally distinguish these cases by the partial or general swelling at the 
upper part of the neck, often with tenderness and an inability to open the jaw. 
Mr. Porter thinks that they differ from those of laryngitis in the breathing, although 
obstructed, being less sibilous, and more gradually oppressed; and in the dimi- 
nished mobility of the larynx, when pressed from side to side against the spine. 
We* should conceive, that the absence of the peculiar cough and hissing hoarse- 
ness of laryngitis might, in some cases, better assist the diagnosis. Spasmodic 
affections of the larynx, may generally be distinguished by the complete absence 
of fever, and by the suddenness of the attack; but they may not be so easily dis- 
tinguished from the oedematous laryngitis supervening on chronic diseases, which 
is, in effect, generally combined with spasm: still, in this case, there is usually a 
previous slight access of fever, and increase of the chronic symptoms. Spasm of 
the glottis is a very rare affection in a4ulls, and occurs only in hysterical or highly 
nervous subjects. 

Prognosis. — Laryngitis has been considered, by Dr. Cheyne and others, to be 
the most fatal of all the infiammations. Of seventeen cases observed by Bayle, 
during six years, only one recovered. Of twenty-eight cases collected (from 
various authors) by iNIr. Ryland, ten recovered; which he justly considers to be 
above the average. In most of the fatal cases, death took place between the first 
and the fifth days. The prognosis must, therefore, in all cases be unfavourable; 
and the more so, as the disease has lasted longer, and with progressive increase of 
the difficulty of breathing. When the face loses its colour or becomes livid, and 
the faculties obtuse, from the circulation of black blood, the danger is extreme. 
On the other hand, decrease of the difficulty of breathing and of swallowing, a 
returning freedom of expectoration, with an improved expression and colour of the 
countenance, give rational hopes of recovery.''] 

Treatment. — This is a disease in which, if in any, it is necessary to be most 
active in treatment. No trifling practice is admissible here. We cannot trust to 
nature; nor can we trust to medical measures alone; — for it is necessary (in cases 
which last any time, and which become very severe) to use the combined force of 
niedicine and surgery. 

Bleeding. — The first thing to be done is, undoubtedly, to bleed freely in the 

' Dr. C. J. B. Williams. »> '•' Library of Medicine;" Volume 3; Pages 42 and 43. 



720 DISEASES OF THE LARYNX AND TRACHEA. 

arm; — to make the patient faint, if we can; and then to cover the throat with 
leeches. I am taking it for granted that the patient is able to bear it. The disease 
may attack a person with syphilitic sore-throat; and he may be worn out with 
mercury and disease; so that we may not be able to bleed in the arm; but still, in 
most cases, I am satisfied it would be best to set the patient upright, and take as 
much blood as he can spare; — be it three, or four, or twenty, or thirty ounces; and 
to produce fainting, if possible. There can be no rule for the quantity; but it may 
be necessary to take thirty .or forty ounces, and to apply from six to thirty leeches; 
according to the age and strength of the patient. After the leeches, a poultice for 
some time may be a good application; and then, after all, a blister, if we please; 
but not earlier. 

Mercury. — In this disease mercury is recommended, even by those who do not 
ascribe any active power to mercury in general. It is of the highest importance 
to get the mouth tender as early as possible; and therefore we must not wait a 
couple of days for salivation to take place. A solitary case of this disease is re- 
corded in the "Medico-Chirurgical Transactions;"* where ten grains of chloride of 
mercury were given every two or three hours, till ptyalism was produced; and as 
soon as the patient began to spit, the affection ceased. I have treated ma*ny cases 
of the disease in this manner; and with the greatest success. In a case of this 
kind, it will not do to give a few grains of calomel night and morning; for the 
patient is in constant jeopardy; — we are never sure of his life, from hour to hour. 
It would be good practice to rub in mercury on the extremities. If we exhibit mer- 
cury by the mouth, it is necessary to give it in large and repeated doses. I will 
not say any thing about the dose; because if we know that the patient is soon 
affected by mercury, a small quantity will do. I only state that it is necessary to 
get the mouth sore, in one way or other, as soon as possible. 

Bronchotomy . — If the patient be in great danger, — if his attacks of difficulty of 
breathing come on frequently, it will not be right even to wait for ptyalism; but it 
will be requisite to make an opening into the throat; — so as to enable the patient to 
live till the mercury produces its effects. Bronchotomy,* is absolutely necessary, 
in many cases of this disease. By opening the air-passages below the part in- 
flamed, instantaneous relief is afforded; and the patient will live so much the 
longer. This cannot have the effect of curing the disease, but it has the effect of 
enabling the patient to live longer; — to live, therefore, till we adopt other means to 
cure him. I have had (to speak as a pathologist) some very beautiful cases of 
this description; where the combined force of the two great divisions of the pro- 
fession, has most decidedly saved the patient's life; but where neither would have 
done alone. A mere opening of the larynx will not cure the inflammation, and the 
patient may die before the mercury can have any effect; and, therefore, it is neces- 
sary to watch the patient constantly; and if the symptoms decidedly grow worsen 
the operation ought to be performed without delay. It is an operation which, if 
properly performed, can do no harm. The dyspnoea arises, as I have said, from 
an cedematous state of the "rima glottidis;" and if we enable the patient to breathe 
notwithstanding that, as the inflammation subsides the redema goes down. The 
paroxysms of difficulty of breathing, clearly arise from spasm; and if an opening be 
made below, so that the patient can breathe through it, the disease may occasion 
as much spasm as it chooses; — the patient is safe. 

Spasmodic Closure of the Larynx. — The least pressure in these parts will occa- 
sion spasmodic difficulty of breathing. In the "Medico-Chirurgical Transactions,"" 
Mr. Lawrence describes the case of a person, who had attacks of dyspnoea, from 
very slight pressure of an aneurism of the "arteria innominata. The direct dimi- 
nution of the trachea by the tumour, was found to be very inconsiderable; but it 
was sufficient to produce irritation, and to cause violent attacks of spasmodic 
dyspnoea. 

But, independently of this oedema and tension of the parts, the inflammation of 

» Volume 9; Page 31. ^ From ^^oy^oq^ the windpipe; and t6|UV(w, to cut. 

« Volume 6; Page 227. 



DISEASES OF THE LARYNX AND TRACHEA. 721 

the membrane itself, will throw the parts around it into violent spasm; — just as 
occurs in inflammation of the urethra and bladder. When inflammation exists 
about the larynx, the person is continually seized with a violent difficnlty of 
breathing, without any pressure, but merely from the irritation; and many persons, 
without any inflammation about these parts deserving the name of "laryngitis," 
Aviil die in a moment. I have seen several cases of persons, who have been seized 
with a sudden difficulty of breathing, when they were supposed to have only 
a common sore throat; some of whom have died in the course of three or four 
hours, and some in a minute. When inflammation exists in the fauces, and ex- 
tends to the glottis, without descending to the larynx and producing laryngitis, the 
person may be seized with spasmodic difficulty of breathing, and die instantly. I 
once saw a young man, who, in consequence of a fright, became very nervous, and 
therefore liable to spasmodic diseases. He merely caught a common sore throat, 
for which six leeches were applied; and, while the ward was full of medical men, 
a violent spasm seized his throat, and he died instantly. Every thing was done 
for him that could be done; but he was quite dead. I have seen several patients 
with more decided inflammation than this, (but still not with inflammation deserv- 
ing the name of "laryngitis,") who have died in a moment. When, therefore, 
there is laryngitis, we may well suppose how dangerous the case is; and how 
necessary it is to be active in the highest degree. Wiienever a patient becomes 
very hoarse, and we hear his voice hissing ("sibilous") through the larynx, and 
find the tube is tender on pressure, alarm should instantly be taken, and the dis- 
ease treated actively: — although the patient may make no particular complaint 
himself; and although, on looking into the throat, we cannot discover any thing 
particular. 



SECTION II.— CHRONIC LARYNGITIS. 

Symptoms. — A much more common disease than this, however, is chronic 
laryngitis; an afi"ection of which many cases occur. This species of the disease is 
attended by a very hoarse cough, and likewise with a hoarseness of the voice; and 
sometimes the person, both when coughing and talking, makes a sort of crowing 
sound. The alterations in the voice are very great. There is hoarseness, rough- 
ness, squeaking, and crowing; and sometimes it is nearly suppressed. The cough, 
too, varies in the same way. Sometimes it is very hoarse; and sometimes very 
shrill. The respiration in chronic laryngitis, is occasionally hissing; but not neces- 
sarily so. It is observed in most cases; but by no means in all. There is a copi- 
ous discharge of mucus, and sometimes of pus. In these cases, I have always 
observed pain on pressure. If the lungs be sound, we must learn that chiefly by- 
means of auscultation; — by ascertaining that the sounds of the chest are healthy; 
and that there is no pectoriloquy. However, it is sometimes difficult, when the 
voice is nearly suppressed, to make up one's mind on the subject. Some say they 
can tell it as well when the voice is suppressed, as when it is not; but I confess I 
have not attained that perfection. This disease may occasion great emaciation; 
and from that circumstance, as well as on account of the discharge of mucus of a 
puriform character, patients may easfly be supposed to be in a state of pulmonary 
consumption; audit is a fact, that the disease does sometimes coexist with "phthi- 
sis pulmonalis." 

Diagnosis. — [The most characteristic signs of chronic laryngitis, are the perma- 
nent change of the voice, and the peculiar cough before described; with hissing 
breathing, and pain or tenderness in the larynx, when these happen to be present. 
Except in syphilitic cases, where the fauces are also diseased, little is to be learnt 
from examination of the throat; for it is impossible to see or reach further than the 
epiglottis, and to get a view of this is a matter of difficulty. Neither is crepitation 
felt on pressing the larynx to be depended on; for, according to Trousseau and 
VOL. I. — 46 



722 DISEASES OF THE LARYNX AND TRACHEA. 

Belloc, this may be produced in a healthy larynx. Dr. Stokes deseribes, as a ste- 
thoscopic sign of chronic laryngitis, a harshness in the sonnd of the air passing 
throngh tlie larynx, — giving the idea of a roughness of surface, perceptible even 
when the breathing is not distinctly stridulous. In a fevv cases he observed (above 
the thyroid cartilage) a rhonchus, like the sound of a valve in rapid action, com- 
bined with a deep humming. We* much question that the latter sound was seated 
in the larynx; for such a sound is often produced in the jugular veins. When tlie 
laryngeal constriction is considerable, the peculiar sound of the passage of air 
through it will sufficiently distinguish it; and where it is slight or altogether 
absent, laryngeal disease may yet be known as the cause of the cough and other 
symptoms, by the negative indications of the thoracic organs; — the sound of per- 
cussion and of respiration being good throughout the chest. But pulmonary tuber- 
cle is very commonly conjoined with laryngeal disease; and the two affections are 
apt to disguise each other. The noisy laryngeal respiration, and the absence of 
the voice, may destroy the chief distinctive signs of phthisis in its early stages; but 
as the disease advances, the dulness on percussion, and perhaps cavernous rhon- 
chus in some part of the chest, — particularly under a clavicle or scapular ridge, — 
with a more copious purulent expectoration, night-sweats, and more rapid emacia- 
tion, sufficiently announce this most destructive complication. When the breath 
and sputa in laryngeal disease are very fetid, it may be suspected that some part of 
the cartilages is dead. This is generally the case where chronic abscess opens out- 
wardly, about the thyroid cartilage. 

Frosrnosis. — The milder and simpler forms of chronic laryngitis, are by no 
tneans incurable; in fact, they generally yield to judicious treatment: and were it 
not for their liability to exacerbations from acute oedematous inflammation, and to 
complications with pulmonary diseases, they could hardly be called dangerous. 
Both these destructive complications may be apprehended when the disease has 
continued long, with increasing severity of symptoms of the voice and respiration, 
■with a change of the cough from dry and ringing to loose and undivided, with in- 
creasing purulent expectoration, and particularly if the disease has resisted treat- 
ment. If, from the history of the individual, there be any suspicion of a scrofulous 
tendency, and j^.articularly if symptoms of pulmonary disease, — such as slight cough, 
shortness of breath, pains in the chest or shoulders, quickened pulse, &;c., — preceded 
those of the laryngeal aflfection, the prognosis is unfavourable; and if there are found 
any physical signs of phthisis — such as dulness under a clavicle, — the case of the 
patient must be considered almost hopeless. Fcetor of the breath and sputa, im- 
plying mortification of the cartilages, is also very unfavourable; but it is more pro- 
bable that the dead portions of these may be thrown off, than that tuberculous 
disease of the lung combined with a laryngeal lesion can be cured. In all doubtful 
cases, particularly those of a syphilitic origin, the state of the general health and 
strength, as well as the degree of the local affection, must be duly taken into ac- 
count, in estimating the probable issue of the case."] 

Morbid Lesions. — After death from this disease, we find the common results of 
chronic inflammation. The mucous membrane is frequently thickened, — frequently 
indurated, — frequenUy granulated; — exceedingly rough, and containing numerous 
little cavities (if I may so call them). Frequently it is ulcerated. The same ap- 
pearances very often extend along the trachea. 

Treatment. — In the treatment of this chronic form of the disease, we are by no 
means so successful as in that of the acute. In fact, the treatment, for the most 
part, is very unsatisfactory. The best method we can adopt, is the repeated ap- 
plicaiion of leeches, and subsequently of blisters. The internal exhibition of mer- 
cury, too, is of the greatest use. If the disease be a scrofulous inflammaiion, how- 
ever, of course mercury will do no good, but rather make things worse. It is best, 
in almost all cases, to give it a fair trial; — taking care not to hurt the constitution; 

» Dr. C. J. B. Williams. '' "Library of Medicine;" Volume 3; Page 49. 



DISEASES OF THE LARYNX AND TRACHEA. 723 

but to make the mouth moderately sore, and to keep it so; — to treat it as a mere 
chronic infiammaiion. It will very frequently subside; but far more frequently, I 
believe, the treatment is very unsatisfactory. • 

On account of the sufferings of the patient, and the harassing cough, it is often 
necessary to give narcotics, to procure sleep. Conium answers exceedingly well. 
Some have found relief from the inhalation of the fumes of tar; and others from the 
inhalation of chlorine; — either by diffusing it through the apartment of the patient, 
or making him breathe through water in which a quantity of chlorine exists. But 
it is very necessary, in all these cases, to proceed cautiously. 'I'ar-fumes, chlorine, 
and many of these things, will produce very great irritation, even in small quantity; 
and therefore it is right always to begin by impregnating the water, or the apartment, 
very moderately; and, if it produce no irritation, then we may go on to a great 
extent. 

Some have recommended, as internal medicines, copaiba and cubebs; because 
they have done good in irritation of another mucous membrane. I have not been 
satisfied with these medicines; but as they are recommended, I mention them. 
Some have recommended the application of lunar caustic. A solution of nitrate 
of silver is made, and a sponge, dipped into it, is pressed down to the "rima 
glottidis;" so as to produce a new action there, and lessen the morbid sensibility; 
• — with the hope, that the same good change which is observed at the spot at 
which the nitrate of silver is applied, may spread downwards. I have known t"his 
remedy employed; and, as may be imagined, fruitlessly; but if the disease were 
situated merely at the "rima glottidis," good would be done by it. I have no ex- 
perience of it myself; but I have seen cases in which I understood it had been em- 
ployed without any harm. 

[MM. Trousseau and Belloc place much confidence in medicaments applied 
directly to the diseased part; and some of those which they recommend are of a 
very energetic kind; — such as nitrate of silver, corrosive sublimate, sulphate of cop- 
per, (fee. They may be applied either in solution or in powder. The solution 
which they have found most effectual, is that of nitrate of silver, in the large pro- 
portion of from one to two parts in four parts of distilled water. This solution 
may be applied to and behind the epiglottis, by a small roll of paper bent at its 
moistened end. A more effectual mode is with a small round piece of sponge, 
fixed to a long rod of whalebone bent, at an inch from the sponge, to an angle of 
eighty degrees. The patient's mouth being opened wide, and the tongue pressed 
down with a spoon, the sponge is passed to the top of the pharynx; as soon as it 
reaches the fauces, a movement of deglutition takes place, which cariies the larynx 
upwards, at which moment the sponge is brought forward, and squeezed under the 
epiglottis, and the solution freely enters the larynx. Convulsive cough, and some- 
times vomiting ensue; but the application causes no pain. A less disagreeable mode 
of applying the solution, is by a small silver syringe, filled one-fourih with the so- 
lution, and three-fourths with air. To this is affixed a tube five inches long, bent 
at the free end; which being carried beyond the epiglottis, the syringe is forcibly 
discharged; and, in consequence of the air in it, throws the solution, not in one 
stream, but in a fine shower; part of which enters the larynx. The patient is then 
made to rinse his mouth with, and swallow, salt water, or water acidulated with 
muriatic acid, which decomposes the remains of the nitrate; the same precaution 
should be used, where this agent is applied in substance. MM. Trousseau and 
Belloc found this application (which they term "cauterization") highly beneficial 
in several cases of chronic laryngitis. In cases of aphonia, probably dependent on 
relaxation rather than inflammation, it effected a cure in a few days; in some worse 
forms of the disease, with probably ulceration of three or four years' standing, ils 
repeated application during five or six w^eeks was successful; and it produced con- 
siderable temporary improvement, in three cases which proved afterwards to be 
tuberculous. Solid substances may be applied to the larynx in powder by insuf- 
flation; as recommended by Aretgeus for "angina maligna." The powder is put 
into one end of a reed or glass tube, and the other is carried back as far as possible 



724 DISEASES OF THE LARYNX AND TRACHEA. 

into the month: after a full expiration, the patient closes his lips around the tube, 
and inspires suddenly and forcibly through it; by which some of the powder is car- 
ried into llie larynx and trachea. The cough which is excited should be restrained 
as much as possible; — to prevent the too speedy expulsion of the medicine. The 
powders used by MM. Trousseau and Belloc, are subnitrate of bismuth, which may 
be used pure with safety and advantage in most forms of chronic laryngitis, even 
that accompanying phthisis; calomel with twelve times its weight of sugar; red 
precipitate, sulphate of zinc, and sulphate of copper, each of which must be mixed 
with thirty-six times its weight of sugar; alum with twice its weight, and acetate 
of lead with seven times its w^eight of sugar; and nitrate of silver with twenty-two, 
thirty-six, or seventy-two times its weight of sugar. The last is said to be most 
effectual in erythematous laryngitis, with erosions or ulcerations. Calomel and red 
precipitate have proved beneficial in ulcerations, whether syphilitic or not; but they 
should not at first be repeated oflener than twice or thrice a week. The others 
may be used twice or oftener daily, according to the nature of the case. The 
powders should be impalpably fine: the least roughness or perceptible fragment of 
a crystal excites such efforts to cough, as insure the expulsion of the powder. 
This description of the treatment of MM. Trausseau and Belloc, is taken from an 
abstract in the "British and Foreign Medical Review;" and appears to be w^ell 
worthy of the attention of British practitioners; — proving the safe direct application 
of powerful agents, which (as in external diseases) are likely to improve the action 
of the diseased parts.*] 



SECTION III.— CROUP. 

Synonymes, — Acute inflammation, of a very violent description, when it attacks 
the larger portion of the air-tubes, is situated (for the most part) lower down in 
children than when it occurs in adults. That intense, violent, adhesive inflamma- 
tion, — inflammation, at least, causing a portion of fibrin to be thrown out, — which 
attacks adults, usually affects the larynx; so \,h?i{ laryngitis is the disease of adults; 
and the disease of children, corresponding with this, is croup; — "cynanche trache- 
«/i5," or (more properly) "tracheitis." The latter term is the most simple; and 
every body knows what is meant by it. The disease has been called "angina 
trachealis;" because there is a quantity of lymph formed. In this country it is 
called "croup;" in the east, I understand, it is called "roop;" and perhaps it is so 
in other places. 

Symptoms. — This disease is marked by a rough, clanging, ringing cough; — a 
cough which gives the idea of sound conveyed through a small brass pipe. Be- 
sides tliis cough, if the disease be severe, there is hissing ("sibilous") respiration; 
but it is chiefly in the inspiration that it is heard. It is harsh, rough, shrill, or 
hissing; — there being various modifications. The voice, too, is either harsh, crow- 
ing, or nearly suppressed. There is a difficulty of breathing; and this is felt par- 
ticularly during inspiration. These are the most common symptoms. There is no 
diflaculty in swallowing; no pain in the throat, except at the lowest part; no pain 
in the larynx (where there is always pain or tenderness in laryngitis); but in croup, 
at the lowest part of the throat, where the trachea exists, there is frequently pain 
on pressure. The expectoration is mucous; sometimes mixed with fibrin and 
shreds of lymph. As this is a violent disease, there is violent pyrexia. During 
the first stage the face is flushed, the pulse is rapid, and there is great anxiety of 
countenance. Sometimes the peculiar clanging cough is heard for some days before 
the child is ill enough to show its complaint; so that many mothers have been sur- 
prised, on being told by a medical attendant (who has accidentally been in the house, 
and heard this peculiar cough,) that the child was in danger. 

Varieties. — [We may meet this disease under two essentially different forms. 

« '* Library of Medicine;" Volume 3; Pages 50 and 51. 



DISEASES OF THE LARYNX AND TRACHEA. 725 

It may occur, in the first place, as a primary, idiopathic, and active inflammation 
of the respiratory mucous membrane; in which case the accompanying fever is 
symptomatic. In the second place, we have \{ preceded by fever, and the formation 
of false membranes in the pharynx and the cavity of the mouth; which membranes, 
by extending downwards into the glottis and larynx, produce the symptoms of 
croup, in the advanced stage of another and totally different disease. 

The greatest confusion has arisen, from authors not carefully separating these 
two forms of disease, in their descriptions of croup, and in their opinions as to its 
treatment. For the sake of clearness, P shall arrange their symptoms in pairs of 
opposite characters; — distinguishing the affections by the name of " primary" and 
"secondary" croup. 

Primary Crol'P. Secondary Croup. 

1. The air-passages primarily engaged. 1, The laryngeal afFecdon seco7idary io dis- 

ease of ihe pharynx and mouth. 

2. The fever sympiomaiic of the local dis- 2. The local disease arising in the course 
ease. ' of another affection, which is generally 

accompanied by fever. 

3. The fever inflammatory. 3- The fever typhoid, 

4. Necessity for antiphlogistic treatment, 4. Incapability of bearing antiphlogistic 
and the frequent success of such treat- treatment; necessity for the tonic, revul- 
ment, sive, and stimulating modes. 

5. The disease sporadic, and in certain situ- 5. The disease constantly epidemic and con- 
ations endemic, but never contagious. tagious. 

6. A disease principally of childhood. 6. Adults commonly affected. 

7. The exudation of lymph from the glottis, 7. The exudation spreading to the glottis, 

from below upwards. from above downwards. 

8. The pharynx healthy. 8. The pharynx diseased. 

9. Dysphagia either absent or very slight, 9. Dysphagia common and severe. 

10. Catarrhal smptoms often precursory to 10. Laryngeal symptoms supervening with- 
the laryngeal. out the pre-existence of catarrh. 

11. Complicalion with acute pulmonary in- 11. Complication with such changes rare, 
flammation common. 

12. Absence of any characteristic odour of 12, Breath often onaracteristically foetid. 
the breath. 

From the consideration rf these characters, we must admit that, independently 
of minor differences, there is a broad line of distinction between these affections 
of the throat. In the one, the windpipe is the seat of an idiopathic, primary, and 
highly inflammatory disease; while in the other, its affection is accidental, incon- 
stant, and secondary to a diseased state of the pharynx; which, in its turn, is 
either symptomatic of, or closely connected with, a morbid state of the whole 
system. Yet, as P said before, the want of an accurate distinction between these 
affections, has led to the greatest misapprehension; and we see British physicians 
ridiculing the opinions and treatment of the continental practitioners, and vice 
versa; — the error, all the w^hile, arising from the confounding of two essentially 
different affections. In the croup, as described by British authors, the utility of 
antiphlogistic treatment has been tried by experience.''] 

Duration and Progress. — The disease may last from twenty-four hours, to 
three or four days, or even severed days; and the child may either die completely 
exhausted, or be suddenly cut off in a moment, by spasm. Just as death some- 
times occurs suddenly, so does amendment. Generally, patients recover by de- 
grees; but sometimes they recover very rapidly, — almost suddenly. When reco- 
very is exceedingly slow, shreds of fibrin are perhaps spit up for several weeks. 

Morbid Appearances. — On examination after death, we find (of course) redness 
of the trachea; and such is the intensity of the inflammation, that lymph lies upon 
the red membrane; — sometimes forming a complete tube, and even extending into 
the bronchia. Besides this tube of lymph, which is so continually seeiiy we fre- 

» Dr. Stokes. 

^ Dr. Siokes, on Diseases of the Chest; Part Ij Section 3j Pages 205 to 207. 



726 



DISEASES or THE LARYNX AND TRACHEA. 



qiienlly observe a quantity of puriform, and even bloody fluid, in ibe air-tubes. 
When we open an inflamed serous membrane, we always see lymph lying upon 
the afl'ected part; but besides that, we always see more or less turbid serum, even 
so thick and yellow as to approach to pus; and sometimes there is pus. So in a 
nuicous membrane, when it is inflamed very intensely, besides flbrin, there is a 
quantity of thin fluid, inclining more or less to pus; and rat last actual pus. There 
is also a bloody fluid. 

Jige at ivhich it occurs. — This disease occurs chiefly in children, between 
weaning and puberty. It is occasionally seen in infants at the breast, but more 
frequently not till they are weaned; and Professor Home, of Edinburgh, says, 
that the sooner children are weaned, the sooner they are liable to it. They have 
more experience at Leith than we have here; and observations, therefore, are more 
easily made there. It chiefly affects those of a full habit of body. 

Causes. — The cause is undoubtedly, in almost every instance, cold and wet. 
It occurs, therefore, more frequenUy in winter and spring, than at other times; and 
if it occur in summer, it is generally when a damp evening has succeeded to a hot 
day. It is seen most frequently in a situation near the water side; — in fact, in all 
damp situations. It is more frequent, too, in northern than in southern latitudes. 
It is sometimes epidemic; — that is to say, a great number of children, in particular 
seasons, are afl'ected with it. An endeavour has been made to pervert the word 
*' epidemic''^ from its common original meaning; — " that which attacks people at 
large." In that sense we have a peculiar signification; so as to distinguish between 
epidemic and contagious diseases. But contagious diseases may be epidemic; — 
not from this cause or that; but merely because they extend temporarily over a 
whole district at once, But although this disease is frequently epidemic, I cannot 
believe that it is ever contagious; — at least, I have never been able to satisfy myself 
that such was the case. It certainly does often afi'ect more than one in a family 
at once; but this may only arise from all the children in the family being exposed 
to the cause at the same time; and from another circumstance, — that there is a 
constant tendency to it; and therefore children in the same family may be supposed 
liable to the same disease. Now and then, a peculiarly striking circumstance 
takes place; and we are inclined to believe that the disease must be contagious; 
but I think mistakes are frequently made in the case of croup. I will not say that 
it is never contagious, because I have not seen every circumstance that other 
people have; but, from what I have seen and read, I cannot persuade myself that 
it is contagious. It is a fact, that many children have it in the same neighbour- 
hood; but then they have been visited with the same vicissitudes of atmosphere; 
and the occurrence may thus be explained. And when it occurs in the same 
family, this fact might explain it; — together with the additional circumstance, that 
all their constitutions are predisposed to the same disease. I know, too, that seve- 
ral children in a family will have it, but at different times; and some of the chil- 
dren in a family will be sure to have it; and therefore I presume there is a consti- 
tutional tendency to it; — ^just the same as in inflammation of other parts. Professor 
Dupuy says, that it once occurred in dogs at Alfort. and that the same appearances 
were observed in them, as in human beings. 

Nature. — [The nature of croup has been the subject of much discussion. In 
Dr. Copland's "Dictionary,"* the reader will find an account of the various 
opinions which have been held respecting it. Our limits do not permit us*" to 
enter into these; and we shall only give that view which, in the present state of 
our knowledge, seems most tenable; and which best comports with the whole 
history of the disease, and the effects of remedies on it. These indubitably prove 
true croup to be essentially an itillammatory disease of the air-passages, especially 
of the trachea and larynx. But why does it differ from the catarrhal or bronchitic 
inflammations which we find to occur in the same parts? Many authors seem to 
consider its seat to be the same as that of catarrhal inflammation, and that the 



a Volume 1; Part 2; Page 449. 



b Dr. C. J. B. Williams. 



DISEASES OP THE LARYNX AND TRACHEA. 727 

difference of its product (lymph instead of nuiciis) is to be ascribed to the early 
age at which it most frequently occurs. But this is insufficient: for at the same 
age, we meet with bronciiitis affecting every portion of the air-tubes, yet without 
constituting croup. Others again, and among them Dr. Copland, refer the pecu- 
liarity of the product to an excess of albumen m the blood;* but even this, although 
it probably has a share in determining the amount of membranous or other solid 
formations within the air-tubes, does not alone seem sufficient to cause it; nor can 
it be ascribed to the intensity of the inflammation; for although the albuminous 
effusion is generally thickest and most tough in sthenic cases of croup, yet it is 
pretty abundant in asthenic cases; — so much so, that Andral and Gendrin consider 
plastic inflammatmns of mucous membranes to be rather of the sub-acute than of 
the most acute kind. To say that the inflammation is one of a specitic character, 
throws no light on its nature. But does not the pathological and anatomical his- 
tory of croup seem to point out, that the seat of its inflammation is deeper than that 
of bronchitis? The distinct and circumscribed position of the inflammation and 
painful constriction in the most marked cases; its fixedness in this part, — not wan- 
dering or creeping about, as catarrhal inflammation does; the tenderness, and some- 
times the swelling of the trachea and larynx externally; the nature of the product 
of tlie inflammation, — which is coagulable lymph, as from serous or cellular 
membrane; the thickened state of the submucous texture found afier death in the 
earliest stages, and the tendency of this texture to suppurate in chronic cases, 
where the subject approaches adult age, — seem to render it probable, that the in- 
flammation owes its peculiar character and results to its being more deeply seated, 
more of a phlegmonous character than mucous inflammations, and involving essen- 
tially the submucous cellular tissue. This view has not been generally held, Mr. 
Ryland alone distincdy inclines to it, when he remarks, that " the inflammation of 
croup appears, in the first instance, chiefly to affect the cellular tissue that enters 
into the composition of the mucous membrane, and not the muciparous follicles 
themselves; and the albuminous exudation is poured out by the secernent arteries 
of tile cellular structure." Dr. Stokes remarks, that no satisfactory explanation of 
the greater frequency of croup in the infant has been given; and he seeks to account 
for it by the general fact of the predominance in the young subject of white tissues, 
which reproduce their kind. This idea may lead to an explanation, but it does 
not set it forth; and it leaves still a mystery why croup differs from bronchitis in 
the same subject. But if we examine the air-tubes of young subjects, we find in 
them, as in other parts, an abundance of the fine submucous cellular tissue; while 
the mucous membrane is more fine and less complex than it becomes in after-life; 
when, from the continued irritations to which it has been exposed, its follicular 
apparatus attains its full activity and development. The blood, too, in the young 
subject, abounds with the plastic material of nutrition: which is more abundantly 
thrown out under the influence of inflammation, than in the adult. Yet, as long as 
the inflammation, even in young subjects, is confined to the mucous membrane, 
the disease is simply catarrhal or bronchitic, and its product mucous or purulent. 
But the inflammation may readily reach the active and vascular submucous tissue; 
and then it has the more fixed character of the inflammation of croup, the product 
of which easily transudes through the fine mucous membrane; and, as in the analo- 
gous case of serous inflammations, — which are also seated chiefly in the subserous 
tissue, — the product is coagulable lymph.'' In adults, where the mucous membrane 
is more developed, and the submucous tissue less so, inflammation is less likely to 
reach the latter: when it does, it attacks the looser parts of the larynx, and, modi- 
fied by the active mucous secretion, its product is pus, instead of lymph; or it may- 
be confined to the tissue, and cause the oedema, thickening, or purulent infiltration 
of laryngitis. 

The pathological history of croup is quite intelligible. The inflammation may 
commence in the submucous tissue, or it may have been first catarrhal; in which 

"» "Dictionary of Practical Medicine;" Volume 1; Part 2; Page 4G1. 
»» See Pages <d^ and 108. 



728 DISEASES OF THE LARYNX AND TRACHEA. 

very common case, catarrhal symptoms precede those of croup. The inflamma- 
tion immediately causes increased sensibility of the contractile fibres, and intersti- 
tial eflusion in the lining of the trachea and larynx: hence results the constriction, 
partly spasmodic, partly from swelling of the air-tubes; and hence the croupy in- 
spiration and cough, and the hoarseness. Afterwards lymph is poured out in a 
liquid state; and, becoming concrete, forms the false membrane; — another cause of 
obstruction to the passage of the air: both directly by its bulk, and also by the 
spasmodic contraction which its presence causes in the muscular fibres of the tube. 
The latter cause acts especially when the false membrane reaches to the larynx, 
and excites its very irritable muscles: in such cases, the paroxysms of dyspnoea 
and cough are frightfully severe and suffocating. The share which spasm has in 
causing the dyspnoea may be inferred from the fact, that in no case have the air- 
passages been found so much blocked by the albuminous secretion, as to account 
for the amount of the obstruction; and in many cases the constriction has appeared 
greatest, where litde or no exudation was found after death. It must not be for- 
gotten, however, that oedematous s\yelling — like that of erysipelas — may disappear 
after death. The separation of the concrete matter from the tube, and the preven- 
tion of its becoming permanently adherent and organized, is doubtless owing to the 
mucous secretion, and the continued motions of the tube. In cases where the 
albuminous effusion is less plastic, or the follicular mucous secretion more abundant, 
the matter may be liquid and purulent; and this generally takes place in the bron- 
chitic variety. The collapse which takes place towards the fatal termination of 
croup is, like that in bronchitis, to be ascribed to the imperfect state of the function 
of respiration, and the consequent injurious effect on the vital powers. The 
lividity, coldness, occasional attacks of convulsions, &c., are the result of the cir- 
culation or stagnation of imperfectly oxygenated blood. From the same cause 
arises, also, the congestion in the lung; which may in parts take on the irritation 
of inflammation, and become hepatized. The emphysema occasionally detected 
in the lungs, is plainly produced by the violent efforts of breathing.^] 

Treatment. — The treatment of this disease must be energetic and decided;— 
just as I stated was requisite in laryngitis.'' It would be right to bleed from the 
arm, or jugular vein, perhaps; and to apply a number of leeches over the throat. 
It is to be considered as an inflammatory disease, that must be treated briskly. I 
would make the same observation respecting leeches, that I have already done" re- 
specting other inflammatory diseases of the throat. I should prefer leeches to a 
blister, and general bleeding to local; but I should follow up general by local bleed- 
ing. After the leech-bites had bled well, with the assistance of a poultice, I would 
repeat them, if necessary, and then apply a blister. There is extreme danger here; 
and therefore mercury should be given with the greatest freedom. Whatever dis- 
putes there are about mercury, we shall find, that in acute hydrocephalus, in 
laryngitis, and tracheitis, mercury is of the highest importance. Children will 
bear a larger quantity of mercury, in proportion, than adults; and it would be right 
to give a child, every two or three hours, as much as it would bear without vom.it- 
ing and purging. This is a much better practice than the administration of emetics. 
Many cases will get well with emetics; but this will be successful in a larger num- 
ber of instances. The warm-bath is useful, but not of high importance; and when 
the leeches have bled well, some have advised applying cold to the throat. I see 
no impropriety in it. The good effects of applying ice to the heads of children, 
justify the application of ice in a bladder to the throat; but I have no personal 
experience of it. 

Bronchotomy. — Some have recommended bronchotomy in this disease; but I 
believe it generally fails. Bronchotomy can only be a temporary measure.'* It 
may enable the patient to breathe well for the time; but, of course, it can have no 
effect upon the inflammation. If the disease were not so extensive, it might be 
beneficial, by giving us time to cure the affection; but, unfortunately, we frequently 

* " Library of Medicine;" Volume 3; Pages 55 and 56. *" See Page 719. 

» See Pages 719 and 722. d See Page 720. 



DISEASES OP THE LARYNX AND TRACHEA. 729 

have inflammation of the trachea, larynx, and all the ramifications of the bronchia; 
so that it is hardly possible for the child to recover from such a mass of disease. 
However, bronchotomy has been tried in many cases, and failed; and I have 
myself employed it without success. A number of cases are recorded, where h 
was of no use; though it appears occasionally to have been of service. One in- 
stance (there may be more) is recorded in the " Medico-Chirurgical Transactions,"^ 
by Mr. Chevalier; who made an opening into the trachea; the consequence of 
which was the discharge of a quantity of viscid bloody fluid, and the patient 
speedily recovered. If, after the ordinary treatment of the disease, — free bleeding, 
mercury, blistering, the application of cold, and (if we choose) the administration 
of emetics, — if we cannot make the mouth more tender, or bleed any farther, and 
yet the child is dying, — it would be better, if the friends would allow it, to make 
an opening into the trachea, — in order to give the patient a chance; but, in a great 
number of cases, it is a very slender chapxce indeed. I would not do it till I had 
told the parents that the child would die without it, and would most likely die 
when it was done; for otherwise it would be said, that we had cut the child's 
throat, and killed it. It is a frightful thing to make an opening in the air-passages, 
unless we prepare the patients (or their friends) for it. 

Seneka. — In America, they recommend a decoction of seneka in this disease. 
But this is a stimulating substance; and, if it does good, I cannot believe that it is 
in the active inflammatory stage. When the inflammation is subsiding, and great 
secretion is going on, it may stimulate the parts and " brace them up;" but I have 
not been tempted to give the remedy in the active acute form of the disease. 

Liable to JReciir. — This disease, however, occasionally takes place without any 
inflammation; or, at least, any important inflammation. Children who have once 
had the croup, will frequently, on catching cold, have a crouping cough, — a little 
hoarseness; so as really to labour under the signs of croup; but, in such cases, the 
pulse is not quickened, and the child is not particularly ill. If a child have once 
had the croup, there is in general litde fear from other attacks. If parts have beeri 
once inflamed, they soon fall into a state of inflammation again; but then it is not 
active inflammation; and sometimes the inflammation is scarcely perceptible; — the 
disease appearing to be merely spasmodic. I have known children have six or 
seven attacks of croup. 

It is always safe, in these cases, to apply antiphlogistic treatment; — not vigor- 
ously, as ill the first instance; but to put a number of leeches on the throat, and 
administer calomel once or twice a-day, and (if we choose) an emetic. These 
means generally dissipate the disease. I know that some patients neither require 
leeching nor purging; and are benefited at once by an emetic. A light inflamma- 
tion has occurred; it has thrown the parts into a state of spasm; and an emetic will 
frequenfly cure it; but it is generally safer (unless we know that an emetic has 
cured the child before) to apply leeches to the throat, and give a dose or two of 
calomel. We are never sure that it is merely a spasm. There may be some little 
inflammation, which is increasing; and therefore it is the safest plan to begin with 
this treatment. If the child be not worse, but plays about, then the best thing is 
to give iron. Iron is a good thing to lessen morbid irritability in any part of the 
body. If there be inflammation it will do no good; but if there be mere morbid 
irritability, I know it is one of the best things. I shall have occasion to state that 
spasmodic cough, of a ringing character, yields most readily to iron. It is best not 
to begin with it; but to adopt antiphlogistic treatment for a day or two; and then 
we may give iron safely. The sesquioxide may be administered in treacle; or the 
sulphate in sugar, or tea. Children sometimes will not take it without these ac- 
companiments. 

» Volume 6; Page 151. 



730 DISEASES OF THE LARYNX AND TRACHEA. 



SECTION IV.— ORGANIC AFFECTIONS OF THE LARYNX AND 

TRACHEA. 

The Larynx, — Besides simple inflammation of the larynx and trachea, these 
parts are subject to various organic diseases. The larynx is frequently in a state 
of ulceration; and not unfrequently there are excrescences upon it; — looking, to all 
appearance, like warts. They are the same as warts on the genitals. Sometimes 
scrofulous tubercles form there. Sometimes scrofulous abscesses form in the cel- 
lular membrane; and sometimes there is cancer, and melanoid deposit. 

As far as I know, in the greater number of cases, it is impossible during life to 
make a diagnosis between simple chronic inflammation of the larynx, and these 
organic changes. We And a person with tenderness of the larynx, and hoarse- 
ness; — his voice, perhaps, being reduced to a whisper; he coughs a great deal, and 
the cough is ragged or shrill; there is wasting, perhaps a constantly quick pulse, 
and tenderness; — showing, altogether, that the larynx is diseased. But I confess, 
I am not able to distinguish between simple chronic inflammation of these parts, 
and ulceration, or the existence of excrescences, or the existence of various de- 
posits. 

In the commencement of such cases, I should recommend the remedies of 
chronic inflammation; — leeches over and over again; blisters afterwards, if we 
choose; a seton in the neighbourhood of the larynx; the exhibition of mercury; 
and narcotics to lessen the irritation. If these things do no good, — if the patient 
gels worse, the corporeal strength is decaying, and the symptoms in the throat (so 
far from diminishing) are increasing, — then we may suspect there is organic dis- 
ease; and we shall generally be right. It is only in the latter stages of the disease, 
that any distinction can be made. When my remedies fail, I then begin to think 
there is organic disease. 

Occasionally the larynx is ossified. Sometimes it becomes completely ossified; 
and deglutition is rendered v'ery diflicult. The larynx cannot move up and down; 
and the passage of the throat becomes so much diminished, that the patient can 
scarcely swallow; and, indeed, he dies of the disease. 

The Trachea. — The trachea, likewise, sometimes gradually becomes ossified; 
and all the various diseases that I mentioned* under the head of organic affections 
(melanosis, scirrhus, cancer, and encephaloid disease) occur here. But more fre- 
quendy we have thickening of the mucous membrane, induration, considerable ex- 
crescences, and scrofulous tumours; and then the common eff'ects of inflammation; 
— ulceration; the formation of abscesses; and, finally, a carious state of the car- 
tilages. ^ 



SECTION v.— CATARRH. 

General Character. — This is a very slight inflammation of the larynx, trachea, 
bronchia, and the mucous membrane above these parts; — that portion called " the 
Schneiderian membrane" (from having been described by Schneider); and the 
membrane of the frontal sinuses, and even the conjunctiva of the eyes. The in- 
flammation, in this disease, is not by any means so intense, as that which occurs 
in laryngitis and tracheitis; for it is an instance of common inflammation of a 
mucous membrane. It is, in general, a very slight inflammation; but it extends 
through the whole tract, from the conjunctiva of the eyes; — running down the 
lachrymal canal; and not only afl^ecting the membrane of the nostrils, b\it also the 
frontal sinuses, the throat, the tongue, the larynx, the trachea, and the bronchia. 
As it aflecls such an extent of surface, dangerous symptoms more frequenfly arise 

» See Pages 195 to 215. 



DISEASES OF THE LARYNX AND TRACHEA. 731 

than we are aware of. This, in medical language, is called "catarrh;'"' and, in 
common language, we call it "a cold." 

Symptoms. — There is a feeling, at the same time, of soreness tliroughout the 
body; and generally there is tenderness of the surface; which makes the person 
uneasy, if he press much upon any one part. There is stiffness, and an aching of 
the whole body; but it is chiefly felt in the back of the neck. Tiiere is likewise 
headache; — I presume, from the congestion 'in the frontal sinuses. Perhaps there 
may be more or less congestion within the head; but I should think that it arises 
chiefly from congestion of the frontal sinuses; — at least that the former is inferior to 
the latter. There is likewise chilliness, and morbid heat. The patient is chilly, 
and creeps towards the fire; and yet if we touch him, he is hotter than he should 
be. There is great sensibility of the surface; so that the least breath of air blow- 
ing upon him, causes a sensation of cold. The mind also is affected. There is 
heaviness of the head; — sometimes amounting to stupor; so that people are quite 
stupid. From the state of the conjunctiva, there is frequently stiffness and smart- 
ing of the eyes; and, from the irritation of the membrane within the nostrils, there 
is sneezing. There is, also, from the disturbance of the membrane, loss or im- 
pairment of smell, and apparently of taste. People say they can neither smell nor 
taste. I believe they can taste, although they cannot smell. Many things may 
be smelt as well as tasted; and these are tasted just as acutely as before. From 
the inflammation in the air-passages, the breath is hot; so that when we have a 
cold, the air expired from the lips is hot; — as though it came from a hot place. 
Ttiere is generally hoarseness, some cough, and a little soreness at the front of the 
chest. When the mucous membrane is inflamed, it is sore at the division of the 
trachea; and there is soreness in the situation of the larger branches of the bronchia. 

Increased Secretion. — All the parts that I have mentioned, discharge more 
freely than in the healthy state. They are all covered with mucous membrane, — 
if the conjunctiva can be considered a mucous membrane; they are all in a state of 
slight inflammation; and therefore they are in a state of preternaturally increased 
discharge. The eyes " run" (called " lachrymation"'*); and there is a discharge 
from the nose (called in Latin " distillatio;" or, as we say, " catarrhus"). The 
discharge from the nose, is likewise called " coryza.^^" At first, the secretion is 
limpid; like drops of water from a rock. It is thin and transparent; but afterwards 
it grows more copious and thick. 

As the symptoms decline, the quantity of the secretion declines; and, as all the 
symptoms go away, there frequently arises a little inflammation about the mouth 
and nose, and an eruption; so that the common people say the cold is going, 
because there is a "breaking out" about the mouth. When the cold goes off, and 
the inflammation within ceases, it is very common for slight inflammation of au 
herpetic character*^ to take place about the mouth. During the existence of the 
disease, the tongue is white, the skin dry, and the urine red; and when all is 
declining, the urine has a lateritious sediment; — the common symptoms of inflam- 
mation. There is also a loss of appetite. The stomach is much affected in this 
disease. People cannot eat; and sometimes there is also an affection of the m.u- 
cous membrane down the cBsophagus, and in the stomach. There is heat and pain 
there, and tenderness on pressure. The pulse during the disease is quick. 

Progress and Duration. — The affection has a disposition to begin above, and 
travel downwards; so that persons know very well which part of the mucous mem- 
brane is inflamed, at different times. When it is the mucous membrane of the 
frontal sinuses and nose, they say it is " in the head;" — they feel so heavy and 
stupid. Then that goes off, and they begin to cough. As it leaves the upper part, 
it generally increases in the lower; and then, after a tickling in the throat, and 
hoarseness, there is frequently pain down the front of the chest, and cough; and 
also more or less difficulty of breathing. After that the tickling of the throat is 
diminished. But though it travels downwards, it frequenUy mounts up again. 

* From jtaraf^gw, to floio doum. * From Xaxfu/u*, a tear. 

c Froiuxaga, t/ie head; and ^sa>, to Jloio. ^ See Page 410. 



732 DISEASES OF THE LARYNX AND TRACHEA. 

Sometimes people are beset with it in all parts at once; but generally, if the disease 
be sliglit, we see it travel downwards; and if a person have a relapse, it will come 
aofain above; but then people say they have "caught a fresh cold." The disease 
will last from twenty-four hours to some weeks; and sometimes it is the forerunner 
(as 1 stated before'') of violent inflammation of the larynx, or of the bronchia. It 
is often the prelude to various active inflammatory diseases. 

Causes. — The common cause of this affection, is the application of cold — espe- 
cially when united with moisture, or when the body is over-heated and perspiring; 
and more particularly when the cold is applied partially. Many persons have a 
common cold in a few minutes, if exposed to a draught; but they will bear expo- 
sure to the air without any such efTect. Mere cold will cause it, without any sub- 
sequent application; because, while sitting in a room without a fire, when we 
ought to have one, the nose will begin to " run," before we go into a room with 
a fire. While we remain in the cold room, we begin to sneeze; and other symptoms 
of catarrh come on; — proving the action of the cold itself. Most probably the 
constriction of the skin being so great, the Schneiderian membrane passes into great 
activity. Change of residence appears to increase the susceptibility to the disease. 
Some susceptible people always take cold if they change their residence; and some 
will catch cold without leaving their beds. 

Treatment. — The best mode of treatment, is to keep the body perfectly warm; 
— so as to get rid of the chilliness. It is usual to increase perspiration by wine 
and brandy, and other stimuli; but it is better to do it by caloric itself. The warm- 
bath, or a vapour-bath, is very good; and a local bath is also very proper; and 
when the patient is warm, plenty of hot liquids, without any wine or brandy, are 
exceedingly useful. If we put wine and brandy into hot liquors, there will most 
likely be headache afterwards. 

Diet and Exercise. — During this time a person loses his appetite; and therefore 
nature indicates that he should take but little food; and that little should be chiefly 
fluids, and of a weak nature. When a person has been ill for any length of time, 
one of the best modes of getting rid of the cold, is by perspiring through exercise. 
Exercise in the open air if possible; or good exercise, at any rate, — so as to pro- 
duce considerable perspiration, — is one of the best remedies. But great care must 
be taken not to catch cold, when perspiration is induced; for if a person allow 
himself to cool suddenly, when he is hot, his last state will be worse than his first. 
Good brisk walking, or dumb bells, or battledore and shuttlecock, or skipping, are 
highly serviceable. The patient should be careful to keep himself warm after- 
wards; or he will catch cold upon cold, till the most serious effects are produced. 

Influenza. — Catarrh is sometimes epidemic; and then it goes by the name of 
"influenza.""' We have numerous returns of this epidemic catarrh throughout 
Europe; and it is not confined to the human race; for horses, dogs, and cats are 
all liable to it. There was a very remarkable influenza in England, in the year 
1782; — there having been one in the East Indies and China, in 1780. It appeared 
(as many epidemics do) to travel westward; — having made its first appearance in 
the east. Respecting that epidemic, it is mentioned that an East Indiaman (the 
Atlas) had its crew attacked, while sailing from Malacca to Canton; and when it 
arrived at the latter place, they found that the people had all had influenza there, 
about the same time that the crew had had it at sea. This was an argument against 
the disease being contagious; for if the people had it out at sea, and found, when 
they arrived at a distant part, that the inhabitants had had it about the same time, 
it shows that it must have been something atmospherical, and not any thing com- 
municated from man to man. There has been a great difl'erence of opinion respect- 
ing the contagiousness of diff'erent epidemics of this kind. Some contend that this 
and that influenza is merely epidemic; and others, that it is epidemic through its 
contagious nature. We have had epidemics of this description, but I never saw 

* See Page 730. " The Italian word for ''influence." 



DISEASES OF THE LARYNX AND TRACHEA. 733 

any thinff to make me believe that the disease was contagious; though I should be 
sorry to deny it merely because the cases that came under my notice, did not ap- 
pear to be contagious. Strong facts have been adduced to show that it is conta- 
gious; and then there are others, equally strong, tending to show the contrary; — 
just as is the case with regard to cholera. 

" The symptoms are usually more severe than in common catarrh. When the 
disease is epidemic, it is not so slight as when sporadic. When epidemic, there 
is generally complete loss of appetite, great lassitude and debility, and a very severe 
cough. It will attack persons both out of doors and in doors indiscriminately; 
and also individuals at sea. Sometimes it affects every member of a family at 
once; and sometimes it affects them in succession. 

The epidemic influenza attacks people of all ages; but children less than others. 
It is sometimes fatal to persons who have chronic disease of the chest. An influ- 
enza is sufficient to stir up inflammation, when it exists in any part of the body. 
When the disease is not epidemic, but sporadic, it lasts from a few days to a few 
weeks; and when it is strictly epidemic, it generally continues for a few months. 
What the cause of it is, I do not know. 



SECTION VI.— SPASMODIC AFFECTIONS OF THE LARYNX. 

[Endowed with a curious and complicated muscular apparatus, and with exqui- 
site sensibility, the larynx is liable to various forms of neurosis. Of these, the 
active have only, as yet, been investigated; while of the existence of the passive 
forms scarcely any notice has been taken. Under the first head we may class the 
spasmodic croup of children, the spasm of the glottis in hooping-cough, and the 
Various forms of hysterical, nervous, and sympathetic cough; while of the second 
we can only say, that paralysis of the muscles of phonation is seen in certain cases 
of cerebral disease; and that, reasoning from analogy, we may further admit the 
existence of another form of paralysis, similar to that of the intestines in ileus, and 
of the intercostal muscles in pleurisy, and resulting from the same cause; — namely, 
the inflammation of a tissue in connection with the muscular fibre.*] 

a. Laryngismus Stridulus. 

Resembles Croup, — [There is a disease which often attacks the larynx, espe- 
cially that of infants and children; which has so near a resemblance to croup, as to 
be very generally confounded with it; and which is hence known by the name of 
*« spasmodic croup." But notwithstanding the resemblance of many of its symp- 
toms, it is essentially different from it, and ought to be arranged in a different place. 
The distinctive characters of bronchlemmitis or croup are, inflammation of the 
mucous membrane of the trachea and bronchial vessels; and the secretion of a 
peculiar concrete and membrane-like material, that lines the tracheal tubes, and 
threatens suffocation by obstructing them. In the disease before us, we have neither 
inflammation nor membrane-like secretion; while the sense of suffocation is pro- 
duced, not by obstruction, but by spasm. 

Distinguished from Asthma. — Nor is it strictly an asthma; though it makes an 
approach to it, and forms the " Spasmodic Asthmas" of Millar, Parr, and various 
other writers. In asthma, the constriction commences in the chest, and chiefly 
exerts itself there; though the spasm may extend to the upper part of the trachea. 
In spasmodic laryngismus, the constriction commences in the larynx, and is chiefly 
confined to that organ; though it may extend to the chest. In the former, the 
respiration is wheezy, but the voice is not stridulous; in the latter, the voice is 
stridulous, but the respiration is rarely wheezy, or rather rarely so in an equal 
degree; — evidently showing a difference in the seat of the two diseases."] 

* Stokes on Diseases of the Chest; Part 3; Section 1; Pa^fe 261. 

b Dr. Mason Good's " Study of Medicine;" Class 2; Order 2; Genus 2. 



734 DISEASES OF THE LARYNX AND TRACHEA. 

History and Progress. — [This convulsive affection occurs by paroxysms, with 
longer or s«horler duration in different cases, and in the same case at different times. 
It consists in a peculiar mode of inspiration, which it is difficult accurately to de- 
scribe. The child, having had no apparent warning, is suddenly seized with a 
spasmodic inspiration; consisting of" distinct attempts to fill the chest, between each 
of which a squeaking noise is often made; the eyes stare, and the child is evidently 
in great distress; the face and extremities, if the paroxysm continues long, become 
purple; the head is thrown backwards, and the spine is often bent, as in opistho- 
tonos: at length, a strong expiration takes place; a fit of crying generally succeeds; 
and the child, evidently much exhausted, often falls asleep. In one of these attacks 
a child sometimes, but not frequently, dies. They usually occur many times in 
the course of the day; and are often brought on by straining, by exercise, and by 
fretting; and sometimes they come on from no apparent cause. They very com- 
monly take place after a full meal, and they often occur immediately upon waking 
from sleep; though, before the time of waking, the child had been lying in a most 
tranquil state. As the breathing is affected by these paroxysms, the complaint is 
generally referred to the organs of respiration, and it has been sometimes called 
*' chronic croup;" but it is very different from croup, and is altogether of a con- 
vulsive character; — arising from the same causes, and relieved by the same reme- 
dies, as other convulsive affections. Accompanying these symptoms, a bending of 
the toes downwards, clenching of the fists, and the insertion of the thumbs into 
the palm of the hands, and bending the fingers upon them, is sometimes found, not 
only during the paroxysms, but at other times. Clenching the fist with the thumb 
inserted into the palm of the hand, often exists for a long time in children without 
being much observed; yet it is always to be considered as an unfavourable symp- 
tom, and frequently is a forerunner of convulsive disorders; — being itself a spas- 
modic affection. It rarely happens that a child recovers from an attack of this sort, 
unless the progress of the disorder has been interrupted by a timely application of 
proper remedies, without a general convulsion. Then the friends become alarmed; 
and a disease which had existed for two or three months, is, for the first time, con- 
sidered to be important enough to require medical assistance; after all the farrago 
of popular medicines — such as "fit-drops," "soot-drops," assafcetida, &c.— have 
been ineffectually applied. Convulsions of this description seldom, if ever, occur 
after the expiration of the third year of a child's life; and not often in children 
which have lived by sucking till they have teeth, and have never taken animal food 
till the "denies cuspidal!" have come through the gums; this, however, is liable 
to some exceptions.^] 

Causes. — [The principal causes of the croupy convulsion in children, in a prac- 
tical point of view, are: — 1. Dental Irritation. 2. Gastric Irritation. 3. Intes- 
tinal Irritation. And here P must make the all-important practical remark; — that 
I have never seen the measures suggested by this view of the causes, when early 
and effectually enforced, fail in remedying this disease. Besides these especial 
causes, there are others which act upon the nervous centres. Passion, vexation, 
and certain odours, are of this class; and (singular as it may appear) the state of 
sleep predisposes, at least, to attacks of this kind of convulsion. 

Pathology. — The origin of this disease was erroneously referred to the cere- 
brum by the late Dr. J. Clarke, to whom we owe its detection; and to compression 
and consequent paralysis of the pneumogastric and its recurrent nerves, by the late 
Dr. Hugh Ley, to whom we are indebted for an otherwise invaluable treatise upon 
it.'' It is, in reality, an excitauon of the true spinal or excito-motory system. It 
originates in: — I. The Trifacial, in teething. 2. The Pneumogastric, in over 
or improperly-fed infants. 3. The Spinal Nerves, m constipation, intestinal dis- 
order, or catharsis. These act through the medium of the Spinal Marrow, and: — 

* Dr. John Clarke's "Commentaries on the Diseases of Children." 
»» Dr. Marshall Hall. 

c " An Essay on the Laryngismus Stridulus, or Croup-like Inspiration of Infants. Bv 
Hugh Ley, M. D." 



DISEASES OF THE LARYNX AND TRACHEA. 735 

1. The Inferior or Becurrent Laryngeal, the constrictor of tlie larynx. 2. The 
Intercostah and Diaphragmatic, the motors of respiration. When the croivirto- 
inspiration passes into actual convulsion, the larynx, from being partially, be- 
comes perfectly closed; and there are violent expiratory efforts, with consequent 
conorestion of the encephalon, and all its terrific train of evils. The same mode of 
viewinsf this important subject, leads us to give its proper place to each of the 
series of symptoms: the spasmodic or spinal are the first in order; the cerebral 
the second. We are thus enabled to see tiie just relation and position of effusion 
into the ventricles of the brain, with regard to this disease; it is the effect, not the 
cause. 

Treatment. — The proper mode of treatment comprises the remedies — 1. Against 
the attacks. 2. In the attacks, and in the threatening of the attack. 3. Against 
their effects. The remedies against the attacks, or the prevention, consists in avoid- 
ing all the exciting causes: dental, gastric, or intestinal irritation; passion; vexation; 
disturbance; interrupted sleep; &;c. The remedies in the threatening of attacks, 
consist in the watchful and prompt repetition of the same treatment, lancing the 
gums, and relieving the stomach and bowels. The sleep especially should be 
watched; and if there be a sardonic smile, or starting, or other symptoms, the little 
patient must be gently awakened; and the remedies just enumerated should be 
administered. Mental agitation must be most cautiously avoided. After the gum- 
lancet, I would advise a copious enema of warm water. If there be great threaten- 
ing of an attack, 1 would tickle the fauces, dash cold water on the face, and irritate 
the nostrils; — having the patient placed, as speedily as may be, in the warm-bath. 
To guard against the effects of the attacks, we deplete the blood-vessels about the 
head with cupping, or leeches; apply an alcoholic lotion constantly all over the 
head; or, if the case be urgent, the ice-cap. In addition to these measures, the 
secretions must be corrected; — mild mercurials being given, perhaps, to affect the 
system; and diuretics, if the urine be scanty: afterwards, change of air is of un- 
doubted efficacy; and a very mild tonic plan may be added with advantage; as 

minute doses of the sulphate of quinina, of the carbonate of iron, &c. Sponging 
with warm salt-and-water, is also a valuable auxiliary remedy. It is impossible to 
conceive the vast importance of this subject. If any thing could add to this import- 
ance, it is the fact that the convulsions of infancy frequently lay the foundation of 
epileptic attacks in youth, or adult age. Sometimes the transition is so gradual and 
continuous, that the two affections are proved to be obviously the same. 

With the same objects, the diet and the condition of the bowels must be attended 
to with eciual energy. All irritation must be avoided; and, among these, drastic 
medicines must be ranged. A young nurse's or ass's milk should constitute the 
diet. Enemata of warm water may be used, effectually to relieve the bowels, night 
and morning. The "tinctura hyoscyami" and hydrocyanic acid are important 
auxiliaries; but especially change of air. A cold lotion, the ice-cap, and perhaps 
leeches, must be used to guard tiie head; the feet must be fomented and kept care- 
fully warm.^] 

h. Nervous Affections of the Larynx in the Adult. 

[We meet witli spasm of the glottis in the adult, either with or without organic 
disease of the larynx; though in most cases it supervenes on chronic laryno-eal 
affections. In females, however, we find it as one of the symptoms of the protean 
hysteria; when it may be a transient or long-continued affection. The spasm is 
commonly during inspiration. 

P have not materials to enable me to enter into an account of the various hysteri- 
cal and nervous affections of the larynx in females; but shall merely enumerate 
those which I" have observed, most of which have been long known: — 1. Simple 
aphonia, supervening on mental excitement. Its duration is exceedingly various, 

a Dr. Marshall Hall, on Diseases and Derangements of the Nervous System; Chapter 5: 
Pa-es 171, 172, 173, 181, and 182. 
b Dr. Stokes. 



736 DISEASES OF THE LARYNX AND TRACHEA. 

and its disappearance often as sudden as its invasion. 2. Fits of croupy breathing. 
3. Long continued stridulous breathing, without fever. 4. A hard, loud, sohtary 
cough, without any stridor. In its more violent forms, this has got the name of 
"tussis ferina." 5. A similar cough, followed by an inspiration not stridulous; but 
with the expiration long, sonorous, and groaning; so as to resemble the howling 
of a dog. 6. A short but teasing cough, occurring in the most rapid succession; 
and during the paroxysm causing the greatest distress and exhaustion. 7. The 
most violent form of the "tussis ferina;" with greatly increased action of the heart 
and arteries, hurried breathing, loud puerile respiration, and profuse sweatings. In 
such a case P have seen the disease continue for more than a year; yet there was 
no emaciation. 

Other forms may also occur; but the above are those which have fallen under 
my* own observation. With respect to diagnosis, the points of importance are, — 
the coexistence of other hysterical phenomena, or their having preceded the symp- 
toms; the absence of fever, the character of the cough; the loant of the regular 
succession of phenomena as observedin laryngitis; the frequent absence of hoarse- 
ness; and, lastly, the resistance of the symptoms to ordinary antiphlogistic treat- 
ment."] 

Spasmodic Cough. — There is a cough, which occurs every now and then; and 
which is not the "/ioojomg"-cough;" but what may be termed ^'•spasmodic cough." 
This affection is, perhaps, united with a degree of inflammation; or perhaps not; 
but if it be united with inflammation, it is out of all proportion to it. I believe this 
is what is meant by ''spasmodic cough." I have seen a few instances of a most 
violent cough, tearing persons in pieces, like hooping-cough; but still it was 7iot 
hooping-cough; and it occurred in adults. 

In this disease, iron is by far the best remedy. I have cured every case which 
I have seen of it, by the exhibition of the sesquioxide of iron. In many of these 
cases there is no indication for bleeding; although, if the patient be robust, it may 
be expedient to bleed in the first instance; but I have always treated such cases with 
the sesquioxide, and with great success. In every case where the cough is out of 
proportion to the inflammation, or where there is an organic disease (even con- 
sumption), iron appears to be the best remedy. Many cases attended by cough 
and expectoration, which have been mistaken for phthisis, have given way to this 
remedy. 

Nervous Cough. — I have now and then seen a very extraordinary cough in 
young women. All very extraordinary cases, independent of organic disease, are 
to be seen in young women. Cases are continually seen in young women, of so 
extraordinary a nature, that we could not believe in their accuracy, if we merely 
read them in books. I recollect very well seeing a young lady, single, — for these 
cases almost all occur in single ladies, — who complained, that every time she 
inspired, she coughed, night and day. She breathed slowly; but when the time 
came for expiration, she coughed. Nothing was expectorated; and on listening to 
the chest, there was nothing preternatural to be heard. She had coughed in that 
way for months. At first the cough was quiet when she slept; but when I saw 
her, it would not allow her to sleep. I did her no good; and what became of her 
I did not hear. It was the most extraordinary case I ever saw. I have no doubt 
it was a nervous cough; — that it did not depend upon any inflammatory or organic 
disease; and that it would cease entirely of itself, in the most sudden manner. 

Barking Cough. — Occasionally females will have a barking cough. Sometimes 
they will have a violent spasmodic cough, such as I have now described, only 
modified in various ways; so that they will make all sorts of strange noises (such 
as shrieking); — unattended by organic disease, and apparently arising from a mere 
nervous derangement of the parts. The exact nature of these affections I have not 
been able to ascertain. 

» Dr. Stokes. 

»> Dr. Stokes, on Diseases of the Chestj Part 1; Section 3; Pages 263 and 364. 



BRONCHITIS. 737 

Jlphonia. — It is ri^ht to mention, that the voice is sometimes lost, or reduced to 
a mere vviiisper, — without any inflammation, — without any cedema, — without any 
obstruction, as it would appear, of the parts. This affection, which is called 
"aphonia," occurs chiefly in females; and is altogether what we call '' ^nervous 
complaint." It occurs sometimes in boys as well as in girls; but it is chiefly an 
aff'ection of women. I think it is easily made out. There is no tenderness of the 
larynx on pressure; there are other nervous symptoms in the body; and the person 
is weak and nervous altogether. Frequently there is no tenderness on pressure, 
and frequently no cough; or if there be cough, there is nothing else; — no pain 
with it; — no expectoration; and the disease frequently comes on suddenly, and 
goes off in the same manner. It has frequently come on in the course of a few 
minutes; — at any rate, in a day. It ceases, perhaps, as suddenly; and then comes 
on again. 

There is no danger whatever; but sometimes persons lose their voice for many 
months; and I have heard of cases where they have lost it for years; and, from a 
sudden circumstance, without any apparent reason, the voice will return. I do not 
know any mode of treatment better than the shower-bath; and attention to the 
improvement of the general health, in every possible way. 



CHAPTER V. 

BRONCHITIS. 
SECTION I.— ACUTE BRONCHITIS. 

When inflammation attacks the air-passages at large, and particularly those 
within the chest (the ramifications of the bronchia), and affects these latter very 
severely, the disease is termed "bronchitis" (from jS^oyj^^oj, and itis); — inflamma- 
tion of the bronchia. 

Synonymes. — This is the most common kind of inflammation of the lungs. 
The far greater number of those who have what is called " inflammation of the 
lungs," have inflammation of the ramifications of the bronchi; so that there is 
nothing heard of now but " bronchitis;" whereas we formerly used to hear only 
of "pneumonia," or "peripneumonia." But since it has been ascertained that 
the inflammation which we every day see, resides in the mucous membrane of the 
bronchia, the term "inflammation of the lungs" has fallen into less frequent use; 
and we have, instead, the term " bronchitis." One portion of the substance of 
the lungs is made up of the bronchial tubes, and therefore the term " inflammation 
of the substance of the lungs" is very proper; because those tubes are an integral 
part of the lungs. 

General Symptoms. — In this affection, which occurs every day, the breathing 
is quick a)ul shallow. To make up for the shallowness, the patient breathes 
quickly. If the patient breathe deeply, the mucous membrane is put upon the 
stretch so much, that it occasions great uneasiness. He is more comfortable when 
he takes a small quantity of air into the chest; but it must be accomplished more 
frequenUy than on ordinary occasions. There is frequently a sense of constriction 
of the chest, and of soreness about the larger bronchia. It is sometimes difficult 
for a patient to lie down; but in other cases he can do perfectly well. There is 
every variation as to cough. In some persons there is intense cough; if they even 
turn a little in bed, it shakes the bronchial membrane sufficiently to produce cough. 
Some cannot turn; some can scarcely lift their arms; — ihey cannot produce so 
slight a motion of the chest as that, without experiencing cough. In other patients 
the cough is by no means severe. If it be severe, people are confined to their bed; 
but if not, the motion produced by exercise makes the breathing more diflicult. 
VOL. I. — 47 



73S BRONCHITIS. 

The Expectoration. — From the first there is some expectoration. The mucous 
membrane cannot be so irritated, without secreting more than it should; and this 
expectoration may increase to a very great amount. If the inflammation become 
very severe, it diminishes again; — but still the patient has more secretion than in 
health. If a person have a very active inflammation, the secretion diminishes; 
and then, when the disease declines, or degenerates into the passive or atonic form, 
the secretion may become immense. At first it is thin; but it soon becomes thick, 
and frequenUy of a very yellow colour, — so as to look almost like pus; only it is 
very glutinous; and, for the most part, swims in water. It may appear very 
black; — as black as if soot had been mixed with it; but there are various other 
shades; — blue, green, yellow, and white. This expectoration is not excessively 
tenacious. It is certainly viscid; but not so tenacious as when the air-cells are 
inflamed. In the latter case, the matter is so tenacious, that if a person spit into a 
vessel and turn it up, the expectorated matter will not run out, but will adhere to 
the sides. 

Headache, — There is headache, sometimes very severe, when the cough takes 
place. The headache is of that character, when it exists at all, that patients 
almost always describe it as "a splitting headache;" and sometimes there is 
drowsiness. There is great congestion in the head; and a more or less inflamma- 
tory state. 

The Pulse. — The pulse is accelerated. It may be as high as 100; or even still 
higher. As the inflammation aff'ects a mucous membrane, the pulse is generally 
large and soft. It may be hard; — for there is a great variety in these things, but 
for the most part it is full, and rather soft; or, at any rate, not 2. firm pulse. There 
is not the softness of debility; but a pulse of no remarkable /joz^^er. 

State of the General Surface. — The skin is frequently dry; and, of course, the 
tongue is dry, and generally of a dirtyish white colour; and sometiiiies it is covered 
with a great deal of mucus. Tlie skin, for tlie most part, is hot; and now and then 
persons sweat violently. The face, too, shows great congestion. General con- 
gestion probably takes place; for. in many cases, there is drowsiness and headache; 
and there is likewise redness and fulness of the face. At the moment of coughing, 
the veins of the temples and neck are greatly distended, and the whole face becomes 
turgid. 

Progress of the Disease. — If the disease go from bad to worse, the patient can- 
not lie down at all. His face becomes livid, from the congestion. The lips become 
purple; and I have seen the face become really black; — of such a hue that I could 
not have believed it had been the result of bronchitis, if I had had it represented to 
me. It was as dark as when a patient has taken nitrate of silver to a great amount; 
or where there has been a communication between the two ventricles of the heart. 
The pulse, at last, becomes weaker and softer; and, at the very last, vermicular. 
The surface becomes blue; and both the forehead and chin are bedewed with a 
cold clammy perspiration. In this stale of things, the expectoration becomes very 
scanty, or ceases altogether; not because it is not secreted, but because the patient 
is too weak to expectorate it; so that he may almost be said to be drowned in- 
wardly by mucus. In cases which are left to themselves, or badly treated, it is 
said that dyspnosa comes on about the fifth or sixth day, and is followed by death. 

If, on the other hand, improvement take place, the constriction is removed. The 
cough is not much diminished; but it does not hurt the patient as it did. There is 
copious expectoration. The pulse becomes slower and softer; without, however, 
becoming so soft as in health. The surface perspires; and the tongue becomes 
moist. Still, if the case be severe, there is a discharge which appears to be puri- 
form. In other cases, the patient neither gets well nor dies; and then there is con- 
siderable expectoration. Still the pulse is kept up, and still it is hard. Inconsequence 
of the coufrh, he does not gain strength; but perhaps becomes more and more ema- 
ciated. He has night-sweais; and at the end of many months he may die, or get all 
but well; and then when he is exposed to a common cold, he may have difliculty of 
breathing, and more or less bronchitis; so that some persons who have been ill, will 



BRONCHITIS. 739 

never be able to get through a winter without an attack of asthma; — that is, short- 
ness of brea'hing. 

Signs afforded by Auscultation. — Besides these symptoms, however, there are 
others which may be learned by the ear. As bronchitis is an inflammation of the 
inner surface of those tubes through which the air passes, they are necessarily 
aUered in diameter; and instead of being only moistened, there is an abundance of 
mucus, and mucus of a different consistence to what it usually is; we must there- 
fore suppose that there will be a very difl'ereni sound in this disease, from what 
there is in health. On listening over the part that is inflamed, we hear, instead of 
the natural murmur, a sound both louder and rougher than usual; and if the in- 
flammation be very great, the sound is then so loud and rough, as to resemble the 
snoring o{ &omQ small animal. This is called the noise of "so?ioroi^5 respiration," 
or "sonorous rattle,'''' Some choose to use the Latin word "rhonchus;"* and some 
say *'rale;" and would not say "ratde" for the world, because it is not scientific. 
However, there is a rough snoring sound: something like the bass string of an in- 
strument. Besides that, we frequently observe a squeaking or shrill sound; — some- 
thing like the chirping of a bird; and that is termed ^'sibilous rattle." It is frequently 
shrill, like the noise made by a grasshopper. One or both of these phenomena we 
constantly observe. Of coursa they are not heard all over the chest; but only at 
those parts where the tubes are afl'ected. 

There is another peculiar circumstance in this affection; namely, that all at once, 
while we are listening, the sound occasionally ceases entirely; and if we continue 
to listen, we hear it again as before; or if v\'e make the person cough, we then hear 
the sound of respiration again. This is peculiar to the disease; and arises, as is sup- 
posed, from a large tube becoming temporarily obstructed by mucus; — so that its 
ramifications get no air; and, when the mucus is removed, the air enters as before. 
When the sound of respiration ceases in a part, if we only make the patient cough, 
that is generally sufiicient to dislodge the mucus, and the respiration returns. This 
is called, by Laennec, a pathognomonic sign of this disease. 

Sometimes, on placing our hand over the chest, we discover a vibration at the 
same moment; but that is not always the case. It depends upon the extent, or the 
intensity of the affection. If the air pass with great difficulty, it shakes that portion 
of the chest. However, it is not of very great importance. 

Auscultation of the Cough. — TWxs wheezing (as we call these ratdes in English) 
occurs, not only when the person is speaking, but in a much more marked degree 
when he is coughing. If we have a doubt about the nature of the disease, — as to 
whether it is bronchitis or not, — because we do not hear a sonorous or sibilous 
rattle, by making the patient cough, we may then determine the nature of the case 
to a certainty. In coughing, there is generally a more violent inspiration; and as 
soon as we produce that, it will have the desired effect. Frequently also this dis- 
ease may be detected at the back and root of the lungs, when we cannot find it any 
where else. In that situation, both in respiration and in coughing, sonorous and 
sibilous ratdes are frequendy heard, when they are heard nowhere else. In most 
instances, persons can tell a case of bronchitis without this; but sometimes they 
cannot. Sometimes a patient will breathe quickly, and the pulse will be quick, 
and yet we are at a loss to say what the disease is. Sometimes I have known it 
difl^icult to say whether the disease was in the chest or not; whereas, by listening 
to the chest, and making the patient breathe quickly and cough, the disease has 
been fiiirly made out. In listening to the respiration, in a case where we suppose 
there is bronchitis, it is right to make the patient breathe as quickly as he can; 
and we shall then hear the sounds more distinctly; it causes still more full re- 
spiration. 

If the affected part be at a considerable distance from the front, we cannot hear 
the ratdes well. The nearer they are to the surface, the louder we hear tlieni. 

Signs afforded by Percussion. — In bronchitis the sound on percussion is not 

* A snorting, or snoring. 



740 BRONCHITIS. 

altered; on striking over every part of the chest, we find it sound as in health. At 
the very moment at which we may cease to hear respiration at one part, if we 
strike that part, we still hear a hollow sound: and for this reason; — although respi- 
ration is not going on, there is air tliere. There is no fluid collected, and no solidi- 
fication of the lungs; but the air is there much as it is in health; and therefore, on 
striking, we have the natural hollow sound. 

[Dr. Stokes, in the following propositions, has indicated the present state of our 
knowledge with respect to the physical diagnosis of simple bronchitis: — 

" 1. In almost all cases, percussion gives no direct sign. 2. An accumulation 
of mucus in the lower portions of the lung, may give a certain degree of duliiess. 
3. In the great majority of cases in which there is a coexistence of the signs and 
symptoms of bronchitis with dulness, we may infer the existence of some disease, 
either of the parenchyma or of the pleura. 4. Conversely, the absence of dulness 
with the existence of irritation of the lung, gives a great probability that the case 
is one of simple bronchitis. 5. A copious effusion of muco-purulent matter may 
exist in the bronchial tubes, without a perceptible dulness of sound on percussion. 
6. In certain cases of bronchitis with effusion, a metallic sound may be produced 
on percussion. This is somewhat similar to the bruit de pot fele of caverns; but 
is to be distinguished from it by the clearness and greater diffusion of sound, and 
absence of the stethoscopic signs of a cavity. 7. In many cases, on application of 
the hand, a distinct vibration is felt, in accordance with the motions of respiration. 
8. The modifications of respiration, as observed by the stethoscope in bronchitis, 
seen to be connected with mechanical obstruction more or less complete, and which 
may proceed from one or all of the following causes: — turgescence or hypertrophy 
of the mucous membrane; the existence of various secretions; and, lastly, the oc- 
currence of spasm. 9. In the mode of recurrence of the various phenomena, there 
are the greatest possible differences in different individuals. 10. As a general rule 
it may be stated, that the more intense the sonorous, sibilous, or mucous rales, or 
any combination of them, during ordinary respiration, the more severe may the 
disease be considered. II. But in certain cases of intense bronchitis of the minuter 
tubes, the sounds during ordinary respiration cease to be a measure of the intensity 
of disease; as they become louder during the convalescence of the patient. 12. In 
the secretive stage of bronchitis, the mucous rattle may occur, on the one hand, 
with large and isolated bubbles; and, on the other, may pass into a rale almost 
crepitating; — the sound on percussion still continuing clear. 13. In consequence 
of bronchial inflammation, the entrance of air into a certain portion of the lung may 
be prevented; in which circumstances, the signs are nullity of respiration, with 
persistence of clearness of sound. 14. This obstruction may result from organic 
change of the mucous membrane, or from the plugging up of the tubes by their own 
secretion. 15. In the first of these cases, the absence of diminution of the respi- 
ratory murmur is permanent, while in the second it may be temporary, and remo- 
vable by a fit of coughing; yet, even in this case, the obstruction by concrete 
mucus has continued from the period of its occurrence, until the fatal termination. 
16. If in a case of mucous catarrh, a sudden dyspnoea supervenes, with absence or 
diminution of the respiratory murmur in a particular portion of the lung, — this 
portion also preserving its clearness of sound on percussion, — we may make the 
diagnosis of obstruction of the bronchial tube by its own secretion."*] 

Treatment. — The treatment of this disease is perfectly easy. We have only 
to bleed the patient well, and to follow it up by local bleeding. According to some, 
the latter answers better at the back, than at the front. I do not know that this is 
the case, but some say they have contrasted the two modes; — which is more than 
I have done. I have generally been contented with cupping at the front. Some 
say there is more advantage from cupping on one side of the spine; and others 
prefer the root of the lungs, and the large vessels. I am quite sure that, in this 
disease, mercury is of the greatest use. I have had many cases that have yielded 

» Dr. Stokes, on Diseases of the Chest; Part 1; Section 2; Pages 79 to 81. 



BRONCHITIS. 741 

the moment the mouth has become sore. Or if we choose, instead of making' the 
mouth sore, great advantage may be derived from the exhibition of tartar emetic in 
large doses; — so as to keep the patient nauseated, and from time to time produce 
vomiting. Vomiting causes a great discharge from the affected parts; and therefore 
it is more useful than in any other inflammation. In many inflammations, it would 
be dangerous to practise vomiting; but in bronchitis many trust, next to bleeding, 
to the exhibition of full doses of tartar emetic; — a grain or more every three or four 
hours. However, I am not so satisfied with this plan, as with making the mouth 
sore; but if the patient do not go on so fast as we could wish, then we may give 
tartar emetic afterwards. Nevertheless, I am quite satisfied that making the mouth 
sore is one of the most expeditious modes of cure. I need not say that blisters, low 
diet, and moderate purging, are also exceedingly proper. The treatment is that of 
common inflammation;" and if it be well practised in time, and if the patient be not 
the subject of chronic bronchitis, the treatment is easy enough. If the patient have 
acute supervening on chronic disease, our chance is slight; but even then the case 
must be treated on the same principles. 



SECTION II.—ASTHENIC BRONCHITIS. 

Symptoms. — It is to be particularly remembered, that bronchitis will sometimes 
destroy life in the most insidious manner. It may exist without pain, and may 
then be easily passed over; I mentioned that it will frequently exist with little 
cough,* — not half the cough that is often present in common catarrh; — and then 
also it may be easily passed over. The patient is considered to have " a litde 
cold;" but tliere is such prostration of strength, as surprises every body; and in 
three or four days the individual is past hope. I have known several cases of this 
description. This occurs particularly in those advanced in life; and therefore, 
whenever we are consulted by individuals near sixty, or who have passed that age, 
and we observe difficulty of breathing, the respiration hard, and the pulse quicker 
than it ought to be, it is well to listen to the chest, and find what disease he has. 
The respiration may be sonorous, sibilous, or both; or perhaps mucous; and the 
patient may be labouring under excessive inflammation of the bronchia. We may 
hear these sounds in many parts of the chest. 

Pathology. — This species of the affection is called ^^asthenic bronchitis;" — that 
is, the form of inflammation which is described as atonic;" where the inflamma- 
tion, however active, may be attended by no great strength of constitution; and 
where it very soon degenerates into passive inflammation, or the patient absolutely 
sinks. There is no power in the system; but the parts themselves are more or 
less inflamed: and at that lime of life, witli such a state of the constitution, the in- 
flammation is sufficient to expend all the powers; and at the end of a few days the 
patient sinks. When a patient, therefore, in the decline of life, has a cold suffi- 
cient to make him call in medical assistance, it is necessary carefully to examine 
the breathing; and to observe whether it is frequent or not. It is also right to 
listen all over the chest; in order to ascertain whether there is not a pretty con- 
siderable degree of bronchitis; — considerable either in degree or extent; for some- 
times it is inconsiderable in degree, but considerable in extent; and that is quite 
sufficient to hurry the respiration. 

Treatment. — This is an unpleasant case to treat; and I have lost many such 
patients in a winter. They are usually seventy years of age, or older; they have 
bronchitis; they cannot bear much bleeding; their powers are gone; and it is fre- 
quently vain to attempt to relieve them. All we can do is to bleed to two ounces; 
to bleed locally; to apply blisters; to get the mouth sore; and to give emetics; but 
we cannot do much with any thing. 

Tonics. — When the sonorous and sibilous rattle degenerates mio mucous ranle; 

* See Page HS. ^ See Page 737. " See Pages 111 and 130. 



742 BRONCHITIS. 

if this be observed all over the chest; if the patient's powers be gone, and he can- 
not lift himself in bed without aid, — we may occasionally get him through, by 
good support, by wine and milk, and (according to the practice of some) by bark; 
but very frequently, in spite of all that can be done, he will slip through our 
fingers. It is always provoking to lose a patient; but there is sometimes an espe- 
cial reason for it; and we lose our credit, because we have not alarmed the family, 
as we should have done. When old people are attacked with this disease in such 
an insidious manner, and their strength is all gone, it is very easy to offend the 
family by saying the patient has "only a cold," when he is all but dead. I have 
heard some old practitioners say, that these cases should be treated with bark and 
wine from the very first; and that they invariably cure the patient. One always 
doubts a man who says he cures every complaint, however excellent his plan may 
be. The powers have been prostrated, from time to time, by some cause or other; 
but after the first bleeding (with wjiich, perhaps, we cannot go far), and after 
blistering, and producing a slight afl^eclion of the mouth, or nausea and vomiting, it 
is necessary, in a short time, to support the patient well; and if there be any doubt 
about the propriety of going on with this strengthening plan, it is better to do so; 
— giving an emetic every day, so as to clear out the chest, and induce a free secre- 
tion; and during the rest of the day, giving bark or quinina, and good nourishment, 
or even wine. 

Opiates, — In these cases it is necessary to procure rest by means of opiates or 
narcotics, of various descriptions; but the essential thing is to cure the bronchitis. 
The bronchitis frequendy comes on in an insidious manner, and is accompanied by 
no constitutional signs; but it is in old people that this particularly happens. We 
never see it in children, or in the middle period of life; but in those advanced in 
years we see it every day. 

Sometimes called Peripneumonia Notha. — It is this form of the disease that 
has been called " peripneumonia notha;"— as if there were bastardy not real^ peri- 
pneumonia; but I believe the word is used very indefinitely. Sydenham applies 
this expression to common bronchitis; where the head is •' ready to split," and 
"where all the symptoms present are such as I described as common to bronchitis." 
We had better abolish the term ^^ peripneumonia notha;^^ and remember that there 
is a disease of the air-tubes (that is, bronchitis) that may be active, — accompanied 
by strength; and must be cured by strong measures; and that sometimes it is 
attended by no strength at all; or, at least, that the strength will all go away in a 
day or two; and that whatever measures are adopted, must be employed the first 
few days. I believe the term '^peripneumonia notha''' was supposed, by some, 
to apply to the latter state only; but if we read Sydenham, we shall find it clear 
that he applies the term to those cases where there is considerable pain. 



SECTION III.— CHRONIC BRONCHITIS. 

Bronchitis is very frequently a chronic disease. Sometimes, and indeed gene- 
rally, this is a mere degeneration of the acute form. In some persons, the disease, 
when it has once begun, however acute it may be, never ceases. At least, they 
have it every winter afterwards. Subsequent attacks of the disease may not be 
active, but more or less passive; and some patients have the aff'ection for two or 
three years, and then they die. But if we ask many asthmatic people (as they are 
called), — that is, persons who have passive bronchitis every winter, — they will 
say that it came on originally after severe inflammation of the lungs, or a very 
violent cold. 

Jige at luhich it Occurs. — It is in the middle aged and the youno-, that chronic 
bronchitis is most frequently the consequence of a very acute aflf'ection. In old 
people, it generally comes on very slowly; and is the consequence of what is 

»» See Pages 737 and 738. 



I 



BRONCHITIS. 743 

apparently nothing but catarrh; — that is to say, a very sliglit acute attack of bron- 
chitis, in old persons, degenerates into chronic bronchitis. In old people, too, it 
comes on very imperceptibly. They will perhaps have a severe cold one winter, 
and have it for two or three months; and then, the next winter, they will have it 
still worse; and so they go on, as long as they live; — having it worse and worse 
every winter. 

Commonly called Asthma, — This chronic bronchitis passes, vulgarly, under the 
name of " asthma;" and even among some medical men (especially those educated 
a long time ago) the term "fl.s//im«" is applied to bronchitis. Now asthma is, 
properly speaking, a pectoral difficulty of breathing. I say ";;ec?or«/;" for the 
causes of many difficulties of breathing, are situated in the larynx or in the wind- 
pipe. A spasmodic dyspnoea may be situated allooether in the larynx. Asthma, 
however, is purely pectoral. A spasmodic difficulty of breathing, such as true 
asthma, is frequently united with inflammation or congestion of the muco-us mem- 
brane of the bronchia; that is, with chronic bronchitis; because when the mucous 
membrane is inflamed, it is commonly thrown into spasm; and unless it be re- 
moved, the muscles are also thrown into a state of spasm. 

Humoral Asthma. — When the two diseases are united, they pass under the 
name of " humoral asthma;" — that is, spasmodic difficulty of breathing, with a 
great quantity of fluids in the chest. The "humoral asthma," mentioned in old 
writers, is nothing more than what I have now stated. 

Frequently a Cause of Asthma. — Chronic bronchitis is very frequenfly the 
cause of asthma. When a part has been frequently ijiflamed, it becomes exces- 
sively irritable, and at length spasm takes place; so that, when a person has chro- 
nic bronchitis, it is worse at one place than another, — it is worse at one season 
than at another; and the patient will be seized, all in a moment, with additional 
difficulty of breathing. We may sometimes have spasm without any inflamma- 
tion of the bronchial tubes; but a common cause of spasmodic difficulty of breath- 
ing, is (certainly chronic bronchitis. 

Varies in Degree. — This chronic bronchitis, whether united with a spasmodic 
condition or not, varies in degree; from great congestion of the bronchial mem- 
brane, and of the whole lungs, down to a mere gleet, — a mere flux or gleet of the 
mucous membrane; in which state the mucous membrane may be red, or it may 
be without the ordinary signs of inflammation. We may have nothing but a mere 
gleet; — such as occurs in gonorrhoea when it has long gone by; and which, of 
course, does not deserve the name of inflammation. It appears to me (as I men- 
tioned formerly*) that, in the latter case, there is exactly the same state as we see 
in a serous membrane, where it pours forth a great quantity of fluid, but where no 
signs of inflammation can be discovered. On the contrary, the parts are whiter 
than usual, and have the appearance of satin. 

Symptoms: Cough. — In all these varieties of chronic bronchitis there is cough. 
Tiiere is also copious expectoration; and the expectoration is of all descriptions; — 
frothy, ropy, mucous, serous, watery, tenacious, and viscid (like gluten). Some- 
times it is short and creamy; — ^just like pus; and sometimes it is absolutely piUHi- 
lent. These varieties of expectoration frequently exist, at the same time, in 
diff'erent proportions; and sometimes they succeed each other. The expectoration 
may be sweet and inodorous; or it may be dreadfully fetid; but there is no danger 
from the latter circumstance. I have seen females with expectoration so fetid, that 
their sisters could not bear to sleep with them; — so fetid, that they were disagree- 
able to themselves, and yet no sign of danger whatever presented itself, and the 
patients did exceedingly well. They were going about without any particular 
ailment, except that they had a copious expectoration. In colour it will some- 
times be bluish, sometimes bbick; or it may be yellow, green, brown, or reddish. 
'I'he latter is owing to the admixture of a little blood in it. Then, as to quantity 
it may vary from a few ounces to two or three pints, in the twenty-four hours. 

» See Pas:e 107. 



744 BRONCHITIS. 

Dyspnoea. — The other symptoms vary in intensity. There may be dyspnoea, 
or there may be none at all. There may be merely cough and expectoration; but 
that is more particularly the case in what may be called mere "gleet of the mu- 
cous membrane." When there is congestion of the lungs, or a spasmodic con- 
striction, we may have difficulty of breathing; and in other cases there may be 
such dyspnosa, that the patient cannot lie down; — such dyspnoea, that it will cause 
plethora of the head, face, and neck, distension of the jugulars, suffusion of the 
eyes, and (I might almost say) blackness of the nose and lips, or even of the whole 
face. In such cases of extreme congestion, the extremities may become cold and 
blue, and the urine scanty. The pulse may be either full, or small and feeble. In 
short, there may be all those symptoms which make many believe that hydroihorax 
has existed; — that, unquestionably, there has been water in the chest. It is in cases 
of this description that we are told, every day, by those who never employ their 
ears, that such a patient has water in ihe chest; and yet, on opening them, find 
none at all, or not sufficient to explain the symptoms. I have frequently seen per- 
sons with all these severe symptoms; and yet, on opening the chest, there has not 
been a drop of water found in it; but I have found the lungs so congested with 
blood, that they would not collapse. On listening with the ear, all this was clear 
beforehand. Respiration was heard at the lowest part of the chest; whereas, if 
water had been there, we could not have heard respiration. On whatever side 
water exists, if the person be upright, there can be no respiration in the situation 
of the water; and on striking the part there can be no hollow sound; — on the con- 
trary, the noise produced is like that occasioned by striking a solid, fleshy part, — < 
like the thigh. Chronic bronchitis, therefore, may sometimes exist without any 
congestion of the lungs; or there may be the greatest degree of congestion. 

Signs afforded by Auscultation. — This disease is very easily recognized, with- 
out auscultation; but the simplicity of the affection can only be determined by the 
aid of the ear. A person may easily say that another has bronchitis, whether it 
is acute or chronic; but without the aid of the ear, it is frequently impossible to 
say whether there is not something worse than bronchitis. Bronchitis may be 
frequently cured, or so reduced that little may be left; but there may be present 
another disease of a fatal character; and we may be able to ascertain this only by 
the ear. In chronic bronchitis the rattles (before described*) may exist, in most, 
or nearly all parts of the chest; and they will be in different parts on different 
days. The different rattles may occur on different days; — "sonorous" rattle one 
day, "sibilous" another, and " mucous" a third.'' The "mucous" rattle is seldom 
continuous. It generally arises from the presence of a great quantity of mucus; 
and if patients clear the lungs well, (as they generally do,) once or twice a day, 
then the rattle ceases. In this, as in the acute variety of bronchitis, the respiration 
may occasionally cease in particular parts. It is by no means so frequently sus- 
pended as in the acute form of the disease; and some say that it never is; but 
occasionally it is lost; and then, for the most part, we hear it again. 

Mistaken for Phthisis. — That form of the disease which is characterized by great 
expectoration, and that of a character nearly resembling pus, which is attended 
by a litde dyspnoea, but by no signs of congestion, and which is followed by ema- 
ciation, — so that people waste, and at last become hectic, is continually mistaken 
for phthisis; while, on the other hand, that form in which there is congestion, is 
mistaken for hydrothorax. That species, which is so often mistaken for phthisis, 
and passed by, may (if properly attended to) often be cured. This form, indeed, 
is better known by the general symptoms, than by the peculiar symptoms I have 
just mentioned. It is ascertainable by the ear, and by the absence of other symp- 
toms of phthisis; — ^just as the congestive form of the disease is known, not only 
by passive symptoms, but by the absence of signs of hydrothorax, or of disease 
of the heart, and so on. This form of the disease is known by the absence of 
pectoriloquy; and by other signs, which I shall hereafter mention. 

» See Page 739. " See Pages 710 and 711. 



BRONCHITIS. 745 

Cafarrhus Senilis. — Various names are given to the affection just tlesoribetl. 
When it occurs in old people, it is called "catarrhus senilis'^ It is a kind of bron- 
chitis, attended with various degrees of congestion, and frequently none; but 
attended with gleet, and a great discharge; and occurring in old people. It is 
nothing more than an ordinary affection of a mucous membrane; — that mucous 
membrane being the bronchial. 

Dry Catarrh.^ — Laennec considers the affection just described to be a peculiar 
form of chronic bronchitis; — a form more frequently attended with asthmatic com- 
plaints than any other. He says, that what is called "asthmatic spasm.odic diffi- 
culty of breathing," most frequently arises from a kind of bronchitis in which the 
secretion is exceedingly viscid; and in which the mucous membrane is thickened 
and swelled, — particularly in the small branches; so that some of them are nearly 
blocked up; and in which the secretion is glutinous, — even firmer than pilch; and 
is disj)osed to form globules the size of hemp or millet-seeds, semi-transparent, 
and of a pale gray colour. I have no observations of my own on this subject. I 
have not been able to verify Laennec's remark; but as he asserts it, it is worih attend- 
ing to. Where we find asthma occurring, we ought to suspect that it is not a pure 
disease, but dependent upon bronchitis; and we ought to ascertain whether the 
expectoration possesses the characters just enumerated. He says that these globu- 
lar bodies are seen in the expectorated phlegm; and that occasionally they are less 
consistent, and grow yellow; and sometimes resemble the vitreous humour of the 
eye. Such an expectoration is hardly noticed by the patient, in the midst of the 
common mucus which is secreted from the large branches; and which gives rise to 
so slight a cough, as not to merit his attention. He says the difficulty of breathing, 
— the spasmodic ailment, is almost the only thing of which the patient complains. 

Here then is a third disease, which may be supposed to exist without chronic 
bronchitis; and which has continually been mistaken. Chronic bronchitis, attended 
by emaciation, may be mistaken for phthisis; where there is great congestion, it 
may be mistaken for ivater in the chest; but that particular form where there is an 
exceedingly viscid secretion, with small globular bodies, is (according to Laennec) 
continually mistaken for pure asthma. 

Treatment. — The treatment of chronic bronchitis is very various under different 
circumstances. According as the symptoms are inflammatory, and our patient 
strong, must our treatment approach to that for the acute disease; and according as 
the patient is weak, and there are signs of passive rather than of active infiamma- 
lion. so must we be careful in lowering the strength. 

Cautious Removal of Blood. — In the latter case, where there are signs of con- 
gestion rather than of inflammation, and the powers of the patient are feeble, — we 
may very easily conceive the great importance of not taking away a drop more 
blood than is absolutely necessary. Where we see the face black, the body bloated, 
and the legs swollen, and only a small quantity of urine is formed, it may be neces- 
sary to take away a small quantity of blood; — perhaps a little from the jugular 
vein: or we may cup the patient between the scapulae, and on the front of the chest; 
but the loss of more than a few ounces can seldom be borne. 

Diuretics. — Diureiics and emetics are of the greatest utility. By diuretics we 
unload the lungs considerably. There is always a great collection of serous fluid 
in the air-cells and tubes, and by diuretics we produce a great alleviation to the 
patient. It is a good practice to combine digitalis and squills. We may give many 
diuretics together, when we cannot increase any one of them. When we cannot 
give the patient a large dose of squills without making him sick, we may add 
digitalis. It is certainly a very common occurrence to be able to give diuretics 
together, many of which have a tendency to produce sickness, without producing 

* The expression of '^dry catarrh" involves a contradiction, if we look to etymoloijyj 
since the word ''catarrh" denotes a flux or discharge; hot as this phrase has been used by 
the moderns, I shall employ it (in this place) to designate those inflammations of the bron- 
chia, which are attended with little or no expectoration. — Laennec, on the Chest; translated 
by Forbes; Part 1; Book 1; Chapter Ij Section 5. 



746 BRONCHITIS. 

more sickness by the combination of the whole, than if we gave only one of them. 
The efBcacy of a diuretic is jjenerally thought to be much increased by giving a 
small quantity of mercury. This is an old remark; and I believe it is a correct 
one. It is stated, that diuretics act more powerfully upon the kidneys, if we give 
a small quantity of mercury with them, than if the latter be omitted. 

Emetics. — Great relief is derived from the exhibition of emetics; and among the 
best is ipecacuanha. By giving antimony two or three times every day. we debi- 
litate the patient; and this is not a case for diminishing the strength. We only 
want to unload the air-tubes; but antimony is a very depressing agent; and if given 
every day for a fortnight or three weeks, it may produce great irritation of the 
mucous membrane of the stomach (gastrodynia); and therefore I think ipecacuanha 
is the best. Patients will bear, not merely fifteen or twenty grains, but thirty; and 
it is a safe medicine. I am told that if given in large quantities, it comes from the 
stomach, and produces no more effect than a small one. It is of great use to give 
an emetic every morning, or every other morning, and thus clear out the bronchia; 
it is an excellent remedy. "When acute bronchitis has lasted a considerable time, 
and we do not deem it proper to evacuate, emetics may be repeated more freely; 
— especially in the case of children. When the case is not very severe, a nau- 
seating dose of ipecacuanha, squills, and other things of that description, is very 
useful. Among the best expectorants are those which excite nausea. 

Do not Purge. — It is always necessary to attend to the bowels. If we do not, 
there is still more congestion; but it is very dangerous to purge briskly. In these 
cases the powers of the patient soon sink; and it is better to trust to emetics and 
diuretics. 

Blisters and Dry Cupping. — It is frequently of very great use to blister the 
chest; but the employment of tartar emetic ointment is rather a severe and cruel 
mode; and I have not seen that it is any better than an ordinary blister. Some 
persons are fond of *'dry cupping." There is no loss of blood in that operation; 
and yet there is a great determination of it from the inner parts. 

Narcotics. — Besides remedies of this description, it is frequently necessary to 
employ others of a soothing nature. Among the best is hyoscyamus, or conium; 
which may be given night and morning. There is no rule for the dose of these; 
but we may increase them to a much larger quantity than we begin with. I have 
seldom found stramonium of much use in lessening the cough. It is not to be 
compared with hyoscyamus, or conium, or opium. Opium is one of the best 
things; but, in many of these cases, there is a great disposition to heaviness of the 
head; and opium has the inconvenience of confining the bowels; so that though it 
is a good medicine in the form, of Dover's powder, yet it is not so good as hemlock 
or henbane. 

Inhalation of different Vapours. — We may soothe the air passages much, by 
making the patient inhale different vapours. Patients may inhale the steam of hot 
water; but one of the best modes is not to let them inhale the steam, but to have a 
vessel so contrived that the air they breathe comes through hot water. We cannot 
charge air with a dose of salts; but there are many things which may be taken up 
by the air, and which may be inspired in this way: we might make a solution of 
opium, or of extract of conium, and let the patient breathe through it. I have not 
much experience of it; but I have put hyoscyamus and conium into water, and 
have made the patients breathe it; and this has afforded great relief. Some persons 
have used prussic acid; and they say it has been productive of great relief. Chlorine 
may be introduced in this way; and I have seen it lessen the irritation. Some 
persons employ iodine; but it is right not to use more than one drop of the satu- 
rated solution of iodine. Some patients will bear three or four drops, but some 
will not bear more than one; and I have known some people wlio could not bear 
one drop, put into three quarters of a pint of water. It is right to begin with the 
smallest quantity; and never to increase it beyond what is borne without the least 
irritation. I had a patient in St. Thomas's Hospital, who laboured under chronic 
bronchitis; and who found great relief from breathing through tanner's liquid. 



BRONCHITIS. 747 

Without taking- any medicine, the tanner's liquid diminished his cough, and lie 
became much belter. People living in the neighbourhood of tanners' ])its, often 
find their respiration improved. 

Tonics. — Where there is no fulness of the chest, but the bronchitis resembles 
phthisis; — where the patient wastes away, and has a tiresome cough, tonics are of 
great advantage. Where there is a disposition lo dropsy, emetics and diureti(;s are 
proper; but where the patient is more or less hectic, and is spitting- up a great 
quantity, — a state which often occurs in young persons, — tonics are of great use; 
and iron is one of the best. In the first volume of the " Medico-Chirurgical Trans- 
actions,"* there is an interesting case of a lady, supposed to be in a consumption; 
but by means of three grains of sulphate of iron, taken twice a day, she got well. 
I have had cases of that description without end; — rwhere persons were supposed 
to be on the verge of phthisis; but where there was nothing but bronchitis. There 
were no signs of tubercles; but there was irritation of the mucous membrane; — 
producing constant tickling in the throat. 



SECTION IV.— EFFECTS OF CHRONIC BRONCHITIS. 

a. Dilatation of the Air-Tubes, 

When chronic bronchitis has existed for a length of time, it is very common for 
something more than congestion, and a thickening of the mucous membrane, to 
take place; it is very common for the bronchial tubes to become dilated. Some- 
times one, sometimes several branches, and occasionally the whole of the branches 
in one lung, will become so large, that those which naturally should admit only a 
fine probe, will have a canal equal to that of a common goose quill, or even suffi- 
cient to admit a finger; and perhaps these dilated branches are seen spreading to 
others, not nearly so large as themselves. This is the consequence, in some in- 
stances, of chronic bronchitis; but whether it is that the particular tubes become 
hypertrophied, so as to grow to this diameter, — groiv, in every sense of the word; 
or whether they become so distended with mucus, that they acquire this increased 
cavity, I cannot say. It is, however, by no means an uncommon occurrence. 

Varieties. — There are two or three varieties of this dilatation. Sometimes we 
see it throughout the tube; and it may occur in one tube or several; and, not un- 
frequently, the coats of the tube are hypertrophied and indurated at the same time. 
Secondly, the tubes are sometimes only enlarged in one spot; and then a mere 
cavity exists. It is occasionally so large, that it will contain a nut. In a third 
form, the dilatation will occur at intervals; so that there is a series of small enlarge- 
ments. The pulmonary texture, on being cut into, appears as if it were swollen 
with a number of small red tumours; and the whole become filled with a puriform 
secretion. In this last form, the coats are said to be always thin, — as though the 
dilatation had arisen merely from mucus; while, in the two first forms that I have 
mentioned, the coats are generally hypertrophied; and the dilatation appears to be 
the result of the hypertrophy. Hence it would appear, that this dilatation occurs 
sometimes from hypertrophy, and sometimes from a mere obstruction by mucus; 
and the result is that, in two forms of the disease, either the whole length or a part 
of the tube is dilated; — ^^just as is the case sometimes with the heart; while, in the 
third form, there is a series like a string of beads; and the coats are exceedingly 
thin; as though the change of form resulted, not from hypertrophy, — for then the 
parts would not be thinner, — but from simple distension. In cases of this descrip- 
tion some other symptoms arise. The disease is attended with great debility; and 
the patient is " broken-winded." 

Auscultatory Signs. — It may be supposed that such an alteration as this, will 
give rise to some alteration in the sound of the chest. This is a matter rather of 

• Page 13. The case is reported by Dr. Sianger. 



74S BRONCHITIS. 

curiosity and of pathology, than of practical importance; but still, if any disease 
produce any symptom whatever, it is right to know what that symptom is; — whe- 
ther it will turn to good account or not. We ought to make it a general rule to go 
straight forward, and make as accurate a diagnosis as possible, whether we can do 
good or not; because, if it be not of practical application to-day^ yet it may become 
so by-and'by. 

When small tubes are dilated, they approach nearer to the natural size of large 
tubes; and therefore, if there be any difference in the sound of respiration, in the 
sound of a cough, or in the sound of the voice, in the large branches, it ought to 
be the same when lubes become large ones;— and this is actually the case. 

If it so happen that certain tubes are dilated, we then hear, instead of the respira- 
tory murmur before mentioned,* a sound approaching to that of the bronchia, and 
even approaching to that of the trachea. Tliis is one of the chief signs of the 
bronchia being dilated. They may, as I have just said, be dilated to such an extent, 
as to sound very much like the trachea; but, in general, we have only bronchial 
respiration. 

If any of the bronchial tubes be very much dilated, so that small tubes attain 
the size of large ones, we have over the former just such a sound as we have over 
the latter in health. Bronchophony occurs at a part where it should not exist; and 
if the bronchial lube be dilated enormously, — nearly to the size of the trachea, so 
that it amounts to a cavity, — we have pectoriloquy; and pectoriloquy is neither 
more nor less than the same sound which we always hear, on applying the stetho- 
scope to the larynx. It must be a very extreme dilatation, however, to enable us 
to hear the voice come through the tube in this way. It is common to have 
bronchophony; but to have pectoriloquy, is a rare thing. Indeed, there must be 
a larger dilatation than I ever met with. Such a dilatation occurs from time to 
time; but it is so rare that I never met with it. There are drawings of it; and 
there is no doubt as to the existence of the fact. In dilatation of the bronchial 
tubes, therefore, there is bronchial respiration and bronchophony; and if the dila- 
tation be very great, there is tracheal respiration, and a tracheal voice. Of course, 
the nearer the tube is to the surface, the more clear are these sounds. 

b. Diminution of the Air-Tubes. 

Chronic bronchitis, however, will sometimes induce the very opposite state. 
Instead of causing the tubes to become dilated, it may cause their coats to become 
thicker; and the canal will tlius be diminished. 

From Effused Lymph. — Sometimes there is lymph effused within; so that the 
tubes are completely obstructed. When lymph has been effused within, and the 
tube has been obliterated for the time, it has been called " a bronchial polypus.'''' 
It is nothing more than the same occurrence that takes place in croup; — that is to 
say, lymph is effused; only not in a tubular form. I once knew a case of gonor- 
rhoea, which filled the urethra with lymph; which lymph was discharged in a 
tubular form. Where the bronchia have been obstructed by lymph, it has been an 
instance of chronic inflammation; — at any rate, not of acute inflammation. In old 
books, it is said, that nobody could imagine what was the matter with the patient; 
and that then such a' mass as this has been spit up. In cases of this kind, it is 
easy to say what would be the auricular symptoms: at the obstructed part there 
would be no sound of respiration; and as soon as the lymph was spit up, there 
would be the murmur again. 

Contraction of the Sides of the Tube. — But without such a cause of obstruction 
as this, the tubes are sometimes blocked up. The cavity is obliterated by the sides 
becoming thickened and contracted; and then, of course, no respiration is heard at 
the part; and this want of respiratory murmur is permanent. In the case of acute 
bronchitis, it will cease (from a temporary obstruction of the tube) for a few hours; 

« See Page 801. 



BRONCHITIS. 749 

but congliing removes the obstruction, and we hear the sound of respiration again; 
but when the obstruction arises from a contraction of the tubes, the want of respi- 
ration is permanent. 

c. Dilatation of the Mr- Cell 3. 

Improperly termed Emphysema. — Chronic bronchitis produces a farther change, 
precisely of the nature of dilatation, of which I have already spoken. The minute 
tubes of the bronchia terminate in the air-cells; and it occasionally happens that 
the air-cells are dilated by this disease. This has been called ''''emphysema of the 
lungs;" but I think it an improper expression; because by " emphysema''^ we 
mean the presence of air in the cellular membrane, where there ought to be no air. 
Now in this case there is no air m the cellular membrane, — no air in any place but 
where it ought to be; only the part which contains the air is too large, — contains 
too much. 

^^ppearance of the Cells. — These dilated air-cells attain, in general, only the 
size of millet-seeds; but here and there one may be seen the size of a hemp-seed, 
and even as large as a cherry-stone. When they are the size of cherry-stones, it 
is very probable that many cells are dilated into one common cavity. I should 
think this was the cause. At the termination of each twig of the bronchia, where 
it is as fine as a hair, the air-cells are situated all along it, — ^just like grapes upon a 
stalk; I think it probable, therefore, that when a bronchial twig is dilated to a great 
size, the air-cells which separate from it, are dilated into one. Occasionally, those 
of the greatest magnitude actually project on the surface of the lung; and' are so 
prominent as to present a large globular form externally. Sometimes they are as 
large as a walnut, and even larger. There is a preparation at St. Thomas's Hos- 
pital, where there is a tumour of this description on the surface of the lung. In 
extreme cases of this kind, the edges of the lung are quite translucent, and stand- 
ing awav from the body of the lung. 

Occasionally attended by Emphysema. — If the quantity of air be very considerable, 
the sides of the cells may crack; and then a com.munication is established between 
them and the cellular membrane; so that true emphysema is superadded. In that 
case, the tumour upon the surface of the lung may attain a very great size; and the 
air may, by pressure, be forced about. But notwithstanding that the cells occa- 
sionally crack, and that air escapes into the cellular membrane of the lung, still it 
is found, that it does not move about very extensively; — not so extensively as it 
does in other parts of the body. 

General Appearance of the Lung. — If lungs with dilated air-cells be inflated 
and then dried, (which, I imagine, is the best way of preserving them,) the dilata- 
tion of particular air-cells will be seen, on cutting into them, to be more considera- 
ble than appeared externally. When the dilatation is considerable, and at the 
same time so extensive as to occupy the whole lung, we find, on opening the chest, 
that instead of collapsing, the lung rebounds, and projects beyond the chest. A 
lung thus aflected, necessarily sinks less in water than a healthy lung; and, on 
being handled, does not crepitate in the usual way, but gives such a sound as 
would arise from the slow escape of air; and we cannot empty it so readily as a 
healthy lung. The tissue of the lung is drier than in health; and even the roots of 
the lungs have not the usual infiltration found in that part. The lungs resemble 
those of a reptile, more than those of a man. The lung of a frog has a large re- 
ceptacle for air, — not the minute cells that we have; and on opening the animal, 
the lung escapes the boundary of the chest. When only one lung is thus affected, 
it has been seen to become so much more bulky than the other, as lo push aside 
the mediastinum, if on the left side, and to produce an enlargement of the heart, if 
on the right side. 

Best described by Laenne.c. — Laennec has described this condition of the lungs 
far more accurately, and far more minutely, than any of his predecessors; but (as 
may be seen from his engravings) it was well known to Dr. Baillie. Dr. Baillie 



750 BRONCHITIS. 

speaks of an enlargement of the air-cells, causing the lungs to resemhle those of 
amphibious animals/ He considers it probable that two or three cells may be 
broken into one;'' and therefore, although Laennec has the credit of having first 
described it, it is right that we should give Dr. Baillie his due. Dr. Baillie also 
remarks, that Sir John Floyer distinctly describes the disease, as seen by him in a 
mare; and he considers the remark as applicable to the human subject. "The 
bladders," says Sir John Floyer, " are either broken, and admit the air into the 
membranous interstices, or else they are over-distended; like a hernia in the peri- 
tonseum. This will produce an inflation of the whole substance of the lungs; and 
that a continual compression of the air and blood-vessels, which will produce a 
constant asthma." He was aware of this dilated condition of the air-cells; and he 
describes asthma as occasionally caused by this over-distension. 

Causes. — The causes of this over-distension, and rupture of the coats of the air- 
cells, may be a violent inspiration and retention of the breath; — such as occurs in 
blowing a wind-instrument. It may be from a mere debility of structure, — a loss 
of elasticity; but the most common cause is the want of a due expansion of the 
lungs. Whatever prevents any one part of the lungs from expanding, when the 
thorax expands; — v/hether it be a material obstruction of the bronchial ramifica- 
tions; or a com|)ression of them; or whatever else; — it will occasion those parts 
which remain dilatable, to keep dilated in a corresponding increased degree, in 
order to fill up the vacuum which the expansion of the chest occasions. When we 
inspire, we dilate the chest; and the air rushes down the trachea, and the lungs 
follow the dilated portions. If there be any part ihat will not dilate, then (I pre- 
sume) other parts are over-dilated, to fill up tlie vacuum; and, in that way, those 
parts which we distend are over-ilhiended, in order to compensate for the want of 
distension in other parts; and when once over-distended, they are often unable to 
recover themselves; just as is the case in other parts of the body; — the urinary 
bladder, for instance. I presume it is on this account, that dilatation of the air- 
cells is so common in persons labouring under chronic bronchitis; — especially 
where the membrane is most thickened; and where the secretion, if there be any, 
is tough and adherent, so as to produce obstruction. Such, at least, is the expla- 
nation wJiich presents itself to my mind. 

Laennec, however, gives a different explanation. He supposes that the air 
which passes through the imperfectly obstructed tubes, in chronic bronchitis, can- 
not easily escape again; but there it remains, imprisoned in the air-cells, by a 
mechanism somewhat similar to the mechanism of the valves of an air-gun; and 
the succeeding inspiration introduces a fresh supply; so that the accumulation is 
very great. I cannot refute this explanation; but the occurrence of the facts upon 
which I ground my explanation, is indisputable; and Laennec, to prove his opinion 
right, should have shown that the dilated air-cells are those belonging to the tubes 
in which obstruction exists. That he has not done; and I conceive they are not 
those in which there is obstruction. 

Auscultatory Signs. — The existence of this state of the lungs, — morbid dilata- 
tion of the air-cells, — cannot be known without the use of the ear. Dr. Baillie, of 
course, knew nothing of auscultation. It was not known or practised till after his 
time. But he says, with great truth, — " When the cells of the lungs are much 
enlarged in their size, persons have been remarked to be long subject to difficulty 
of breathing, more especially on motion of the body; but I believe no symptom is 
at present known, by which this disease may be discriminated from others incident 
to the chest."" The dyspnoea does not differ from the same symptom in other 
circumstances. It frequently occurs in paroxysms; and will continue for many 
years. But the pathognomonic signs are obtained from percussion and ausculta- 
tion; — not from either alone, but from the union of the two; for if, when the air- 
cells are greatly dilated, we strike that part of the chest, a sound is heard exactly 

» " Morbid Anatomy;" Chapter 4; Section 7. 

•> " Morbid Anatomy;" Chapter 4; Section " Symptoms." 



I 



PNEUMONIA. 751 

as in health, and perhaps even clearer; for, owing to there being but little pulmo- 
nary substance there, we have a sound more iiollow than even in health. This is 
the first thing whicli we must expect. Then, by listening to respiration at the 
part, there is very little murmur audible. Instead of a number of minute cells, with 
air rusding in them, there are only two or three cells largely dilated; and therefore 
the air c^mnot rustle as before; so that we hear very litde of the respiratory mur- 
mur. The air which is there, scarcely leaves the air-cells; — scarcely passes to and 
fro. The part is not expanded; and the consequence is, that there is very litUe 
motion of the air. But it is to be remembered, that we do hear some respiratory 
murmur; and this is the distinction between the presence of air in the pleura, and 
the presence of air in merely dilated air-cells. If air exist in the pleura, there it 
remains; and we have more sound than usual; but, on listening, there is no respi- 
ratory murmur; for the air is in a state of stagnation. In the case of dilated cells, 
however, there is a little air driven out, and a little drawn back again; and there- 
fore there is a trifling respiratory murmur. In the one case there is none; but in 
the other there is some. 

It is said that when this afiection is extensive, there is another pathognomonic 
sign; the inspiration is made with a crackling sound; — as if the air were entering, 
and distending lungs which had been dried, and the cells of which had been uni- 
versally dilated. The lungs are drier in this state than in health; and when the 
case is very severe, the inspirations are attended with the sound I have just de- 
scribed; — a sound similar to that produced by blowing into a dry bladder. This 
has been termed by Laennec "dry crepitous ratUe, with large bubbles." It is an 
odd appellation; but it conveys the idea of dryness, and is therefore a "dry crepi- 
tous rattle;" and it gives us the idea of the bursting of bubbles, on the surface of 
fluid; and therefore Laennec says — "with large bubbles." These are extreme 
casfes. I never witnessed one of them. If we reflect a moment, there is no diffi- 
culty in remembering this. When the tubes are dilated, they approach to tlie size 
of the bronchia; and the sound must, therefore, be the same in the former as in the 
latter; and if the air-cells be dilated, it stands to reason that we cannot have the 
same minute murmur, that we have when the air is passing into a thousand minute 
cells. It is also evident that we shall have a clear sound there, — ^just as in health; 
because there is air there, as before; and if the dilatation be very considerable, we 
have a clearer sound than before; because there is little else there but air; — little 
pulmonary substance. 

Treatment. — Nothing can be done, either for bronchial tubes or for air-cells that 
have fallen into this dilated state. The treatment will not vary from that proper 
for chronic bronchitis. We must treat the case on general principles. 



CHAPTER VL 
PNEUMONIA. 



Having concluded the subject of inflammation of the a\r-titbes, I shall now pro- 
ceed to inflammation of the a\v-cells. A large number of cases of inflammation of 
the lungs, are considered to be inflammation of tiie substance of that organ; but they 
are in fact nothing more than bronchitis. In by far the greater number of instances, 
it is not inflammation either of the air-cells, or of the cellular membrane; but in- 
flammation of the bronchial tubes. Occasionally, however, we have inflammation 
(as it would appe;ir) of the air-cells themselves. This, properly speakiuir, is "peri- 
pneumonia."^ The term ''pneumonia''''^ is the name given to any inilammation 

* From 77«5t, about; and mivfxooVj the lung. b From mivfjutsv, the lung. 



752 PNEinvIONTA. 

of the heart and pericardium;^ but the word ^'peripneumonia''' is more properly- 
applied to inflaiiimatioii either of the air-cells, or of the cellular membrane around 
them; — whichever it may be.** For myself, I have no doubt that the inflammation 
is seated in the air-ceils themselves; and it is in this point of view I shall now 
speak of it. 

General Symptoms. — The common, well-known symptoms of this disease, — 
those which are discernible without the aid of the ear, — are very much like those 
of bronchitis. There is pyrexia, general feverishness, rapidity of respiration, shal- 
lowness of respiration, cough, and expectoration. In bronchitis, I mentioned that 
there is a sense of constriction in the front of the chest; and a soreness (sometimes 
pretty considerable) in coughing;" whereas in peripneumonia, if there be any thing, 
there is rather a deep-seated dull pain. This is sometimes co!ifined to one spot; 
though, for the most part, this dull uneasiness is pretty much diffused; and, indeed, 
is frequently so very slight, that a diagnosis cannot be universally made from it. 
Then the dyspnoea, if people lie still, is by many persons scarcely complained of, 
any more than it is in bronchitis. Some persons, labouring under bronchitis, will 
not allow that they have difficulty of breathing; neither will they in peripneumo- 
nia. Just as in bronchitis, there is frequently violent cough; but sometimes there 
is scarcely any;'' — the cough is infrequent and soft. 

Character of the Sputa. — There is, however, according to Laennec, a decided 
difference with regard to the expectoration. He considers that the expectoration, 
in peripneumonia, is a pathognomonic distinction; and points out the nature of the 
disease. He says that when, in this disease, the sputa are received into a flat and 
open vessel, they unite into so viscid and tenacious a mass, that we may turn the 
vessel upside down, even when full, without the sputa being detached; for, although 
they may partially hang from the vessel's mouih, the great bulk still sticks to the 
vessel. Their tenacity is such, he says, that they vibrate like so much jelly; and 
the tenacity prevents the air-bubbles from breaking, though they are very numerous 
in this kind of sputa, and sometimes very large. The air does not escape, but 
forms bubbles; and for the most part, be they small or large, they remain. I can- 
not confirm or disprove Laennec's assertion, from my own observations; but I think 
all will allow that we must look beyond the sputa, as well as beyond the general 
symptoms, for an accurate diagnosis of this disease. For Laennec allows that the 
sputa are frequently not so viscid; he allows that, frequently, they are of some 
shade of red or green; though for the most part tliey are but little coloured; and he 
allows that, frequently, they are almost destitute of air-bubbles, — frequently a mass 
of mere mucus or pituitous secretion, with a few glutinous, and slightly tawny 
portions. I cannot but think, therefore, as he allows all this, that we ought not 
at all to depend upon the sputa for a diagnosis. Indeed, when the characteristic 
sputa do occur, as they continually do, it is very often only at the onset of the 
disease, — only for a few hours; and sometimes even then only in so small a quantity, 
as scarcely to admit of being collected. 

Morbid Appearances. — The pathognomonic signs of this disease, are acquirable 
by the ear only; but before considering them, it will be necessary to trace the 
appearances in the lungs after death, and the succession of the changes. This is an 
opposite course to what we usually adopt. Generally we speak of post-mortem 
appearances after we have done with the symptoms; but here it is necessary to 
reverse the order; for the symptoms are in accordance with the unnatural changes. 

First Stage. — In the^rs^ stage of inflammation of the air-cells, the lung merely 
suffers an accumulation of blood; so that it becomes more solid and heavier than 
usual. It looks livid externally, and retains the impression of the fingers; — like 
an oedematous limb. On cutting into it, it is found to be of a deep blood-colour, 
and replete with frothy, bloody fluid; but still the lung is spongy: — still it crackles 
under the fingers. This is a stage in which, after death, we find nothing but an 

• The word is not now used in that sense; and the term " peripneumonia^' is very much out 
of fashion. 

" See Pages 737 and 742. « See Page 737. 



PNEUMONIA. 753 

accumulation of blood and serum. As the lung crackles after death, — as it contains 
air to the very last, we expect to hear the murmur of respiration in these particular 
parts during life; and that is the case; and as air is admitted, we expect to hear, on 
percussion, the usual hollow sound of the chest; and that likewise is the case. But 
the murmur which is heard when the inflammation has only reached the first stage, 
in (hat particular part, is accompanied (even from the very first moment of the 
attack) with a crackling sound. We have not the ordinary murmur of respiration; 
but it takes place with a crepitous rattle, as it is called; or, if we please, a crepi- 
tous respiration. It gives the idea of numerous minute, and almost dry bubbles; 
and this dry crackling is heard the more decidedly, the nearer the inflammatory spot 
seems to be to the surface; and those who have employed their ears frequently, 
can from practice tell the exact depth of the inflammation, from the loudness of the 
crackling. The nearer the disease is to the surface, the louder is the crackling. 

Second Stage. — When the inflammation has become more intense (so as to 
constitute the second stage), the lungs are heavy; and ihey become so firm as to 
resemble liver; and on this account the term ''hepatization''^ has been applied to 
this state; but, in my opinion, very absurdly. The lungs are not changed into 
liver. If they were, it would be "hepatization;" but if they only remain as solid 
as liver, — something like liver, it is an improper word. By ''ossification,^^ we 
mean an absolute conversion into bone; and by "hepatization'''' we ought to mean 
a conversion into liver. If a thing is to be named in this way, because it is only 
like another, strange words might be applied to every thing. Andral proposes 
another iexm,— "solidification;'^ which I think better. If the lungs have become 
solid, "solidification" is a correct term. In this state, where the lung has become 
solidified, it will not crackle under the finger; — it has evidently become impervious 
to the air. If we cut it, squeeze it, and scrape it, very little fluid escapes; and what 
does escape, is not frothy; neither is it so thin as that which escapes in the first 
stage. I presume that, in these cases, there is more or less fibrin effused or depo- 
sited; and that is the explanation of the solidity; — the want of air, and the want 
of frothy fluid. When the lung has fallen into this condition, we may presume 
what the symptoms are. On striking that part of the chest where the lung has 
become solid, of course we cannot have a hollow sound. There is no air there, as 
there usually is. There is no room for it; but there is a solid mass; and, on striking 
over it, we have the same dead sound as if we struck over the liver. On listening 
to the part, as it contains no air, of course there is no respiratory murmur; and, 
there being no murmur, there is no respiration; so that we cannot hear the crepi- 
tous ratfle. In \\\q first stage we have crepitous rattle, because there is a thin fluid 
in the air-cells; but here there is no thin fluid in the cells; — they are all solidified; 
and therefore there is no crepitous respiration. If, however, the part happen to be 
situated near a large bronchial tube, we hear the patient's voice there; — on account 
of solids being better conductors of sound, than aeriform bodies. 

Third Stage. — Before death, however, a still further change will take place. 
Inflammation of the lungs tends to suppuration; and, at an advanced period, a 
third stage occurs. But there is a peculiarity in suppuration of the lungs; — the 
pus is diffused, and not collected into an abscess. After the second stage, when 
the third begins, the lung is as hard as before; but it becomes yellowish, or of a 
straw-colour. When the pus is first formed, in small quantity, there is quite sufli- 
cient to change the colour of the lung; but after a litde time the pus is more abun- 
dant, the lung becomes soft, and will yield to the point of the finger. In this 
stage, just as in the second, there is no hollow sound on striking the chest; neither 
is there any respiratory murmur; but a loud mucous rattle; — that rattle which we 
may have an idea of, by recollecting the sound occasioned by air passing through 
soap-suds. Tiie mucous ratde is heard in the bronchia; either from some of the 
pus going into them, or a secretion from their own membranes. 

Mscess of the Lung. — Should an abscess be formed, however, — should the pus 
be collected into a mass, a characteristic symptom will be heard; such as I shall 
mention under the head of "phthisis." But such an occurrence is extremely rare. 
VOL. I. — 48 



754 PNEUMONIA. 

I do not recollect above twice seeing an abscess in the lungs, great or small, result- 
ing from inflammation; and when I did see abscesses, ihey were small and fu!l; 
and just as likely to be the result of a few distinct tubercles, which had existed in the 
lungs previously to the inflammation, as of inflammation itself. Some persons will 
have an old tubercle or two formed in the lungs, without inflammation. That is 
what we see continually. These tubercles may suppurate, and an abscess be 
formed: and if the lung fall into a state of inflammation, the solitary abscess may 
be ascribed to inflammation. When abscesses do occur in the lung, I am satisfied 
that Laennec is right in asserting, that they are almost always occasioned by the 
softening of tubercular deposition, — the softening of scrofulous deposit. "Among 
several hundred dissections of peripneumonic subjects," says Laennec, "I have 
not met with a collection of pus in an inflamed lung, more than five or six times. 
These were not of large extent; nor were they numerous in the same lung." 
Even Broussais, to whom liaennec was in many points indebted, declares that he 
never saw ulceration in the lungs, without tubercles, more than once; and then the 
inflammation resulted from a musket-ball, which was tantamount to a tubercle. 
The reason assigned by Laennec for the rarity of an abscess in the lungs is, that 
the disease is either cured by art, or destroys life before it proceeds to the length 
of destroying the pulmonary tissue; — that death takes place before the disease ad- 
vances so far, as for matter to be formed in the lung, in the form of an abscess. 

Those cases of inflammation of the lungs which end in the existence of abscess, 
are marked by the same auscultatory phenomena, as occur when there is a phthisical 
excavation. We hear the sound come through the tube; and when the patient breathes, 
there is the sound of a cavity; and there is a metallic tinkling; — as if a bell were struck 
^vith the point of a pin, or something very fine. 

Its Progress. — This disease is frequently fatal when it is not of great extent; and 
when it has not passed the first of the three stages to which I have alluded. The 
first and second of these stages, are frequently seen in different parts of the same 
lung; and so may even the third stage. We observe one stage going into another. 

Usual Seat of the Disease. — It is very remarkable that, in the greater number 
of instances, the inflammation commences at the lower part of the organ; and it 
may not extend higher. Consequently, when the disease has advanced, it is in 
the lower part of the lung that the second or third stage is generally found; while 
higher up, the disease may be only in the first stage, or entirely absent. The rigl\t 
lung, it has been asserted, is more frequently affected than the left. Of that I can- 
not speak; but 1 can speak to the fact of inflammation beginning at the lower part 
of the organ, in an infinitely greater number of instatjces than higher up. There 
can be no doubt that the membrane of the air-cells, and not the surrounding cellular 
tissue, is the seat of the disease. In the second stage of the disease, — when the 
lung is solidified, but still red, — if the structure be cut or torn, instead of the natural 
appearance of the cells, the inflamed part has minute granules, round or oval; — cor- 
responding exactly with the appearance which the air-cells would give, if filled with 
a tenacious fluid, and solidified. Indeed, Louis found that, by forcing fluid into the 
bronchia, the same granular appearance might be produced by art; and therefore this 
granular appearance clearly arises from the air-cells being filled with the same tena- 
cious fluid. The crepitous or crackling rattle also, I think, shows the same thing; 
for it is heard in another afl'ection, in which this thick fluid evidently exists in the 
air-cells. In haemoptysis, when bleeding takes place in the air-cells, the same 
sound is heard as in peripneumonia. In haemoptysis, this must arise from little 
bubbles snapping and cracking through this fluid; and as precisely the same sound 
is heard in peripneumonia, I think it is a strong argument to prove that the air-cells 
are affected by the disease; more especially when we see that a certain peculiar fluid 
is spit up in the affection. 

Progress of Amendment. — If, by art, the disease be remedied,— if the inflam- 
mation yield, of course the lung goes through the same stages as before, but in- 
versely. The third stage comes to the second, and the second to the first; and it is 
found that the signs audibly noticed by the ear, go through the very same inverted 



PNEUMONIA. 755 

course. The auscultatory phenomena heard in the second stage disappear: and 
those which occurred in the first stage are heard again. Nothing is more inieresiing, 
certainly, than to trace the reversed order of the changes here. Suppose the disease 
has only gone into the first stage, we hear the hollow sound on striking as in healiii; 
and, on listening, we hear a crepitous rattle, and even a crackling. But while the 
patient is being cured, the crepitous rattle declines; — it becomes fainter and fainter 
every day; and, instead of that, we have tlie natural murmur of respiration more 
and more distinct. Suppose the second stage has been reached, and we are suc- 
cessful; — in that case the want of a hollow sound, on striking the chest, gives way; 
and we hear, by degrees, a little hollovvness of sound, which increases more and 
more every day; till that side of the chest sounds as hollow as the other. The 
respiration had ceased from the lungs having become solid; but we hear a little 
crepitous rattle, increasing every day, till it is heard as distincUy as in the first 
stage; and then, having arrived at the first stage, the disease passes through that 
entirely. The crepitous rattle declines; and the natural respiratory murmur be- 
comes more and more distinct. I mentioned that, in the third stage, we still have 
no hollow sound; but we have a mucous rattle, generally from the entrance of pus 
into the bronchial tubes.* This declines by degrees, if the patient get better; and 
then we gradually hear a crepitous rattle, from the cells losing a part of their viscid 
contents; so that they again admit a portion of air. The chest then regains its hol- 
low sound on striking; and, at last, the crepitous rattle declines. 

Anatomical examination shows the changes of the part to be precisely corre- 
spondent with these auscultatory phenomena. When the first stage is recovered 
from, the lung is found to grow less red, — less turgid. Supposing the patient dies 
from intense inflammation of one part of the lungs, there is a lower degree in an- 
other part; and we find that is only in the first stage; but we are still able to make 
our observations there. Perhaps we have cured the inflammation at that one spot; 
respiration is heard there more and more; while in another part it is heard less and 
less. But the patient dies; and, by examining different parts of the lungs after 
death, and having listened to them through life, we are able to trace the changes. 

Whe.n the inflammation of the third stage is being recovered from, the lungs 
become less turgid; and when the second stage is being recovered from, and the 
lung is going back to the first, the colour also becomes less intense; the texture 
becomes softer; the weight decreases; the organ, on comparison, affords more fluid; 
and the fluid becomes more and more of a frothy character. In the second stage, 
as I mentioned,'' there is a considerable granular appearance; which declines in the 
third, and the vesicular character of the lung returns. When the third stage is 
recovered from, the yellow colour becomes lighter and lighter; the pus becomes 
more aqueous, less thick, and at length frothy; the accumulations of pus are re- 
duced to mere specks; the vesicular appearance returns; the lung crepitates, and at 
lenirth grows natural; and the litde serous infiltraiion that existed is absorbed. 

Importance of the Auscultatory Signs. — Notwithstanding that cases of peri- 
pneumonia are every day recognized, and the amendment or exasperation of the 
disease ascertained, by practitioners who never employ their ears (as though nature 
had given us ears to be used on every occasion, except when we are practising our 
profession); yet the observation of the auscultatory signs, in the three stages of 
peripneumonia, is sometimes more than a philosophical observation, — more than an 
intellectual gratification. Many cases of inflammation of the lungs, I know, have 
been overlooked in the midst of other diseases; or have been totally mistaken. It 
is vain for those who obstinately refuse to avail themselves of the means given us 
by nature (in the sense of hearing) for learning the phenomena of disease, — it is 
vain for them to assert, that they can form an accurate diagnosis on all occasions; 
for these persons are perpetually lamenting, that medical evidence is uncertain; 
and, to my certain knowledge, they do frequently mistake diseases of the lungs 
for diseases of the heart, and diseases of the heart for diseases of the lungs. In 

• See Page 753. * See Page 754. 



756 PNEUMONIA. 

the affection before ns (peripneumonia), if it suddenly supervene during a clironic 
affection of the chest, they continually ascribe the symptoms to effusion, to pleu- 
ritis, to dropsy of the chest, or to sometliing- else; — having no idea whatever of the 
real disease. In phthisis, an aggravation of the dyspnoea, unattended by pain, is 
very common; and is ascribed to effusion into the chest, or the bronchia, or the 
substance of the lungs; and, in chronic bronchitis, such an ag-gravation is ascribed 
to an attack of spasmodic asthma; when the simple trouble of listening to the lungs 
M'ould show crepitous rattle, and prove that the difficulty of breathing arises from 
the presence of peripneumonia. In various fevers (eruptive and simple), in simple 
dyspnoea (without pain), during an attack of rheumatism or of gout, 'peripneumo- 
nia is continually overlooked; and some surgeons have stated, that after severe 
wounds and operations, peripneumonia will occur in the most insidious manner; 
and will not be discovered till all possibility of remedy is over. Surgeons have 
lost patients under operations, after having suffered severe accidents, without know- 
ing why; and, after death, they have discovered that the lungs were inflamed. 
This is a fact that is mentioned in many surgical books. All this mischief will be 
prevented by examining the chest with the ear, in every instance of dyspnoea 
whatever; — where there may be no pectoral symptoms at all; — no signs of any 
morbid affection of the chest; but where pectoral complaints are likely to super- 
vene. This may be avoided by examining the chest, from time to time; — exactly 
as we feel it to be our duty, on other occasions, to ascertain not only the state of 
affected parts, but the state of the head, and of the abdomen. 

Causes. — The causes of this disease are those of any other inflammation. I 
did not mention the causes of bronchitis; because in both diseases they are the 
same. Cold is a common cause; and so are vicissitudes of temperature; — cold and 
heat, applied in the way which I mentioned when speaking of inflammation.^ — 
Both bronchitis and peripneumonia supervene on the other affections of the chest. 
Nothing is more common, than to see bronchitis and peripneumonia united with 
diseases of the heart and pericardium; and so nothing is more common, in diseases 
of the lungs, than to see these affections. In phthisis we have bronchitis (acute 
and chronic) and peripneumonia; and so in every other disease of the chest. In- 
flammation is frequently idiopathic, — arising from a common cause; but sometimes 
it is symptomatic; — being the mere result of another disease in the neighbourhood. 

Treatment. — On the treatment of the disease, I shall not dwell. It is only the treat- 
ment of any inflammation. Patients have sometimes borne the loss of an immense 
quantity of blood: — perhaps more in this disease than in most others. It is in this 
affection that those enormous bleedings, which I mentioned when speaking of in- 
flammation in general,*" but of which I have no experience, are reported to have 
taken place; — a few gallons in the course of a few days. Mercury is of the same 
use in this affection as in bronchitis; and in bronchitis as in other inflammatory 
diseases. 

\\n cases of ordinary acute pneumonia in the adult, the inflammation occupies a 
continuous portion of one or more lobes, and hence is called lobar^ to distinguish 
it from that variety in which the inflammation attacks isolated lobules; thus giving 
rise to the formation of a number of hardened masses, separated from one another 
by healthy tissue. This latter is called lobular pneumonia, the diseased portions 
presenting the same changes in colour, density, (fee, as in lobar pneumonia, to 
which latter the description in the text is chiefly applicable. 

Usually, pneumonia is confined to one lung, and even here it is rare to find the 
whole lung aflfected. Most commonly it is limited to a part of the organ, and 
especially to one of the lobes; the interlobular fissures' thus often forming the 
boundary line between the healthy and diseased portions. The right lung also is 
more frequendy aflfected than the left, in the proportion according to Grisolle of 7 
to 4. This difl'erence in favour of the right lung is observed at all periods of life. 
The satne remark does not hold good of double pneumonia, which although rare in 

• See Page 113. * See Page 133. 



PNEUMONIA. 757 

adults, is much more frequent in children. In lobular pneumonia indeed, which 
is especially met with in cliiltlren between the ages of two and six years, bot'l:i 
lungs are almost always attacked. 

As regards the portion of lung most likely to be affected, it seems now pretty 
well established that the base is more frequently the seat of the disease than the 
summit; but the same preponderance in favour of the lower lobe does not seem to 
obtain, in advanced life or in new-born infants. 

Symptoms, — In his account of the symptoms. Dr. EUiotson appears to attach 
too little importance to the sputa, as a diagnostic feature. The viscid rust-coloured 
sputa in question, are, it is true, not always present, but still very generally so 
during the tirst stage of the disease, and at the same time their aspect is so pecu- 
liar as to render them perfectly characteristic of the affection. It should also be 
mentioned in speaking of the physical sions, that in the second stage of the dis- 
ease, or that of hepatization, not only is the percussion flat and the vesicular mur- 
mur absent, but the latter is replaced by a bronchial respiration, which seems to be 
produced by the passage of the air along the trachea and large bronchia, the sound 
of which is transmitted to the ear through the solidified pulmonary tissue. 

The duration of acute pneumonia is very various. It rarely runs its course in 
less than a week, or extends beyond three. In favourable cases, resolution rarely 
takes place until after the disease has passed to its second stage. When it has 
arrived at its third stage, or that of purulent infiltration, recoveries are not frequent. 

The resolution of this disease is perhaps more frequently accompanied, than in 
the case of any other inflammation, by phenomena which may be considered cri- 
tical. Of these, more or less profuse perspiration and urinary deposits are the most 
frequent; the latter being sometimes spontaneous, and at others taking place only 
by the addition of nitric acid, or under the influence of heat. Diarrhoea, bloody 
urine, herpetic eruptions about the mouth, boils, parotids, &c., have also been met 
with. 

The varieties of pneumonia are very great. Thus while at one time it is marked 
by the most highly inflammatory symptoms, at others it is characterized by typhoid 
phenomena, or by the presence of bilious symptoms, such as yellowness of the 
skin, of the sputa and other excretions. The extent of the disease, whether 
occupying one or both lungs, its form, whether lobar or lobular, the age of the 
patient, and other circumstances, give rise to important modifications. 

It has been already observed that lobular pneumonia is especially met with in 
children. Indeed this is the form usually met with in those who are not over six 
or seven years of age. It is commonly ushered in by catarrhal symptoms, during 
which the respiration is but litde accelerated, and often unaccompanied by any 
evidence of pain, and the fever slight. Auscultation discovers only such pheno- 
mena as belong to bronchitis, i. e. sonorous or mucous rhonchi. After a time the 
pulse and respiration become suddenly accelerated, the skin hot, with oppression, 
restlessness, dilated nostrils, and anxiety of countenance. Still, auscultation may 
discover nothing but a sub-crepitant rattle, and no appreciable dulness may be 
elicited by percussion. It is only in the more advanced stages that we have bron- 
chial respiration and decidedly dull percussion, and even these phenomena are 
usually less marked than in the lobar pneumonia of adults. The pneumonia of 
children differs from the latter, not only in its symptoms, but in the circumstances 
of its origin. It rarely attacks a child previously in perfect health; but is most 
commonly the consequence of some other affection on which it supervenes, as 
measles, whooping-cough, &;c. 

In old people the symptoms of inflammation of the lung are often very obscure, 
at the same time that the danger is much greater than in the middle period of life. 

The same obscurity often attends the inflammations of the lung which come on 
in the course of other diseases. When supervening in the course of severe acute 
febrile diseases, especially of a low grade, the access of pneumonia may be marked 
merely by a sudden increase of fever and prostration, and its symptoms are often 
masked by those of the principal affection. By the careful eniployment, however, 



758 PNEUMONIA. 

of auscultation and percussion, we may generally succeed in arriving at a satisfac- 
tory conclusion, where an aggravation of the symptoms has already led us lo sus- 
pect that some fresh disorder has supervened upon the previous affection. 

Causes, — As already observed, pneumonia is often a secondary affection, and 
here a variety of circumstances, different in different cases, may concur in pro- 
ducing it. When it comes on in the last stage of low fevers, or other diseases in 
"which the system is greatly prostrated, its production is much favoured by the 
tendency to congestion in the most depending portions of the lungs, when the 
patient remains for a length of time in the horizontal position. When it super- 
venes upon tuberculous disease, the presence of these bodies must at least be a 
strongly predisposing cause. The same is true of organic affections of the heart 
and other diseases, which have a tendency to produce irritation and congestion of 
the pulmonary tissue. 

The principal cause, however, of idiopathic pneumonia, is cold. Although met 
with in all climates, it is especially rife in cold regions, whilst between the tropics, 
it is least prevalent; and even then, it is more frequent in those sections which are 
subject to brisk variations of temperature, than where the latter is more uniform. 
It is most frequent, too, during the winter and spring, and diminishes rapidly as 
summer advances. The individuals most likely to be attacked, are those most 
exposed to atmosplieric vicissitudes, as well as to those circumstances calculated 
to favour their influence, such as fatigue and privations. The greater prevalence 
of the disease amongst men, is probably mainly owing to this circumstance, that 
they are much more exposed to these causes than women. Finally, wherever a 
patient is able to trace his attack to any particular circumstance, this is found, in 
the great majority of instances, to be cold, such as exposure to a draft of air, a 
check of perspiration, or the like. Occasionally, however, it is traced to violent 
exertion of the lungs, the inhalation of irritating vapours, &c. 

Treatment. — The treatment, as Dr. Elliotson remarks, is that of inflammation 
in general. Still, however, it may be well to notice some points more particularly. 

The loss of blood has always been the great resource in the treatment of this 
disease. Not only does it lessen the inflammatory action, but it diminishes the 
amount of labour which the lung, already less able to perform its duty, owing to 
the engorgement of a part of its structure, is called upon to perform. By lessening 
the quantity of blood which passes through the organ, we lessen its activity. 
These circumstances, as well as the importance of the organ to life, render free 
venesection, wherever the general system will admit of its employment, especially 
important and useful, and often absolutely imperative. It is scarcely necessary to 
remark, that topical depletion by cups or leeches may be resorted to, after general 
depletion is no longer advisable, and is sometimes particularly useful in relieving 
the local pain and uneasiness. 

Next to bleeding, one of the most powerful agents in controlling inflammation of 
the lungs, is tartar emetic in large doses. The quantities administered by some, 
have been enormous; but at present, most physicians who place their great reliance 
upon it, do not give more than six to twelve grains in the twenty-four hours. Its 
good effects are undoubted, and the rapidity with which the most distressing symp- 
toms are often relieved under its use is said to be particularly remarkable. Several 
conditions, however, such as inflammation of the stomach or intestines, contraindi- 
cate its employment, besides which it may give rise to unpleasant effects. One 
of the most common of these, is inflammation, followed by a pustular eruption, 
and even ulceration, of the mouth, fauces, oesophagus, or even the stomach. At 
times, also, the system seems to be poisoned by its use, so that the symptoms of 
colla[)se, a small pulse, hippocratic countenance, &c., have supervened upon its 
employment, and terminated in death. For these reasons, perhaps, the practice 
has never been very extensively adopted in the United States, where physicians 
are more in the habit of resorting to the drug in smaller quantities, say two grains 
in the twenty-four hours, or perhaps of placing their chief reliance upon calomel. 



GANGRENE OF THE LUNGS. 759 

This remedy, alone or combined with opium, is perhaps one of the most efficacious 
to which we can resort. 

It is unnecessary to allude to all the usual adjuvants of an antiphlogistic course, 
in reference to diet and regimen. The patient should be kept perfectly quiet, his 
shoulders moderately elevated, and the most perfect repose enjoined, at the same 
time that the position should be occasionally changed, in order to prevent the con- 
gestion of blood in the depending portions of the lungs. The most rigorous diet 
should be enjoined, and mucilages with narcotics resorted to, to allay the cough 
and pain, and procure comfortable rest. The efficacy of blisters is doubted by 
some practitioners, and applied at too early a period, before the excitement is suffi- 
ciently reduced, they may, as is well known, aggravate the disease. At a later 
period, however, when the fever is reduced, the strength diminished, and the loss 
of blood no longer admissible, their favourable influence upon the resolution of the 
disease is attested by sound experience. At the same period of the disease, certain 
expectorant remedies, such as senega or squill, may be advantageously resorted 
to. It is scarcely necessary to observe, that in a disease which presents itself 
under such a variety of forms, corresponding modifications of treatment are de- 
manded. Thus in one case, a typhoid tendency, in another, bilious symptoms, 
may predominate, and demand especial attention. When it supervenes in the 
course of another affection, by which perhaps the constitution is already debilitated, 
it is necessary to be very cautious in resorting to loss of blood or other active anti- 
phlogistic measures. 

In young children the abstraction of blood is a less important measure than in 
adults. Its good effects are chiefly limited to the outset of the affection, whilst at 
a later period its debilitating effects are much to be dreaded. Of internal remedies, 
mercury is the most valuable, and exercises the most decided control over the dis- 
ease. It should be given in small and repeated doses, and a little castor oil occa- 
sionally administered to relieve the bowels, when the abdomen becomes distended. 
There is not that risk in children of arresting the expectoration by the use of purga- 
tives, which is to be feared in adults. Of the expectorant remedies, ipecacuanha 
is probably one of the best. Counter-irritation is highly important. Weak mus- 
tard poultices, onion poultices, &c., should be applied, not merely to the chest, 
but to the extremities. Blisters on young children, are apt to terminate in slough- 
ing; and if resorted to, should be applied for a short time only, and followed by a 
poultice over the part. T. S.] 



CHAPTER VII. 
GANGRENE OF THE LUNGS. 

Seldom the Result of Inflammation. — We might suppose that if the lungs ever 
became gangrenous, it would be the result of inflammation; as gangrene so fre- 
quently is in other parts of the body.* But I believe that the severest inflammation 
of the lungs seldom, if ever, induces mortification. Sometimes it may be the case; 
but it is so rare that I have never seen it. The lungs will fall into a gangrenous 
state, and there is more or less inflammation attending it; but the gangrene does 
not appear to be the result of the inflammation. On the contrary, indeed, when 
nature makes an attempt to get rid of a gangrenous spot, inflammation is induced 
all around, in order to discharge it; — so that inflammation is sometnnes the result 
of gangrene. 

Cases. — In my own practice I have only seen two cases of this disease. They 
were of a different kind; and completely illustrated what Laennec has advanced on 

* See Pages 100 and 101. 



760 GANGRENE OF THE LUNGS. 

the subject. On some points Laennec has brought our knowledge to perfection. 
In some cases nothing has been done since his time, and perhaps nothing will be 
done. In one of these cases, in my own practice, the gangrenous part was uncir- 
cumscribed. A large part of ihe lung was of an unnatural colour; — dark greenish, 
moist, and soft; and in some spots it was a mere putrid pulp; — little more than so 
much mud; and of an insupportable odour. In those parts of the lung which I saw, 
that were not in a gangrenous state, the organ was firm, and of a chocolate-colour, 
or a deep green. These appeared to be the three stages of the complaint. There 
was one part a chocolate-colour, or deep green, and quite firm; another part was 
moist and soft, and of a daik green; and the third part formed a perfectly putrid, 
soft, muddy mass. A large portion of each lung was in this condition; — in one of 
the three stages of this affection. In another case which I had, the gangrene was 
in more circumscribed patches or spots. There were patches of the lung, black, 
soft, moist, and offensive in the worst spots; and in other parts, where the lung 
was still firm, it was of a green hue. 

No attempt, in this latter case of mine, had been made by nature to effect sepa- 
ration; but Laennec mentions that a gangrenous piece sometimes detaches itself, or 
is detached, from the surrounding parts; — ^just like a slough from caustic. That is 
an apt illustration of the appearance; because although the patches in my case 
were not separated, yet, if they had been, such would have been the state. The 
gangrenous part becomes dry and shrivelled; — ^just like a spot to which caustic has 
been applied; or it degenerates into a putrid paste, like mud. The surrounding 
structure is inflamed; as in other parts of the body when nature attempts a separa- 
tion. When a dead part separates from the living by inflammation, the latter ends 
in ulceration;* so that the dead part is left without any connection with the living. 
The living part disconnects itself; the dead part becomes isolated; and is afterwards 
separated. If nature succeed, as she does sometimes, a cavity is often found where 
the gangrene existed; and this cavity has a lining membrane. Sometimes no cavity 
is left, but a cicatrix is formed; and the whole appears to have grown up together. 
This appearance has been perfectly well described by Laennec, and by others. In 
some instances, the separated portion makes its way into the pleura, and pluritis 
is induced; and pleurisy, with effusion and pneumothorax, are the consequences* 

Symptoms. — In my two cases,'' the disease was marked by a sudden prostration 
of strength; a cadaverous alteration of the face; great feebleness of pulse; and an 
intolerable fcetor of the breath and sputa. One of these cases occurred in a man, 
who had long suffered from a loud hollow cough, with a copious frothy expectora- 
tion. The other occurred in a woman, who laboured under an encysted tumour 
of the pancreas. In her case a slight cough came on, which attracted no attention; 
and at last symptoms of gangrene appeared. These general signs will point out 
the disease, I imagine, much more than auscultation; but it is evident, that the gan- 
grenous part must have less respiratory murmur than natural, that the part around 
will afford crepitous rattle, and that the cavity will give rise to pectoriloquy. If 
inflammation be set up for the removal of the slough. — causing the bronchial tubes 
to be affected, — there will be a " metallic tinkling;" but I imagine that far better 
evidence than this will be derived from the aspect of the patient; — from the cada- 
verous look, and the great debility; together with the intolerable stench both of the 
breath and the sputa. 

Diagnosis. — When a part has become gangrenous, there is no hollow sound 
on striking the chest, and no respiratory murmur; but their absence may arise 
from numerous causes; and if any inflammation be set up around the dead part, 
to effect its separation, there will be a crepitous rattle; but no one could tell that this 
resulted from gangrene, rather than from some other cause. There are, however, 
certain signs observable by the other senses, which alone would make us believe 
there was gangrene; and these, together with the stethoscopic signs, make it tole- 
rably certain. Sometimes the sputa, in this disease, are white and opaque at first; 

» See Pages 101 and 102. 



HAEMOPTYSIS. 761 

but they grow sanions, purulent, brown, and greenish; and they are, from the first, 
nearly as fetid as whpn the foetor becomes gangrenous. 'J'liis fetid odour of the 
sputa, however, cannot be much depended upon; nor can tiie foetor of ihe breath. 
I have seen other diseases attended with extreme foetor, but without gangrene; and 
I have seen extreme foetor of the breath and sputa, without any danger whatever. 
Sometimes, in bronchitis, the foetor both of the breath and sputa will be extreme. 
I mentioned having seen females, who were in tolerably good health, except that 
they spit upalitUe; and this expectoration was horribly offensive; — so that to stand 
near them was extremely unpleasant; yet they were walking about, and looking 
well.* I saw a case of this foetor of the sputa, and smelling of the breath, in a per- 
son who died of phthisis. Occasionally the matter formed in phthisis is of such 
a quality, that the foetor is much like that of the faeces. There is no danger neces- 
sarily from the extreme foetor of the sputa, neither is there necessarily gangrene; 
but if, conjoined with this, we observe that the sputa are bloody, brownish, or 
greenish; — something like the discharge from a sloughing part; and when we ob- 
serve any thing like little green fragments of lymph, together with a weak pulse, an 
elongated countenance, and a cadaverous aspect; and when the patient is in the 
same state as people who are sinking from mortification in any other part; — then 
there can be no doubt of the nature of the disease. But the mere putrid smell of 
the breath, and of the sputa, certainly ought not to make us conclude that the 
patient must have gangrene of the lung; or, indeed, be in any danger. In the two 
cases of this disease, which I had under my care,^ the persons became, in a few 
days, very much emaciated. The pulse suddenly fell, the teraperatnre declined, 
and the countenance expressed the most extreme exhaustion; but, at the same time, 
I must honestly confess, that I had no idea, in either case, of gangrene of the lungs; 
and was much struck with the appearance after death; I could then compare it 
with the symptoms I observed during life. They were hosp'tal-patients; and it 
was only when opening them, that I discovered the disease. I smelt something 
very horrible when near them; but I ascribed it to another cause. 

Not necessarily Fatal, — When gangrene does exist in the lungs, it is not 
necessarily fatal. There have been clear cases of gangrene of the lungs, which 
have been recovered from; though all the symptoms I have mentioned occurred. 
Nature is sometimes sufficient, when supported by good nourishment, to get an 
individual through an afTection of this description; and to cause a separation of the 
gangrenous part. 

Treatment. — There is nothing peculiar in the treatment. We must support the 
strength of the patient, as in other cases where there is an absence of inflammation, 
and the presence of extreme debility. 



CHAPTER VIIL 

HEMOPTYSIS. 



There is another disease of the substance of the lungs, and of the membrane of 
the air-cells; which, after death, presents very much the appearance of inflamma- 
tion; and, before the time of Laennec, was frequently, (no doubt) mistaken for in- 
flammation. This disease consists in the effusion of blood into the air-cells. I 
shall now, therefore, proceed to the description of haemorrhage from the air-pas- 
sages; — liasmopfysis° This will be in conformity with the plan I have hitherto 
pursued; namely, that of treating first of inflammation, and then of certain other 
affections; among which is haemorrhage. 

« See Page 743. f See Page 750. 

*= From a4;aa, blood, and mvn}, to sj)U, 



762 HAEMOPTYSIS. 



SECTION I.— HyEMORRHAGE FROM THE AIR-PASSAGES. 

General Characters. — This hasmorrhai^e may proceed from the mucous mem- 
brane of the air-passages, or from the air-ce//s. In the one instance, it is not ne- 
cessarily a dangerous disease; in the other it is highly dangerous, in as far as it is 
likely to be very profuse. The greater number of cases of haemorrhage from the 
niT-passages, arise simply from an effusion of blood from the mucous membrane 
of the bronchial tubes. The blood which is spit up is florid, — generally of a bright 
scarlet colour; and it is frothy. It is spit up with a tickling in the throat; the 
pulse is quick; and there is heat in the chest. This is the description of haemor- 
rhage, which takes place most frequently in young adults; between the age of 
puberty, and the full adult period of five-and-thirty. It occurs, particularly, in that 
period during which the chest expands, — in which we "spread," as they say. 
The first part of life is disposed to haemorrhage from the nostrils; the second to 
haemorrhage from the lungs; and the third to haemorrhage from the abdomen. 

Diagnosis. — The disease, in general, is easily made out. The only difficulty 
is to distinguish between it and haemorrhage from the stomach; but the latter is 
usually marked by a discharge of black blood. The blood is either discharged 
from the veins of the stomach; or it lies in the stomach so long after its escape 
from the vessels, that it acquires a venous hue. From the one cause or from the 
other, blood, when discharged upwards from the stomach, is generally black; and 
has also generally lain there long enough to be coagulated; — it is in clots, larger or 
smaller. Frequently, too, it passes through the pylorus, and is seen in the faeces. 
Besides that, it frequently comes up with the food, — with the contents of the 
stomach; and, when it does not, still it comes up with sickness and nausea, if not 
with downright vomiting. We know that people may have a discharge from the 
stojnach without vomiting: sometimes a quantity of fluid comes to the mouth, and 
even portions of food come up without vomiting; and so it is with the blood. 
Occasionally, however, it comes up with decided vomiting. There is frequently 
a great uneasiness about the praecordia, and a fulness about the liver and stomach. 
These symptoms are all absent in haemorrhage from the lungs. The blood, too, is 
florid; and, instead of being mixed with food, it is frothy; and is necessarily mixed 
with air, in consequence of the parts from which it comes. These parts will not 
allow it to stay so long as the stomach; and it generally comes up as soon as it is 
poured into the passages; and therefore it is seldom coagulated. Occasionally, 
however, there is a litde coagulum; for it will sometimes lie sufficiently long to 
become solid and black, before it comes up. In addition to this, we have pectoral 
symptoms in haemoptysis; instead of nausea and vomiting, we have a "stitch" in 
the side, a little cough, and a tickling in the throat. On listening to the chest, when 
the blood is in the air-passages, we hear sibilous and sonorous rattles. 

Causes. — This species of haemorrhage occurs more particularly in those persons 
disposed to consumption; with a fine soft skin, soft hair, and a sanguineous tem- 
perament; and, among these, it occurs more particularly in those who have a florid 
colour. The disease sometimes occurs in those who have evident signs of inflam- 
mation; sometimes it occurs where there is hardly any thing particular to be per- 
ceived about the individual; and sometimes it occurs in those, in whom there 
appears to be great strength of system. It is produced by all the causes of inflam- 
mation.* A blow on the chest, or catching cold, will give rise to it; but it very 
often takes place without any observable exciting cause. Violent exercise, and 
excitement of mind or body in any way, will occasionally produce it; but some- 
times it occurs without any apparent cause. 

Duration and Effects. — It will return at certain periods, — at intervals of a month 
or a twelvemonth; and at last it will cease altogether; and the patient will then 
become the subject of consumption. It is very common for consumption to take 

•SeePasre 112. 



i 



HJEMOPTYSIS. 763 

place in patients who have had several attacks of haemoptysis; but this is not a 
necessary occurrence. I know many persons who expectorated blood, fifteen or 
twenty years ago, and who are now quite well. If a person spit blood, he should 
avoid every thing- which causes an irritation of the chest; but he ought not to con- 
demn himself; for I have known persons spit a considerable quantity, again and 
again, and yet afterwards do perfecdy well. 

Morbid Appearances. — When these patients die, we find nothing unusual on 
examination. If we examine a person who has died of phthisis, and who expec- 
torated blood before there were marks of phthisis, there will be found nothing to 
account for the haemorrhage. It is a mere effusion from the mucous membrane; 
which will pour out blood without a rupture of the large vessels. Small ones will 
sometimes throw out a gush of blood. When treating of haemorrhage in general, 
I mentioned that we sometimes open persons who have died of haemorrhage from 
the stomach and intestines, without being able to find a vessel ruptured. It was 
clearly an effusion from a thousand minute orifices.* 



SECTION II.— HAEMORRHAGE FROM THE AIR-CELLS. 

• 

Sometimes, however, haemorrhage from the lungs is not of this description. It 
does not take place from the mucous membrane; but it is a particular disease, oc- 
curring in the s-'w- cells; and in that case the haemorrhage is generally very profuse; 
far more so than in other cases. 

Morbid Appearances. — On examining patients after death, (for they frequently 
die of the disease in this form,) we find that certain parts of the lung have become 
exceedingly hard; and, if they be near the surface,' the lung is seen through the 
pleura looking very dark. The lung appears variegated; and there are large black 
patches here and there. If they be deep in the substance of the lung, we cannot 
discover their extent; but on taking hold of the lung, hard patches are felt; — some 
as large as nuts, and some as large as walnuts. On cutting into them, we find they 
are of a deep-red colour; and no doubt, in former times, they have been mistaken 
for so many large circumscribed inflammations. These parts of the lung may be 
from one to four cubic inches in extent, and even much larger; and the redness is 
a deep damask-hue. Nay, it is sometimes so intense as to be black;— as dark as a 
black clot of blood. This portion of the lung is not only hard but heavy; and it 
will not crackle under the finger. 

On cutting a portion of the lung in this condition, we observe the same granular 
appearance which, I stated, takes place in inflammation of the substance of the 
lungs.^ This granular appearance, before the part is completely solidified, no doubt 
arises from blood being effused into the air-cells, and there coagulating. The blood 
coagulates in each air-cell; the minute coagulum of each cell becomes a little grain, 
and furnishes this granular appearance. The diseased parts are usually quite cir- 
cumscribed; so that the surrounding portion of the lung is in every respect healthy. 
In inflammation of the substance of the lung, the diseased appearance is gradually 
lost in the healthy lung; but in this disease, in almost every instance, the affection 
is entirely circumscribed; so that within a hair's breadth of it (I might almost say) 
the lung is perfectly healthy. The case is really one of severe ecchymosis; oidy 
that the blood is effused, not into the cellular membrane, (as it is in ecchymosis of 
the surface of the body,) but into the air-cells. That the blood is effused into the 
air-cells, and not into the cellular membrane of the lungs, is proved by the blood 
beino" spit up. If the blood were not in the air-cells, but in the cellular membrane, 
it could not be expectorated. 

Symptoms. — The great symptom of this affection, during life, is spitting of 
blood. Besides the symptom of repeated and copious hosmorrhage, there is cough, 
difficulty of breathing, heat in the front of the chest, flushing in the face, and at 

a See Page 137. * See Page 754. 



76 t HAEMOPTYSIS. 

length great paleness of it. There is also a tickling sensation of thehronohia; — 
just as when haemorrhage cotnes from the air-passages." We cannot tell whether 
the blood conies from the mucous membrane, or from the air-cells, by any of the 
general symptoms; but when it is effused in very large quantity, there is a 'proba- 
bility that it comes from the air-cells. It is said that as much as ten pints of blood 
have been discharged from the lungs, in this way, in forty-eight hours: and Laen- 
nec says that he has seen thirty pints thus spit up in fifteen days. 

The disease may exist in so slight a manner, that no external haemorrhage takes 
place. I have known this state of the lungs to occur, without any spitting of blood. 
The blood has been effused into the air-cells, coagulated there, and produced the 
hard lumps I have described; and, not having been followed by subsequent attacks, 
no blood has been expectorated. Old persons, who were never known to have spit 
up blood, have died from other diseases; and this appearance has been found in 
their lungs. As this lesion evidenUy results from sanguineous exhalation into the 
air-cells, and perfectly resembles the cerebral sanguineous exhalations which pro- 
duce apoplexy, Laennec has named it " pulmonary apoplexy." 

I think all will agree with me, that this is an exceedingly absurd name. So far 
as there is great local congestion of blood and effusion, the phenomena are the same 
as are observed occasionally in apoplexy. But apoplexy is not a state of parts. It 
is a loss of sense and motion; occurring, for the most part, suddenly. Apoplexy is 
a stroke that causes persons to fall down senseless and motionless. In the words 
of Cullen, — " Motus voluntarii fere omnes imminuti; cum sopore, plus minus pro- 
fundo; superstite motu cordis et arteriarum.'"" That is what we mean by " apo- 
plexy." If a person be said to have apoplexy, and we ask the individual how he 
knows it, the answer is, — " He has lost all sensation and power of motion. There 
he lies in an insensible state; and we cannot rouse him." Apoplexy does not con- 
sist in the morbid state of the brain; but in the symptoms which we observe; and 
those symptoms will take place from depression of bone, or from an effusion of 
fluid. Any thing which compresses the brain will produce, not congestion of 
blood, but a loss of sense and motion. Nothing of this kind, however, occurs 
here. There is no loss of sense or motion in this disease; and therefore it cannot 
be apoplexy. Merely because apoplectic symptoms arise from a congestion of 
blood in the brain, or from haemorrhage into it, Laennec has thought proper to call 
this stale of the lung "apoplexy." Apoplexy will frequently arise from a secretion 
of ims pressing upon the brain, or from a secretion of mere serum; — without any 
congestion, — without any fulness of the vessels. This is the case when part of a 
vessel becomes ossified; so that it splits across, and allows the blood to escape into 
the brain. Thus we may have haemorrhage without apoplexy; and we may have 
apoplexy without congestion, and without haemorrhage. I cannot but think, there- 
fore, that it is an extreme abuse of terms, and likely to cause great confusion, to call 
this disease " apoplexy of the lungs;" for there is no resemblance whatever between 
it and apoplexy, — properly so denominated. 

History of the Disease. — It is not long that this disease has been known. Dr. 
Forbes, in his translation of Laennec, mentions (in a note) that, "in 1816, M. Le- 
veille appears to have read a memoir on this subject before the Academy of Sciences 
at Paris; and, in 1817, Dr. Hohnbaum, of Hildburghausen, published three cases 
of sudden and fatal effusion into the substance of the lungs."'' He says, the lungs 
were found distended with dark-coloured blood, partly coagulated and partly fluid; 
and were almost too large for the chest. In one case, the same kind of blood was 
found in the bronchia; and in the other in the pleurae. The cases appeared to be 
nothing more than a laceration of the blood-vessels; and the patients appeared to 

» See Page 762. 

^ "The voluntary motions almost all diminished; with stupor, more or less profound; the 
motion of the heart and arteries remaimns;."~^\Synopsis NosoloeicB Methodicm;^' Classis2 
C' Neuroses''); Ordo 1 {''Comata"); Genus 41 CApoplexia"), See Note (a) to Page 25. 

c "A Treatise on the Diseases of ihe Chest, and on Mediate Auscultation; by R. T. H. 
Laennec, M.D. Translated by John Forbes, M.D." Part 1; Book 3; Chapter's. (Third 
Ediiion; Page 192,; 



HJ3M0PTYS1S. 765 

die from the effects partly of internal hsemorrhao^e, and partly of oppression of the 
lungs, induced by the effusion of blood. They died of syncope and a:<phyxia. 
From the suddenness vvitli which it occurred, and its appearinfi to arise from a lace- 
ration of the vessfls of the lunsf, producing congestion. Dr. Hohnbaum gave the 
name of "pulmonary apoplexy" to this particular case. But we nuist consider, 
that neither sudden death nor effusion constitutes apoplexy; for apoplexy is nothing 
more than a loss of sense and motion. In apoplexy the motion of the heart may 
continue; but volition has ceased, partially or entirely. There can be no doubt, 
however, that Laennec was the first on the Continent who gave a full and accurate 
account of the disease; which he did in 1819. The disease was really not under- 
stood fully, till Laennec wrote upon it at that time; and he then pointed out the 
common connection of this particular state of the parts, with profuse haemoptysis. 
Yet it is singular, (and I may be excused for mentioning it, since there was no 
merit in it,) that I myself published an account of this affection, and gave the 
symptoms during life, and the appearances after death, some two or three years 
before that. 

Case. — The case (which will show the course of the disease very well) was 
that of J. G., aged thirty-five, by business a gardener; — a mild and extremely 
steady man. He had laboured for two years under dyspncea, pyrexia, cough, paia 
of the chest, and bloody expectoration. At length, profuse haemoptysis came on. 
Various remedies were prescribed, but in vain; and he ultimately died exhausted. 
On opening the body, the surface of the lungs presented numerous hard, circum- 
scribed, very dark patches, of various sizes, — from that of a sixpence to the size of 
a crown. A person not of the profession, would have supposed them so many 
mortifications. Blood, however, when accumulated in the small vessels, often 
causes (as Dr. Baillie has pointed out^) a counterfeit appearance of mortification in 
the stomach and ititestines, and in many other parts. Such was the nature of these 
patches. On cutting perpendicularly through them, the hardness and dark colour 
were found extending into the lungs (an inch or less); in a form equally circum- 
scribed as on the surface. The intervening spaces were perfecdy healthy. This 
Laennec also remarked. Nearly the whole of the interior lobe of the right lung 
had undergone the same change as the circumscribed portions in the other lobes. 
This change consisted in a prodigious congestion of blood, which could not be 
squeezed out, and which gave the dark colour and hardness. The slices were 
quite diaphanous; and of a beautiful red colour. No other change, — no disorgani- 
zation, was in any part discernible. It seemed as if the most minute vessels in 
various parts, had become dilated, as in naevi materni; and had thus allowed the 
escape of the blood. Had the symptoms been those of acute inflammation, and the 
blackness not been in detached portions, there would have been nothing singidar; 
nor would there, had the disease been simply chronic inflammation; — indicated by 
a frequent pain at the anterior and lower part of the chest, always yielding to blis- 
ters, and a large quantity of bloody fluid found in the cavities of both pleurae after 
death. But it is surprising that this should occur in patclies; and should have 
induced no suppuration, — no disorganization; but merely haemoptysis and pain. 

There was no great discovery here. I opened the man; the appearances were 
provided for me; and I described them. I pride myself on one thing; — tliat I did 
not call it "apoplexy of the lungs." I gave it no name.'' 

Signs afforded by Auscultation. — The employment of the ear, in addition to 
the general symptoms, may be useful in this disease. It is always desirable, when 
a person spits blood, to know how much disease exists in the lungs; and it is 
desirable to know whether the blood comes from the bronchial membrane, or is 
the consequence of such a state of the air-cells as we have noticed;" because the 

» In his "Morbid Anatomy;" Chapter 8; Section I. 

''The work- in which the case was published, was called the "Annals of Medicine and 
Surgery.-'' I made an exiract from it in my work on Diseases of the Heart (Poge 32); — the 
original publicaiiou being now very scarce. 

<= See Page 703. 



BUSH 



766 HEMOPTYSIS. 

latter form of haemoptysis is far less manageable than the former. In this kind of 
haemoptysis (called •'pulmonary apoplexy"), when only a little effusion has taken 
place, there is a crepitous rattle; but in haemoptysis from liie air-tubes, there is 
not; and for this reason, — the blood is not in the air-cells. When it is in the tubes, 
we have no crepitous rattle; for that always arises from an accumulation, of son>e 
kind or other, in the cells. In effusion of blood in the air-cells, we have crepitous 
ralde at first; but where the blood is more abundantly effused, we cannot have 
crepitous rattle; because no air can be admitted. The crepitous rattle, I have no 
doubt, arises from the air passing through the fluid; and from the air-bubbles burst- 
ing one after the '"^'her. When so much blood is effused into the different air-cells, 
that no air can be admitted into them, and the part becomes firm, there is no cre- 
pitous rattle; nor, indeed, any rattle at all. No respiratory murmur, and no morbid 
respiration is heard; for no respiration can take place long in that part. All that 
can be detected by the ear is, that the part is not healthy. On striking over the 
part, it sounds dead; and on listening, there is no sound of respiration; and we 
learn very well, by the ear, what is the extent of the mischief. In the case I met 
with, the whole of the inferior lobe of one lung had become quite solid. In those 
days, the stethoscope was not invented; and therefore I knew nothing of the 
symptoms that would have presented themselves, if I had resorted to auscultation. 
But if I had employed the ear in that case, no respiration would have been heard 
over a great part of the chest; and on striking, there would have been no hollow 
sound; and therefore I should have known the extent of the mischief. The extent 
of mischief, in this disease, may be accurately learned. We may ascertain how 
much of the lung is solidified, by the extent of a dead, instead of a hollow sound, 
on percussion; and the extent to which there is no respiratory murmur. With 
regard to the treatment, that must be the same, whether the blood come from one 
part, or from another; and therefore it must be for the sake of the prognosis that 
we employ the ear, and make a distinction between the two cases; — the one being 
a manageable kind of affection, and the other extremely unmanageable. 

[Later observations have not confirmed the idea that spitting of blood is the great 
symptom of pulmonary apoplexy. On the contrary, in the great majority of cases 
where the hard masses, or haemorrhagic engorgements, described by Dr. Elliolson, 
have been found after death, no spitiing of blood has taken place. In the few cases 
where a very profuse haemorrhage is met with, no value can be attached to the 
latter as a diagnostic sign, since the same symptom is met with under other circum- 
stances. The general absence of haemoptysis in cases of pulmonary apoplexy is 
not astonishing, when we recollect that the blood is effused into the pulmonary 
tissue. In instances however, where the effusion is very great, rupture may occur, 
and blood may then escape in considerable quantities. Cases are reported in which 
the rupture has taken place into the pleura. We should further recollect that pul- 
monary apoplexy may be accompanied by haemoptysis, at the same time that the 
latter is no consequence of the former, for both species of haemorrhage, that into 
the bronchial tubes, constituting haemoptysis, and that into the proper pulmonary 
tissue, constituting pulmonary apoplexy, may be the joint result of a common 
cause, most usually of some circumstance which occasions obstruction to the pas- 
sage of blood through the lungs. Pulmonary apoplexy indeed, is especially met 
with in connection with organic diseases of the heart, particularly where there is 
obstruction to the passage of blood through the left side, with hypertrophy. 
Besides its occurrence in the course of some chronic affection, it is also met with 
in fevers, where its production must in great measure be attributed to that condi- 
tion of the blood and tissues generally which favour the production of haemorrhage. 

As regards the diagnosis of the disease, it is exceedingly obscure. In very many 
cases, its presence is revealed only by a post-mortem examination. There is no- 
thing cliaracteristic in the physical signs to which it gives rise, and their combina- 
tion is not often such as to render the diagnosis clear. T. S.] 



I 



HEMOPTYSIS. 767 



SECTION III.— TREATMENT OF HEMOPTYSIS. 

General Treatment. — On the immediate occurrence of haemorrhage from the 
lungs, it is right to treat it as inflammation; — to bleed in the arm freely; an<l to set 
the patient upright, and keep him so; in order to make him feel as faint as possible. 
We should keep him in that position, instead of allowing him to lie down. It is 
safe to apply ice to the front of the chest; and this, I think, should always be done. 
There can be no impropriety in it. As soon as we have bled, until ice can be 
procured, we should throw cold water on the chest; and endeavour to produce a 
contraction of the end of the vessels; — in the same way as we proceed in the case 
of the womb. But generally the bleeding soon stops; for a patient seldom dies of 
haemoptysis at the time. Bleeding at the arm, throwing open the windows and 
doors, and taking the clothes oflf the chest, answer very well. The patient should 
not be allowed to move. He should be made easy and comfortable; but he should 
not be allowed to move, or to speak. I have often made persons persevere, for a 
fortnight together, after dangerous haemorrhages; — making them write for whatever 
was wanted. It is proper to starve the patient; to give him nothing but plain 
water, milk and water, lemonade, or things of that description; and it is surprising 
how patients, in this disease, bear cold. I know not a single instance of a person 
suffering inflammation of the chest, from all this exposure; notwithstanding that, 
in other circumstances, he would (in all probability) have suffered severely. 

Acetate of Lead. — The best internal medicine, by far, is the acetate of lead; and 
this must often be given in considerable quantities, before it will stop the haemor- 
rhage. Within a month, I have had three cases of haemoptysis; in which I have 
been obliged to give as much as three grains every four hours, before I could fully 
stop the discharge of blood. It is always safe to begin with 07ie or two grains, 
every six hours; but if the haemorrhage does not stop, but returns every day, it 
would be right to give such a quantity as this every four hours; and if that does 
not stop it, we may give three grains every three or four hours, with perfect safety. 
In all the three cases, the last mentioned doses were given; and no inconvenience 
was felt, except from constipation; which was remedied, every day, by some laxa- 
tive. If we do not attend to the state of the bowels, and procure a motion every 
day, the patient may become the subject of colic; but by administering croton-oil, 
or castor-oil, or some purgative that contains no sulphuric acid, there will seldom 
by any colic or pain of the bowels; which is very troublesome. Some persons 
give opium, to prevent griping; but I have not done so; because I have not found 
it necessary. 

Alode of administering Lead. — Some persons give the lead in a liquid, and 
some iiv a solid form. I have not exhibited it liquid, because it is very nauseous; 
and it answers just as well solid. It mixes up with the extract of colocynth into 
pills, very well; and I have seen the stomach bear it, if given in a pill, much better 
than in the fluid form. That is the case with all acrid and nauseous things; — the 
stomach can bear a pill the best. 

Hydrocyanic Acid. — If the patient's stomach be disposed to reject it, it is use- 
ful to give one or two minims of hydrocyanic acid, three or four times a-day. If 
we are giving the lead only three times a-day, then we might give hydrocyanic acid 
three or four times; but if the lead be administered every four hours, then we can- 
not give the prussic acid so frequently. The dose required to prevent vomiting, is 
exceedingly various. In some it will be prevented by one minim, three or four 
times a-day, taken before the lead; and in other cases, two, three, or four minims, 
will be required. Of all medicines to prevent others from irritating the stomach, 
I know of none equal to hydrocyanic acid. 

Some apply blisters over ilie chest; and they are very useful in these cases at 
last; but tlie application of cold, by means of ice, is better. If the means which 
I liave recommended be adopted, we shall generally be able to control the affection. 
Treat it, in the first instance, as an active inflammation; and when the ha;morrhage 



768 FUNCTIONAL DISEASES OF THE LUNGS. 

is very considerable, treat it as a passive inflammation; or rather combine the two 
modes of treatment. Do all that can be done to prevent an excitement of the pulse, 
by bleeding from time to time, and keeping down the circulation; and at the same 
time adopt the treatment for passive inflammation, by producing a constriction of 
the vessels. 



I 



CHAPTER IX. 

FUNCTIONAL DISEASES OF THE LUNGS. 

Before I describe organic diseases of the lungs, — those in which there is a new 
deposition, or a transformation, or lesions of the substance, — I will consider /z//2C- 
tional diseases of those organs. I will speak first of asthma, and then of hooping- 
cough. Asthma is often connected with bronchitis and hooping-cough; and very 
often with inflammatory diseases; but not necessarily so. Both astinna and 
hooping-cough are frequently unconnected with inflammation; nor is there any 
appearance, afier deatli, that will expl3!in the symptoms. They are frequently 
specific and functional diseases. 

SECTION I.— ASTHMA. 

Definition^— -^Y " asthma"* is meant a spasmodic difficulty of breathing; — a 
spasmodic affection of the organs of respiration, below the larynx and trachea. It 
is frequendy united with organic diseases, or with inflammatory states; and fre- 
quently it is merely the result of irritation; so that we may have it without any 
organic disease, or any inflammation at all. 

Symptoms.— 'In a case of asthma, — pure, genuine asthma, — there is a violent 
sense of constriction of the chest, with a loud wheezing respiration: — heard without 
putting our ear to the chest, or employing a stethoscope. We hear a patient, at 
some distance, wheezing and breathing for his lil'e. Such an attack as this, issoon 
accompanied by a short and difficult cough; but as the sense of constriction goes 
off, the cough becomes freer and deeper; and there is some expectoration. 

During this attack, the face is pale, elongated, and pinched; the nose and ex- 
tremities become cold; the pulse is found to be small and quick; and I have 
frequently observed it to be irregular. The skin, throughout the body, becomes 
rough, — from the retrocession of blood from it; horripilatio takes place; and the 
patient looks as if he were dying. He is cold and pale, and gasping for breath; 
and in such an agony, from the want of it, that one would think him dying; yet, 
in the greater number of cases, there is no danger whatever. 

Usually occurs in the Night. — Such an attack as this, may last only a few 
minutes; or it may last several hours. It generally takes place in the middle of 
the night. The gout, when it first attacks an individual, generally does so in the 
middle of the night; — that is to say, at two or three o'clock in the morning; and 
this is generally tiie case, likewise, with asthma. When it first invades, the pa- 
tient jumps up in bed; throws oflf the clothes; draws aside his curtains, if he have 
any; often goes to the windovir and throws it open also, as he does the door; and 
stands at the window, to get as much air as he possibly can. After a certain time, 
he finds that he breathes more easily, can take a deeper inspiration; begins to cough 
more deeply, and to expectorate; and then he goes to bed again, a great deal bet- 
ter. Very often, at the same time the next night, the scene is repeated. 

* From aaBfAct^M, to gasp for breaik. 



FUNCTIONAL DISEASES OF THE LUNGS. 769 

Premonitory Symptoms. — When a person is subject to this occurrence very 
often, the breathing, for the most part, is not quite free in the intervals. It is gene- 
rally difficult; the patient feels that all is not right; and, at the same time, there is 
generally a great degree of flatulence. A large quantity of wind undoubtedly is 
produced in the stomach. It could not be generated so rapidly by any chemical 
process;— for persons in this condition, just like hysterical women, become, in a 
moment, filled with wind; which comes forth in torrents, apparently interminable: 
and this occurs without any thing being in the stomach, to promote the production 
of it. I think there can be no doubt (and John Hunter was of this opinion) that 
air can be secreted like a liquid; for we see a woman in a moment, from a passion 
of the mind, swell out and pour forth torrents. I believe the wind, in these cases, 
is always inodorous. The gases from the alimentary canal, have been analyzed by 
the French; and their nature lias been ascertained from the contents of the stomach 
and intestines. An account of this maybe found in Majendie's work; but whether 
the wind just referred to has been analyzed, I do not know. I think it has not. 
At the same time, there is generated a very large quantity of liquid, which is quite 
pale; — containing very little saline or animal matter. They are as pure specimens, 
both of wind and water, as can be produced (I suppose) from the animal body. 

Some persons have these attacks only at certain seasons of the year; and some 
only in particular places. If they be subject to the affection, they are rendered far 
more liable to it by eating what is ill-suited to their stomach; — eating articles which 
they have found not to agree with them. Sometimes indigestion precedes an attack 
of this description; sometimes there are symptoms of disturbance of the nervous 
system, — such as sleeplessness and headache; and sometimes there is a great itch- 
ing of the skin. These circumstances occasionally precede the disease. 

Attacks Persons of all J^ges. — The occurrence of the disease is very various. 
Some have it only for a few nights; and some for many weeks. It is a disease 
which attacks all ages. I have seen it, over and over again, in infants at the breast; 
where, from the very slightest degree of bronchitis, — the slightest catarrh, they 
have been seized, at different periods of the day, with violent wheezing; and that 
wheezing has ceased almost as suddenly; and therefore I have no doubt it was 
asthma. I have seen several instances of it, as I suppose, in boys below puberty 
and above it; and very frequently it attacks young adults. Persons may be subject 
to a recurrence of this affection for many years; and then it may cease entirely, 
without being followed by any other disease. A patient may, at one period of his 
life, entirely cease to be asthmatic; and this complete cessation of the disease may 
occur at all ages. With some persons, asthma occurs only in particular seasons, 
from particular circumstances, and from particular states of the weather; but with 
some the tendency to it is so strong, that they are sure to have it wherever they 
are. There are always exciting causes sufficient to produce the disease in them; 
— so extreme is their liability to it. 

Sometimes attended ivith Pain, — I have sometimes seen it attended with very 
great pain. There has appeared to be a violent spasm of the respiratory muscles; 
so that patients have had violent pain; and yet, without any bleeding, — simply from 
stimulating remedies, — this pain has ceased. 

Varieties. — Although this which I have now described, is the regular form of 
the disease, yet (like epilepsy*) it sometimes puts on very great irregularity. Some 
persons, in the fit, will make a crowing noise. Some will have a number of deep 
inspirations successively: and then they will suddenly cease to breathe. There is 
every sort of variety that can be imagined; but still, no doubt, they all deserve the 
name of " asthma." 

Complications. — The disease is literally pure spasm, and does not necessarily 
depend upon any organic cause. But it may be combined with any inflammatory 
disease of the chest; and it may be combined with any organic disease of the 
chest. Even the slightest pressure, in some people, will cause this affection. Mr. 

» See Page 598. 
VOL. I. — 49 



770 FUNCTIONAL DISEASES OF THE LUNGS. 

Lawrence (as I before mentioned) has described a case, in which violent paroxysms 
of asthma were induced, simply by an aneurism of the innominata; — causing the 
least possible degree of pressure upon the trachea.* The disease with which asth- 
ma is most commonly united, is chronic bronchitis. When persons labour under 
the latter affection, besides constant difficulty of breathing, they are subject to great 
aggravations of this difficulty, from time to time; — particularly at night. As in 
this case they spit up a great deal, the afTection is called, by the old writers, '"hu- 
moral asthma." But we continually have chronic asthma without chronic bron- 
chitis; just as we may have the latter without any tendency to a spasmodic affec- 
tion. Sometimes asthma is united with pleuriiis and pneumonia; and on bleeding 
such patients, we have buffy blood; but in a case of genuine asthma, it is rare for 
the blood to be huffy. I do not know that it ever is so. Asthma is frequently 
seen united with diseases of the heart; but then it is to be remembered, that nothing 
is more common, in organic diseases of the heart, than for chronic bronchitis to 
exist. The heart is seldom organically diseased, to any considerable extent, with- 
out the bronchia being more or less inflamed. 

Diagnosis. — The disease is easily distinguished from hydrothorax. On striking 
all over the chest, we have a clear sound; and, on listening, we have respiration all 
over the chest; — which we cannot have if any part of the cavity be filled with 
water. It is distinguished from bronchitis, by the absence of sonorous and sibilous 
rattle, except in the upper parts. Down below, throughout the rest of the chest, 
"we do not hear those peculiar sounds of bronchitis; or, if we do hear something 
like them, they suddenly cease; and then there is the sound of health; but while 
bronchitis lasts, we have sonorous and sibilous rattle; and these only subside either 
from the interference of art, or the disease itself ceasing. In general, a loud respi- 
ratory murmur is heard all over the chest; — louder than it should be. The absence 
of other diseases, together with the suddenness of the attack, the suddenness of its 
cessation, and its extreme aggravation from time to time, will enable us to form our 
diagnosis. 

Prognosis of the Paroxysm. — The prognosis in this disease, so far as the pa- 
roxysm is concerned, is generally good; but 1 have seen people die from pure 
spasmodic asthma. I recollect a young man, who had been asthmatic, being 
brought to the hospital in a great fright; and, when I saw him, he was dying. He 
could only breathe while on his knees and elbows. No signs of any other disease 
were found during life. He was cold and pale, and the pulse was not to be felt; 
and, in the course of two or three hours, he died. He had been accustomed to 
asthma; but this fit produced such a severe asthmatic state, that he did not survive. 
On opening him, no signs of disease were found; but the lungs were all distended; 
had lost their contractile power, so as to be unable to collapse; and were as light 
as a feather. I have read accounts of death from asthma; but it is a rare occur- 
rence indeed. 

Prognosis as to its Termination. — The prognosis, however, must be unfavour- 
able as to the tennination of the disease. Some persons will be liable to it for 
life, if they live in particular situations, in spite of all that can be done. We have 
a prognosis to make as to the paroxysm, and one as to the duration of the disease. 
The one is favourable, and the other unfavourable; but then the prognosis respect- 
ing the distant event, must depend upon the existence of other diseases. People 
labouring under asthma, often live to a great age; and the disease often ceases of 
itself. But we must always consider, in these cases, that there may be some other 
disease; — chronic bronchitis, chronic pneumonia, or disease of the heart; or there 
may be a tendency to phthisis; and all these things must be taken into the account, 
in forming a prognosis. Dr. Heberden"* mentions two cases of the cessation of 
asthma, after it had existed some time: and he also mentions other cases of persons 
suddenly ceasing to be asthmatic; and never having another attack, though they 
have lived thirty years afterwards. I have myself known instances of its cessa- 

a See Pa°:e 720. 

^ In his "Medical Commentaries;" Chapter 11. (First Edition; Pages 62 and 63.) 



FUNCTIONAL DISEASES OF THE LUNGS. 771 

tion, after having existed a considerable time. But we can never prognosticate 
this. If it turn out so, it is all very well; but I think we have no means whatever 
of predicting that it will thus terminate. 

Predisposing Causes. — The predisposing causes of the disease are not known. 
Very often it attacks those who are thin and pale; but they have pure, simple, 
spasmodic asthma. It as frequently, however, attacks those who are short and 
full, — bulky; and these generally have a combination of asthma and chronic bron- 
chitis. They expectorate a great deal; — have " humoral asthma." Of the real 
predisposition, however, we certainly do not know the nature. We know it is 
often hereditary. Asthma attacks many, whose parents (one or both) or whose 
grand-parents have had the disease. It runs in families. 

Exciting Causes. — With regard to the exciting causes of the disease, they are 
(in general) cold and damp, and especially fogs. Some persons have it only in 
cold weather; others have it only in damp, foggy, moist weather; but there is a 
great variety in this respect. Some persons have it only in summer, and are all 
the better for cold weather; and some never have it but in particular situations. 
Most people are better in the country, if it be a dry place; but some are better in 
London; so that persons who have made their fortunes, and retired to the country, 
have become asthmatic; and have been obliged to return, and live in London again. 
I have read of cases, where parties have been obliged to go back to an old house 
in Thames Street. I recollect that particular street; — as damp and dirty as any in 
.London. 

Hay-Jlsthma. — In some persons, this disease is only induced (as it would ap- 
pear) from particular exhalations from the vegetable kingdom; — the emanations 
from grass in flower. These are the people who have asthma only in summer; 
but by far the greater number have the disease aggravated in winter, and are pretty 
well in summer. Some, however, are never asthmatic till about May or June. I 
should think all these cases may be resolved into that particular form of disease, 
which has been called " hay-fever," or " hay-asthma." In some cases, there is a 
simple spasmodic affection of the breath; and in others, there is a violent catarrh, 
united with the spasmodic affection. This is a disease which has only been noticed 
of late years; and respecting which I have some curious facts to adduce. 

History of Hay-Asthma. — Certain writers have spoken of what they call "a 
summer cold;" — "catarrhus aestivus." The first medical composition that I read 
upon the subject, and the first that I ever knew to exist, was by Dr. Bostock, the 
celebrated chemist. It was from him I learned that some writers spoke of catarrhus 
aestivus; but I do not know to whom he alludes. Dr. Bostock states, in the tenth 
volume of the "Medico-Chirurgical Transactions,"* that at a certain time of the 
year he begins to sneeze, — has a "running" of the eyes, and all the other symp- 
toms of catarrh; and that these continue for a certain length of time, wherever he 
is, and whatever he does. In a second paper, published by him in the same work," 
he again refers to the subject; and relates his own case at considerable length. 
Before that time, I had heard people talk about "hay-fever" and "hay-asthma." I 
was told that certain distinguished personages had "hay-fever." It appears to be 
quite an aristocratical affection; — not at all visiting hay-makers, or those who have 
to do with hay and straw. I never met with such a thing in practice; and it 
appeared to me to be a highly gentleman-like, and indeed (I may add) noble affec- 
tion. I could not tell what to make of it; and I disregarded it entirely; — supposing 
it to be a sort of aguish or hypochondriacal affection, of which those who had little 
to do, frequently became the subject. I happened, however, to be attending in a 
family, where the mother of the lady was said to have been the victim of it many 
years. She was a very sensible and superior woman; and she stated that, at a 
certain time of the year, when the grass came into flower, she was dreadfully dis- 
tressed in breathing; and was obliged to leave her house, and go to as barren a place 
as she could find at the sea-side; and there she obtained comparative ease. She 

« Page 161. »• Volume 14; Page 437. 



772 FUNCTIONAL DISEASES OF THE LUNGS. 

told me this had been the case for many years; and that she had tried every thing 
in vain; for nothing did her good. She was not the only member of the family 
afflicted with it; for an uncle, some of her nephews and nieces, and some of her 
cousins, laboured under it. It was decidedly an hereditary family matter. 

As there are some curious features in these cases, I alluded to them in a clinical 
lecture delivered at St. Thomas's Hospital. I knew that the course of which that 
lecture formed a part, was being published;* and I thought the shortest way to 
make the subject known, would be to mention it then. The consequence was, 
that 1 received several exceedingly kind letters, from gendemen unknown to me; 
giving me facts upon the subject; and as the matter is very interesting, I will insert 
a few of ihem. 

Mr. Gordoji's Cases. — One of these letters was received from Mr. Gordon; — a 
surgeon residing at Welton, near Hull, Yorkshire. He stated that, in the "Medi- 
cal Gazette," he had described the very same thing. I was not aware of it at the 
time; or I should have felt it a great pleasure, as well as my duty, to refer to it. He 
says: — 

"I have this evening received Number 186 of the 'London Medical Gazette,' 
dated June 25 [1831].'' It contains"' the report of a clinical lecture which you 
delivered at St. Thomas's Hospital, in March last,*^ on the subject of hay-asthma. 
"In consequence of your expressing a wish to receive information on this extra- 
ordinary complaint, I have taken the liberty of troubling you with this letter. I beg 
leave to state, that I have witnessed several instances of hay-fever, and hay-asthma, 
and, in the eighty-seventh number of the 'London Medical Gazette,' bearing date 
August 1, 1829,^ I published a short account of the nature, symptoms, causes, and 
treatment, of these curious disorders. In that memoir I have observed, that the 
best preservative against their attack, is the cold shower-bath. For the last two 
seasons, however, while employing this, I have administered the sulphate of qui- 
nine, with the sulphate of iron: — the former in doses of two or three grains, the 
latter in doses of one grain, three times a-day. The success which has attended 
this prophylactic treatment, has exceeded my highest expectations. With two of 
the most severely afflicted of my patients on whom it has been tried, it has answered 
so effectually, that both of them have this year [1831] been able to walk through 
a rich meadow, without suffering in the slightest degree; although formerly, if they 
had ventured out into such a situation, they would have brought upon themselves 
all the agonies of spasmodic asthma. 

"The symptoms I have related, were taken principally from the cases of* * * * * *. 
These two gendemen have been annually attacked with hay-asthma, for the last 
fifteen or twenty years. They consulted Dr. B., and must of the eminent English 
physicians, as well as several practitioners on the Continent; but derived no relief 
from what was prescribed for them. By means, however, of the shower-bath, the 
quinine, and iron, they have, for the last two years, obtained a complete emanci- 
pation from their tormenting disorder." 

Another Description of Hay-Asthma. — Another letter is from a practitioner at 
Bristol, who says, — "I knew nothing about hay-fever, as any definite disease; but 
your description of it is, with little exception, a very accurate detail of what I have 
suffered, every June, for several years." — Here was a gentleman who had been ill 
every summer, for several years, without being aware what his particular complaint 
was. — "Were I not," he proceeds, "at the present time annoyed by this trouble- 
some affection, I should probably not have found leisure to give you the trouble of 
reading any thing on this subject. 

"The attack generally begins, with me, at the latter end of May; with great itch- 
ing of the eye-lids; — particularly at the inner canthi; from which I regularly, during 
this month, extract some cilia, which grow very near the cornea, and increase the 
irritation. My most troublesome symptom is sneezing. It is of a violent kind; and 

» In the "London Medical Gazette;" Volumes 7 and 8, 

b Volume 8; Page 384. « At Page 411. 

d March 31, 1831. « Volume 4j Page 266. 



FUNCTIONAL DISEASES OF THE LUNGS. 773 

often continues ei^ht or ten times. The defluxion from the nostrils is most copious 
at these periods of the day; while, in the intervals, I have no catarrhal symptoms. 
Expectoration of clear mucus is also considerable. My sneezing attacks are sure 
to come on while I am visiting my patients; — to my great annoyance. This com- 
fortless state generally continues five or six weeks; but is never sufficient to inter- 
rupt anv of my employments, or render any confinement necessary: though I am 
always free from it when in the house. How far grass or hay has any thing to do 
with this affection, I cannot satisfactorily determine. There certainly are several 
hay-fields within a quarter of a mile of my house. The air seems to make me 
worse; and an open window is my abhorrence, while I am thus indisposed. Last 
week I spent an hour or two in a friend's hay-field, with a party of ladies; but the 
syllabub, the ladies, and the pastoral sports, had no amusement for me; and I was 
glad to get to a corner of the park, where my streaming eyes and nostrils, and noisy 
sternutations, might escape both remark and commiseration. Certainly, during 
that afternoon, in the hay-field, was the worst attack I have had; but whether it was 
the air which was cooler than usual, or the hay, I could not tell. I must however 
confess, that my fancy on the subject has always leaned more to the effect of some 
subUe particles, of an irritating nature, than to the ordinary causes of catarrhal affec- 
tions. My lungs are rather asthmatic; — formerly I had a good deal of asthma. I 
have never found time to try any remedies; but shall certainly bear in mind yours, 
should I have this visitation next year." 

Dr. Bulman's Case of Hay-Asthma. — I have another letter from Dr. Bulman, 
of Newcastle-upon-Tyne. He has given me several cases; of which the following 
is one: — " D. B., aged sixty-six, is of a spare but robust habit, and free from any 
constitutional or hereditary affection; — except, perhaps, the gout. He has been 
liable since his seventh year, if not sooner, to annual attacks of the disease so ably 
described by Dr. Bostock, under the name of ' catarrhus sestivus.'* The disease 
invariably commences (about the second or third week in June) with a sense of 
uneasiness, heat, and itching in the ' tunica conjunctiva;' but the itching is more 
particularly severe along the tarsus, and in the ' caruncula lachrymalis.' On exa- 
mination, this membrane is found to be considerably inflamed; but, except in the 
severer attacks, the inflammation does not extend to the eye-ball. The symptoms 
before mentioned are attended with watering of the eyes, increased secretion from 
the Meibomian glands, a sense of fulness or rather distension of the eye-ball, in- 
tolerance of light, and weight in the forehead. The itching gradually increases in 
violence, till it becomes almost insufferable; — compelling the patient, notwithstand- 
ing every resolution to the contrary, to rub his eyes; by which it is always consi- 
derably allayed. 

*'In the course of a few days, but sooner if the patient has exposed himself to 
the sun, the inflammation extends to the Schneiderian membrane of the nose; and 
is attended with itching and stuffing of the nostrils, increased secretion of mucus, 
and violent paroxysms of sneezing; which are also excited by dust of any kind, 
exposure to the heated external air, effluvium of new-made hay, and the odour cf 
the bean-flower; — perhaps, also, by other odours. As this disease continues to 
advance, the membrane of the fauces and lungs is affected; — giving rise to a sense 
of dryness and extreme itchinsf or pricking in the throat, to slight cough, with 
lightness of the chest, and difficulty of breathing; but there is little or no expec- 
toration. 

" There are several paroxysms daily; commencing with intolerable itching and 
tingling of the eye-lids, and followed by the most violent fits of sneezing, accom- 
panied by a copious discharge of mucus from the nasal passages. After this the 
patient obtains a longer or shorter respite; for the paroxysms occur at uncertain 
intervals; save that one invariably takes place about an hour after risinsr in ihe 
morning. The tightness of the chest and difficulty of breathing, though suffi- 
ciently distressing, have seldom been very urgent; but on two occasions they rose 

• See Page 771. 



774 FUNCTIONAL DISEASES OF THE LUNGS. 

to such a height, that the patient conceived himself in clanger of instant suffocation. 
In severe attacks the eye-lids become OBdematous. During the whole course of the 
disease, the patient is languid and listless; and, though restless, is averse to motion. 
His temper is more irritable than natural; but his pulse is scarcely, if at all, affected. 
His bowels are regular, and his appetite rather increased than diminished. 

" The disease continues till about the end of July, or the beginning of August; 
when it almost imperceptibly declines; and it is remarkable, that the patient is then 
able to expose himself to the hottest sun, without the recurrence of any of the 
above detailed symptoms;" — showing, of course, that it does not depend upon the 
temperature; — " and indeed, during the violence of the disease, exposure to the 
open air early in the morning, and in the evening after sun-set, causes but little in- 
convenience. The patient has had attacks of this disease in France, Switzerland, 
and Italy. In the two former countries it was as severe as in England, but not 
more so; and it is extraordinary, that in Ital3^ notwithstanding he was daily ex- 
posed to the powerful sun of Rome, in the month of June, the disease, though it 
began earlier, was nevertheless considerably milder, and also of shorter duration, 
than elsewhere. 

*' Most of the internal remedies mentioned by Dr. Bostock,^ have been tried; 
but in vain. Bathing in salt water, both cold and tepid, has been had recourse to. 
The former is apparently without effect; the latter has seemed serviceable only so 
far as it has relieved the tightness of the chest, and the difficulty of breathing. Of 
local remedies, the only one which has proved of any efficacy, is the Unguentum 
Hydrargyri Nitratis, properly diluted. This, though it occasions considerable pain 
when applied to the eye-lids, has always greatly allayed the itching and smarting; 
and has even seemed (probably by being carried into the nostrils with the tears) to 
diminish the irritability of the Schneiderian membrane, and hence to lessen the 
violence of the sneezing; — a most distressing symptom. The Vinum Opii was 
tried, many years ago, without any benefit; as in the case of Dr. Bostock.'' 

'* With respect to a residence at the sea-side, it may be observed, that the only 
instance of the disease attacking the patient previously to the usual period, was in 
the last week of May, 1829, during hot weather; — while he was residing, for a 
few days, in an airy house, situated on a cliff overhanging the German ocean. The 
attack, however, was shght, and lasted for two days only; but again returned at its 
usual period in June. As to diet, the patient is decidedly worse when living low. 

"The above detail was written some months ago, and 1 am happy to state, that 
the patient almost entirely escaped the disease this year [1831]; — by merely com- 
mencing, some time previously to the expected period of attack, to anoint the eye- 
lids at bed-time with the ointment; and by bathing them occasionally, during the 
day, with a collyrium composed of rose-water and acetate of zinc; and, after this 
had dried, smearing them with simple spermaceti-ointment; — to remove the stiffness 
left by the collyrium. 

*' I have only heard of one example of this curious disease, in this neighbour- 
hood.*' The patient is a gentleman of fortune; and the instant he approaches a 
hay-field, he is attacked. I have never been able to hear of the disease in the lower 
M'alks of life; though my situation, as physician to two extensive charities in this 
town,** has afforded me ample opportunities of meeting with it, did it exist among 
them. I may add, that none of the patient's family, — that is to say, neither his 
father, mother, brothers, nor sisters, though originally amounting to thirteen, — 
were ever affected in the slightest way by this distressing complaint." 

Mr. Poyseys Case of Hay-Asthma. — There is another case, with which I have 
been favoured by Mr. Poyser, of Wirksworth: — " Mrs. H., of middle age, of a full 
and rather corpulent habit, has been subject for many years to this periodical com- 

' " Medico-Chirurj^ical Transactions;" Volume 14; Page 445. 

^ "Medico-Chirurgical Transactions;" Volume 14; Page 446. 

c Newcastle-upon-Tyne. 

d The "Newcastle-upon-Tyne Infirmary," and the "Newcastle-upon-Tyne Dispensary." 



FUNCTIONAL DISEASES OF THE LUNGS. 775 

plaint. The attack generally commences ab.out the middle of June," — the old time, 
*' sooner or later; according to the heat or closeness of the weather. A sensation of 
heat and irritation is first experienced in the eyes and nostrils; accompanied with 
sneezing, fever, and restlessness. These symptoms (if the complaint increase) are 
succeeded by a sense of constriction about the chest; aggravated very much by 
exertion; and increasing, towards night, to a regular asthmatic paroxysm. In the 
severer attacks of the complaint, there is a permanent wheezing and difficulty of 
breathing; with an inability of moving, or of remaining in a recumbent position; 
and accompanied by pain, fever, quick pulse, and a great degree of general indis- 
position; lasting for some weeks; and leaving great debility, with an oedematous 
state of the feet, ankles, &;c. The treatment has been conducted on general prin- 
ciples." 

To show the hereditary nature of this affection, I will introduce another extract 
from Mr. Poyser's letter: — " Mrs. P. A., also the mother of a large family, has 
had this complaint several years. The symptoms, in her case, resemble very ac- 
curately those described by Dr. Bostock;'' namely, a sensation of heat and fulness 
in the eyes, accompanied with redness and discharge of tears. These sensations 
go on increasing; and a fulness in ihe head is experienced, with irritation of the 
nose and violent sneezing. To the sneezings are added a farther sensation of 
tightness of the chest, and difficulty of breathing; with a general irritation of the 
fauces and trachea. These symptoms are worse by paroxysms, and are often 
traced to changes of the weather and other causes; they do not, however, as in the 
instance of Mrs. H., go on to regular asthma. The complaint wears itself out 
toward the middle of July. This lady decidedly considers the cause of her com- 
plaint to be an emanation from the flowers of grass. It begins when grass comes 
into flower. There is a perceptible increase, or paroxysm, when she is exposed to 
these effluvia; and when the flowering time is over, she can go into a hay-field with 
impunity; which she could not previously do. 

" The father of this lady is immediately seized with violent and continual 
sneezing, and inflammation of the nose and eyes, when he goes into or ap- 
proaches a hay-field; but the symptoms go off when he is removed from the 
smell of the hay. He therefore carefully avoids the exciting cause, and escapes 
the disease. Three of the sons of Mrs. A. are also subject to this disease; and 
their symptoms are similar to hers, though less severe. One of these youaig gen- 
tlemen is now at Geneva; and had the complaint there this summer [1831]. A 
younger son (a boy about ten years old) is made asthmatic by the smell of Guinea- 
pigs." 

We see, therefore, what the character of this complaint is; — that it is not merely 
spasmodic asthma, but excessive irritation of the mucous membrane of the eyes, 
nose, and the whole of the air-passages. It is a combination of catarrh and asthma, 

I have no doubt whatever, that it arises from vegetable matter diffused in the 
atmosphere; that it is derived from the flowers of some plants; and that, in a great 
number of instances, it comes from grass. The lady to whom I have referred,'' 
wrote me a letter, in which she details the whole particulars of her case; and, as it 
contains many interesting facts, I subjoin it: — "I was first afiected with the disease 
in 1798; and from that period have annually suffered from it more or less. It 
usually attacks me about the latter end of May, and continues till the middle of 
July, and sometimes till the close of that month; but this has occurred when the 
weather has been unfavourable, and the hay-harvest has been particularly late. I 
have never suffered after the hay has been got in. 

"The first symptoms are irritation of the nose, violent sneezing, and all the usual 
attendants of 'a cold in the head.' These are succeeded by spasms affecting the 
breath; which have often been so severe as to threaten my life, and are the most 
distressing part of the disease. Violent irritation of the eyes, throat, and the whole 

• "Medico-Chirurgical Transactions;" Volume 14; Page 437. 
^ See Pasre 771. 



776 FUNCTIONAL DISEASES OF THE LIJNGS. 

interior of the head, has been experienced when passing by fields where hay was 
making; which symptoms have all disappeared very soon after entering a room, 
and excluding as much as possible the external air. 

*'I believe the complaint with me to arise principally, if not entirely, from the 
farina of the grass. It has commenced sooner or later according to the season; and 
my first symptom has generally occurred when walking in the fields, and not till 
grass is in flower; and from that time till the hay-harvest is completely finished, I 
suffer whenever I am exposed to the air. 

*'I have tried the sea-air, and also London. The former I found most beneficial; 
although the latter was productive of considerable relief. Ramsgale and Harwich 
have suited me best; which I attribute to the small quantity of grass grown in the 
neighbourhood; and to the bracing air, which has invigorated my general health. 
At all places by the sea, I have been immediately sensible when a land-wind blew, 
and felt instant relief when it came off the sea again; and two years ago, when 
this was the case at Harwich, during nearly the whole of the six weeks I spent 
there, I suflfered scarcely any inconvenience. I walked out daily; went frequently 
on the water; and bathed regularly in the sea. During other seasons, I have been 
obliged to shut myself up entirely in the house; and not to allow a window to be 
opened, or to permit any one who had been into the air to come near me. 

" My children, in approaching me after being in the hay-field have often brought 
on a fit of sneezing, or a spasm of my breath; and this was once effected by their 
sitting down by me to tea, after playing in the barn where the new made hay was 
stacked, some time after the season was over. Once, at Harwich, when walking 
on the shore, I became suddenly affected; which occasioned some surprise, as no 
grass was apparently near; but, on the following day, I found that hay had been 
making on the top of the cliff, at the lime I was walking under it. 

*'At Cromer, two years since [1829], I was suddenly seized with shortness of 
breath, &c., after the complaint had subsided, and all the hay in the immediate 
neighbourhood finished; and upon going into my bed-room, I saw an immense 
stack making, in a yard near the house, with hay which had been brought there 
from a field five miles distant. In 1817, I was perfectly well till the grass was 
cut in our own fields; when my breath became so seriously affected, that it was 
thought necessary to remove me direcdy from the infected air; and I was with 
diflficulty taken from my bed to the carriage which was to convey me to Harwich, 
twenty miles distant: but when I arrived there, I was so much relieved by the 
change of atmosphere, that I walked with ease up two pair of stairs to bed; and 
had no return of illness that season. 

" In packing baskets with hay, I have frequently had fits of sneezing, and tingling 
in my hands; and have every reason to believe, that the seeds of the grass are 
poisonous to me. I have long ceased to have medical advice for the complaint; 
and, by avoiding the exciting cause as much as possible, and using palliatives on 
the, first attack, I have of late years suffered less than formerly, I always confine 
myself entirely, while the hay is making near me; and at other limes I walk with 
salts, or some other pungent scent, in my hand. When I feel the irritation com- 
mencing, if I snuff it up, I can frequently keep off a fit of sneezing. My breath 
is relieved by sedatives; and smoking stramonium will always check the asthmatic 
spasms. 

*'My uncle (Mr. * * ^i^ *^ ^f * * * *^ ^j-jj fjjg g^^^ wqxq affected about the same 
time as myself; — the former with sneezing only, and the latter with all the symp- 
toms. They both attribute it to the grass; and the son is obliged to come to Lon- 
don when his hay is making. A cold season suits me best, and the symptoms are 
aggravated by a close air; which may perhaps arise from the obnoxious particles 
hanging in the air, and being tiius inhaled in larger quantities. I have no disposi- 
tion 10 asthma at any other period of the year; and scarcely ever have a cold, or 
occasion to use a pocket-handkerchief. My habit is relaxed; and I am always 
benefited by a cold bracing atmosphere. I have occasionally found my breath 



FUNCTIONAL DISEASES OF THE LUNGS. 777 

considerably relieved by going out of tbe air, into a crowded assembly; and from 
our own house in the country, to one in a narrow street in the middle of a town." 
The disease has certainly increased rapidly during- the last twelve years; and 
has attacked persons of all ages. Most of those with whom I have conversed on 
the subject, believe it to be occasioned by the farina of the grrass, or something 
poisonous to them, which floats in the air at that time; and which comes when 
the grass begins to flower, and departs when the hay-harvest is over. It is con- 
ceived, by some persons, that it is liie sweet-scented grass which is productive of 
this affection; at least, many persons have decidedly been affected when they have 
gone near sweet-scenied grass in flower; and some ascribe the greater prevalence 
of the disease now than formerly, and conseqnenily the notice of its occurrence, to 
the introduction of some new species of grass into this country. 

Treatment of Hay-v^sthma. — Seeing that the emanations from the grass (the 
pollen, in all probability) is a compound, though I do not know its constitution, I 
fancied that it might be destroyed by the chlorides; — in the same way as some 
animal matter. I therefore requested a gentleman who had the disease to try it; 
and he did so with the most perfect success. This was the first case that I ever 
saw of the disease. A gentleman came to consult me upon it, about three years 
before I saw the lady. I told him, at once, that I knew nothing of the affection; 
and sent him away as he came; — so that neither he nor I got any thing by the 
interview. I told him that I had heard of such a thing as hay-fever, existing among 
distinguished lords and ladies, but I could not conceive what it meant, and there- 
fore I could give him no 'advice. I casually met him, after I had read Dr. Bos- 
tock's paper;^ — and I requested him, as a favour to myself, to try the effect of a 
solution of chloride of lime or of soda. I directed him to place it in saucers about 
the bedroom; to have rags dipped in it and hung upon the backs of chairs; to wash 
his hands and face with it, night and morning; and to carry a small bottle of it 
with him; and to smell it repeatedly in the course of the day. He complied with 
my request; and the result was highly satisfactory. The irritation of the ears, 
(for in his case they also were affected,) the tingling and smarting of the eyes and 
nose, all ceased; and by using this precaution, he got through the summer exceed- 
ingly well. Whether the chloride acted by destroying the emanations, or by les- 
sening the irritability of the mucous membrane, or of the skin, I do not know. 
The chlorides, if well diluted, diminish the morbid irritability of the surface; and 
therefore they might, in this case, have acted in that way. The treatment, how- 
ever, was perfectly successful. The lady* said that she had used every thing, but 
in vain; and I could not prevail upon her to try the remedy. 

In consequence of making this known in the clinical lecture to which I before 
referred," it is said by Dr. Poyser,'' that one of the sons of the lady affected with 
the disease,*^ employed the chloride of soda. Mr. Poyser says, — "The chloride 
of soda has been of great use to this gendeman; removing, at once, the sensibility 
of the nostrils and eyes; and thus allaying the sneezing, cough, and inflamed and 
watery state of the eyes." But he adds, — " Mrs. P. A.*^ has not experienced 
any perceptible advantage from the chloride." Three out of four, however, did. 
"When persons are also subject to spasmodic asthma, I should recommend them 
to breathe through water impregnated with the chloride; and a larger quantity ought 
then to be employed about the bed-rooms, than when they have hay-fever alone. 

Ipecacuanha a Cause of Asthma. — Some persons are peculiarly affected by 
other substances. Many persons have a peculiar susceptibility of ipecacuanha; — 
this is by no means uncommon. If ipecacuanha be powdering in a chemist's 
house, some persons will be seized with a violent paroxysm on entering it. I have 
known an instance or two of this description. I heard a physician say that there 
was a case related on which he could depend, — though I would not myself vouch 
for its accuracy, — of a person who had such a susceptibility of ipecacuanha, that 

a See Page 771. b See Pages 771 and 776. 

« See Page 772. <i See Page 774. 



778 FUNCTIONAL DISEASES OF THE LUNGS. 

on entering a room and being seized with asthma, he declared that there was 
ipecacuanha about. It was at first denied; but at last some one recollected that 
there was a box of ipecacuanha-lozenges in a table-drawer. That was going very 
far; but it is a fact that some persons are seized with asthma, if ipecacuanha be near 
them. 

7%e Smell of Different Animals. — As I shall not have another opportunity of 
doing it, I may mention here, that other persons are peculiarly susceptible of 
various things. Some are affected by the emanations of an animal. Shakspeare 
alludes to some men who cannot bear a gaping* pig;" and some cannot bear a cat; 
— they are made miserable if a cat be near them. It does not produce asthma; but 
the emanation from a cat has such an effect upon them, that they are quite wretched. 
Mr. Poyser (as I mentioned") states, that the son of a lady who had hay-asthma, is 
made asthmatic by the smell of ^^Mnea-pigs. When he is in a room where they 
are, he is immediately seized with difficulty of breathing. I have a note from a 
gendeman, in which he informs me that a nobleman with whom he is acquainted, 
is affected by sneezing and asthmatic affections, by coming in contact with a hare, 
or rather the/wr of a hare; and remains ill for several days afterwards. He experi- 
ences great suffering, whether the hare be dead or alive. 

Dr. King's Caries, — I have another letter on the subject of hay-asthma, — from 
Brighton; but I will only give a portion of it. Dr. King says: — '♦! know a mem* 
ber of parliament, who has come to Brighton every summer for some years, in 
order to avoid the disease at home. A lady also comes from Clapham, for the 
same purpose; and with the same good effect. The lady, however, whom I saw 
with it, told me that she knew a cobbler's wife who had it; and that several per- 
sons of the lower orders, to her knowledge, had the disease. Last year [1830] I 
met, at Lewes, a farmer's wife, subject to the same complaint; and obliged, every 
hay-season, to take refuge in a town. She bears up against it as long as possible; 
and shuts herself close up in her room, till a sense of suffocation comes on, — as in 
common asthma; when she is obliged to throw open the window, by which a fresh 
dose of poison is let in; and the same routine is gone over again, till she is obliged 
to fly. On quitting the regions of hay, she experiences immediate relief. I dined 
lately in company with a lady, who went into convulsions as soon as her plate was 
put before her; — owing to its containing some peas which had been boiled or 
dressed with mint. We carried her out of the room; and she did not feel quite 
well all the evening. Her daughter, who sat next her, was not similarly affected." 

These are circumstances worth knowing; because, if we were not acquainted 
with them, we might ascribe cases of this description to whim and fancy. It would 
be very odd if they were confined to the higher oiders only. It is a thing exceed- 
ingly improbable. The fact is, the lower orders consider the hay-fever as merely 
a common cold; and they do not apply for medical advice unless they are seriously 
ill. They do not think of applying to a public charity, because they are seized 
with a violent sneezing; or if they do, it is a solitary case, and is treated as asthma; 
— the nature and causes of the disease not being known. 

Cases recorded by Laennec. — Laennec had no idea of it; but he mentions one 
or two curious circumstances. The following fact, he says, was communicated to 
him by one of his colleagues; — as affording a curious instance of nervous affection, 
in a man not subject to asthma: — "A man, forty years of age, — slightly hypo- 
chondriacal, but otherwise in good health, — wished to go on horseback to pay a 
visit some leagues distant from his house. As soon as he left the town where he 
resided, which is situated in an extensive plain, he felt an immediate oppression on 
the chest, from the impression of the country air. He took no notice of this at 
first; but the dyspnoea having greatly increased, and being now attended by a sense 
of faintness, he determined to return. He had scarcely turned his horse, when he 
found himself better; and in a few minutes he recovered both his breath and his 
strength. Not suspecting any relation between this momentary uneasiness and his 

» Squeaking. «» "Merchant of Venice;" Act 4; Scene I. « See Page 775. 



FUNCTIONAL DISEASES OF THE LUNGS. 779 

journey, he once more attempted to advance; and was a^ain soon attacked with 
the dyspncea and faintness. On turning towards the town, these passed off. After 
having made repeated attempts to proceed, and always with the same resuh, he 
finally returned; and in just as good health as when he set out. I have lately met," 
continues Laennec, "with a case very analogous to the one just related; only that 
in this the symptoms were more severe, and the cause was different. Count 

H , a man of robust constitution, and although now eighty-two years of age, 

still possessed of a degree of vigour unusual even at the age of sixty, — has been 
subject from his infancy to attacks of asthma; and is habitually somewhat short- 
breathed. Since his fiftieth year he has had a slight cough; and in the morning a 
pituitous expectoration, intermixed occasionally with some yellow sputa. The 
asthmatic attacks have always been unfrequent with him; but they have invariably 
come on if any person has inadvertently shut his bed-room door, or if his night- 
lamp has by chance gone out. As soon as either of these accidents occurs, he 
immediately awakes with a feeling of oppressive suffocation: and after a few 
minutes he becomes insensible. On the occasions alluded to, the attack is got rid 
of by opening the doors and windows, lighting the candles, and carrying the patient 
into the open air. I presume it is the smell of the lamp which causes it; and 
perhaps the emanations from his own body, — the smell of his own perspiration 
when he is shut up. 

We find, therefore, that in many instances of asthma, there is a violent external 
exciting cause; but it varies much in its power in different individuals. A predis- 
posing cause, in many persons, is bronchitis; and, in others, various organic dis- 
eases of the chest. In some persons, without any external excitement at all,— - 
without moisture, or coldness, or confinement from the air, — there will be an asth- 
matic paroxysm; — simply from an irritable state of the mucous membrane, and 
from organic disease. I have already alluded to one case where, from the mecha- 
nical pressure of a smell aneurism, a paroxysm came on, independently of all exter 
nal circumstances.* 

Treatment during the Paroxysm. — The treatment of this disease may be 
divided into two parts; — one part relating to the treatment during the fit; and the 
other to the way of preventing its recurrence. In the fit, if the patient be plethoric, 
it may be well to bleed; but in general this is not necessary. One of the best 
things that can be done is to give the patient a full dose of opium. Frequently a 
very large quantity is borne; — on account of the exceedingly deranged state of 
the system. Forty, fifty, or sixty drops of laudanum, are frequently not more 
than suflicient to relieve the fit. I once had an extraordinary case of this kind; 
where such a dose was given without any effect. A drachm was then given, but 
still without any effect; and so also were two drachms. Seeing this to be the case, 
the medical gentleman who was attending the patient, grew out of patience, and 
gave half an ounce; which was merely sufficient to get rid of the paroxysm. When 
the next paroxysm came on, however, that dose failed entirely; and six drachms 
were given, and produced tolerable relief; but not enough, and at last many 
drachms were given for a dose, with no more effect than that of putting a stop to 
the paroxysm. These are states of the system in which ordinary doses are of no 
use; but, in general, from forty to sixty drops are borne very well; and are suffi- 
cient. It is useful to combine the laudanum, in these cases, with a dose of aether; 
and if we mix them up with ammonia, or with musk, or assafoetida, we shall gene- 
rally add to their good effect. But opium generally answers the purpose. Should 
the patient be plethoric, however, and have chronic bronchitis and fulness of the 
chest, it would be very wrong to give a large dose of this description, lest it should 
produce apoplexy; and it would be right to take away a certain quantity of blood. 
Some patients are relieved by cupping, and some by f/^^y-cupping. 

Treatment after the Paroxysm. — When the paroxysm is over, we may endea- 
vour to prevent its return, by giving a dose of some preparation of opium, together 

» See Page 720. 



780 FUNCTIONAL DISEASES OF THE LUNGS. 

with sether; but in a smaller quantity than in the former case. Some persons have 
told me, that they have seen very ^reat relief from canlharides, in this complaint 
•and in hoopino^-cough. Whether they really are beneficial I cannot tell; but the 
advantage of opium, ?ether, musk, and assafcetitia, is unquestionable. Some liave 
found very great relief from smoking stramonium. I have seen many persons, who 
have derived benefit from smoking the leaves and stalks of stramonium, chopped 
up together. Some have found the smoke of tobacco serviceable; but far fewer 
than those who have derived benefit from stramonium. It is of very great use to 
make patients drink strong coffee, without milk and sugar. It is an old remedy, 
but a very good one. There ought to be no grounds in it, because they may dis- 
turb the stomach; and that organ, in this complaint, is generally much disposed to 
indigestion. If it should so happen that a paroxysm comes on from a hearty meal, 
it will be found very serviceable to give a good emetic, either of mustard or sulphate 
of zinc; — something which will not nauseate the patient long, but will empty the 
stomach as quickly as possible. 

I am supposing, all along, that the patient is free from chronic bronchitis; — has 
simple pure asthma. If, however, there be any chronic bronchitis present, squills, 
digitalis, colchicum, and ipecacuanha, will all be useful; — some by increasing the 
flow of urine, and others by increasing the secretion from the air-passages. Some 
have found relief from opium and prussic acid, and others from hyoscyamus and 
eonium; but if an immediate effect be desired, I think there is nothing equal to 
opium and stramonium. There is no rule for these things; for some persons are 
relieved by one article, and some by another. It is right to consider this as a 
spasmodic disease, which may be removed; and if it can, it should. It may arise 
from a full stomach; and then an emetic is the best remedy. It may arise from 
grass; and then the chlorides scattered about the room, I conceive would be the best 
remedy.* But if we cannot remove the exciting cause immediately, or at all, then 
the best mode of treatmen* is to employ venesection and opium. 

Prophylactics. — With regard to the prevention of the disease, besides the re- 
medies just mentioned, and besides removing the patient from the exciting cause 
if it be known, it is of great use to pay attention to the stomach and bowels. 
Every body knows, that if the abdomen be distended, the diaphragm cannot descend 
freely, and we can scarcely breathe; and asthmatic people suffer, in these circum- 
stances, to a very great degree. Dr. Wilson Philip has spoken highly of galvanism 
in this complaint, and no doubt it does good; but we cannot expect it to be uni- 
versally efficacious, when we consider that asthma is often united with organic 
affections, and with chronic bronchjtis. When persons are very weak, tonics are 
necessary, — particularly iron. Dr. Bree used to exhibit the sesquioxide of iron 
particularly in the disease;" but I have not found it useful, except as a tonic. With 
regard to the inhalation of chlorine, it may be had recourse to in every form of 
asthma. We may impregnate water with it, and make the patient breathe through 
it, and in that way inhale it. The same means may be adopted with regard to 
prussic acid and eonium. Some have found benefit from tar; and others from 
tanners' liquid, put in one corner of the room. Another way of giving persons 
the advantage of these things, is to impregnate water with them; and to make 
patients breathe through the water, three or four times a day. 



SECTION II.— HOOPING-COUGH. 

Synonymes. — The next disease which I shall describe, and which (in some 
respects) is very much allied to the last, is hooping-cough. The disease is so 
called, from the peculiar noise attendant upon the cough. Sometimes it is called 
*' c/iin-cough," because it particularly attacks children; and " chin''' (I suppose a 

* See Page 777. 

b " Practical Inquiry on Disordered Respiration; distinguishing Convulsive Asthma, its 
Specific Causes, «fec. By Robert Bree, M. D." 



I 



I 



FUNCTIONAL DISEASES OF THE LUNGS. 781 

corruption for " hincV) is the German for " chihiy In Latin it is called " tussis," 
— "cough;" or, to show its intensity, "pertussis," — '"imich cough." 

Symptoms. — This disease is easily known when it has been once seen. There 
are occasional fits of violent coughing, with short expirations, — a volley of them; 
and then one deep, long, hooping, crowing inspiration; and iliese are many times 
repeated. A quantity of viscid phlegm is spit up; and very often the child vomits. 
The cough is exceedingly severe; every muscle is put into action; the face grows 
red; the eyes " run;" and then the child, although unable to stand, and apparently 
about to be strangled, runs about and plays an instant afterwards, as if nothing 
were the matter with him. This is very commonly seen: and the cough will 
come on day after day. At first, there is generally some catarrh and bronchitis 
with it; and these are of various intensity, as is also the cough. Sometimes the 
bronchitis is very considerable; so that the child has a constant difficulty of breath- 
ing, a constantly quick pulse, and constant heat; and is exceedingly ill. The dis- 
ease, although to a great degree spasmodic, and sometimes almost entirely so, is 
occasionally, on the other hand, inflammatory in a high degree. When it has been 
inflammatory, and the child recovers, the spasmodic cough will frequently continue, 
even for months after the inflammatory state has subsided. 

Premonitory Symptoms. — The first notice of the disease, is generally occa- 
sioned by the extreme violence of the cough, or by a hoop. Very frequently it is 
not noticed at all, till the child hoops; and then there is no doubt of the nature of 
the disease. In fact, we are never justified in saying that the disease exists, till 
the child hoops. If the disease prevails in the neighbourhood, and the child coughs 
more violendy than usunl, in all probability, it will " turn" (as people say) to the 
hooping-cough. But if the disease be not fully formed, one cannot say with cer- 
tainty that it is the disease, unless the child hoops. 

Duration and Prognosis. — If the bronchitis be violent, or if it continue for a 
great length of time, though not violendy, the child may die. As a mere spas- 
modic aff'ection, hooping-cough does not generally destroy life. In the greater 
number of cases where children die, there is a violent or extensive bronchitis, and 
a violent or extensive inflammation of the substance of the lungs. 

The disease may destroy a child in two or three weeks, or it may not destroy it 
for many weeks; but after the disease has lasted six or eight weeks, it generally 
gives way. It seldom continues longer. Children, however, from the very slight- 
est cold, are apt to hoop again. Some will hoop occasionally during the greater 
part of a twelvemonth; and some, when they have once had the disease, will be 
observed to hoop at a more distant period even than that, if they catch a severe 
cold. 

When a child vomits, it is generally considered a good sign. If there be no 
vomiting with the cough, it is observed by those who have most experience, that 
the child gets worse. Dr. Gregory knew a lady, who never hooped in the disease; 
and therefore it was hardly " hooping-cough.^^ The disease prevailed in the family, 
and she had as violent a cough as the rest; but at the time she ought to have hooped, 
she always fainted. 

The danger is in proportion to the other symptoms; — that is to say, the symp- 
toms of affection of the head, and of bronchitis and peripneumonia. The younger 
the child, the greater the danger. It is a very dangerous disease when it occurs in 
infants. Those who suppose that the disease arises from contagion, consider that 
it remains latent, from a few days to a few weeks; and they suppose that the dis- 
ease itself, when it occurs in an individual, is not capable of communicating con- 
tagion beyond a month or six weeks; — just as is the case with other contagious 
diseases. Gonorrhoea, for example, after a certain lapse of time, — although nobody 
will venture to fix the period, — is not contagious. 

Morbid Appearances. — On opening children who have died of this disease, we 
occasionally find very litde the matter in the lung's. The child may have died 
from something else; for the disease has a great tendency to produce iiydroceplui- 
lus, convulsions and various aflfections of the head; — such affections as we see iu 



782 FUNCTIONAL DISEASES OF THE LUNGS. 

chiUlren.* It is one of the great calamities attending the disease, that the effects 
of it are so fatal. There is such continued difficulty of breathino;, and such violent 
cough, that the vessels of the head are over-distended; and the consequence is such 
congestion and irritation of the head, that hydrocephalus continually occurs. I 
know that violent coughing will overstrain the vessels of the head, and produce 
great mischief; for I saw an infant that had never been well from the moment it 
had coughed violendy. It was so strained, that the parents (from time to time) 
fancied it would die. From the instant of the coughing, the head drooped, and 
convulsions came on; of which it ultimately died; although, till seized with this 
violent cough, it was comparatively well, — having nothing the matter with the 
head; and having only a com.mon cough at first; — such as other children in the 
family had. Thus children die from hooping-cough; or from the efftcts of it, 
rather than from the disease itself; and yet, after death, we can discover very little 
wrong in the lungs. But frequently, indeed generally, on examining the lungs, 
we find a large quantity of mucus in the bronchia. The mucous membrane is 
red, soft, pulpy, and increased in thickness; so that there is clearly bronchitis. 
Frequently, also, the lungs are very solid. The air-cells have become inflamed; 
and the lungs are very much hepatized. I have opened children who have died 
from hooping-cough; and nearly the whole of the lungs have been like liver. They 
did not collapse; and, on pressing them, we could scarcely diminish their bulk in 
the least. When bronchitis takes place, on listening to the chest, tlie common 
signs of that disease are found to be present; — there is the sonorous rattle which 
occurs in the breathing of adults; and we hear the respiratory murmur excessively 
loud and rough throughout the chest, 

Causes, — By far the most frequently it aflfects children; but it also affects adults, 
I heard that the late Archbishop of Canterbury* had it, a short time before he died. 
It is frequently an epidemic disease. It does not, in general, occur more than once; 
except in a mere spasmodic form; — when the parts are thrown into such a condi- 
tion as to produce hooping, although the real disease does not return. Hooping- 
cough is supposed, by some, to depend on a specific contagion. Some deny this; 
but others assert it. I was always taught that this was its source, and I never 
thought of doubting it; but others have done so, and 1 suppose they have a reason 
for it. Any irritation whatever will provoke a paroxysm, when a patient has the 
disease. If a child be put in a passion, or we move it about quickly, or give it 
any thing stimulating, then a paroxysm will take place. There may be various 
exciting causes of a paroxysm; although the peculiar exciting cause of the disease^ 
I presume, is only one; — either a specific contagion, or something peculiar. 

Pathology. — [There has been great diversity of opinion respecting the nature 
and essential seat of pertussis. Cullen, Guibert, Hoffmann, Hufeland, and most 
other German authors, consider the disease as essentially nervous; — depending on 
irritation (not inflammation) of various parts of the nervous system, particularly 
the phrenic and pneumogastric nerves; and causing spasmodic action of the larynx, 
diaphragm, and stomach. Leroi, Webster, and Begin, ascribe the disease to in- 
flammatory irritation of the brain and its membranes. Watt, Badham, Dawson, 
Dewees, Guersent, Laennec, and most other French authors, hold the disease to be 
essentially bronchitic or catarrhal, with the addition of convulsive action of the 

^ I (Dr. EUiotson) was suddenly called to an infant in convulsions, which had begun 
some hours before. It had been labouring most severely under hooping-cough for a month. 
I instantly took away a large quantity of blood from the head by leeches, but was too late; 
the convulsions, insensibility, squinting, &c., never ceased; and the child died in two hours. 
On cutting into the brain, innumerable large orifices of blood-vessels appeared, and the 
arachnoid membrane of the ventricles was an uniform scarlet tissue of vessels. Although 
the hooping-cough was violent to nearly the last hour, the lungs and trachea were perfectly 
free from the smallest mark of inflammation or any other disease; a little mucus only was 
found in the ramifications of the bronchia. This case explains why prussic acid is so 
generally serviceable in hooping-cough. Convulsions are a common efiect of hooping-cough, 
and here arose from it as a disease purely spasmodic, 

•» The Rev. Dr. Manners Sutton. 



m 



FUNCTIONAL DISEASES OP THE LUNGS. 783 

diaphraofm and larynx; excited, according- to some, by an excessive sensibility of 
the inflamed bronchial membrane. A third view, particularly maintained by Des- 
ruelles, is that hooping-couffh depends on inflammation of tlie bronchi, speedily 
causing irritation in tlie brain; whence is reflected convulsive excitement of the 
diaphragm, muscles of the larynx, &c.: which gives to the cough its peculiar 
character. Dr. Copland* considers the disease to be essentially a nervous irrita- 
tion; commencing in the respiratory surfaces, and (through the nerves, chiefly the 
pneumogastric) transferred to the "medulla oblongata;" whence it again affects 
the respiratory apparatus, and sometimes the stomach; and that predisposing or 
concurrent causes may readily convert this irritation, at either of its seats, into 
inflammation. 

In reference to these different views we** may remark, that in many instances 
they do not sufficiently regard the physiological character of those morbid motions, 
which form the chief feature of hooping-cough. Thus we find much ascribed to 
the phrenic nerve and diaphragm; when it is obvious that these agents of inspira- 
tion are little, if at all, concerned in the motions which constitute the cough. We'' 
regard hooping-cough as originating in a specific irritation (almost always inflam- 
matory at first) of the lining membrane of the upper portions of the air-passages. 
This irritation is in the first stage constant, and accompanied with cough and ex- 
pectoration, like those of common inflammatory catarrh; but in the second stage 
it pecidiarly increases the irritability of the laryngeal constrictor and bronchial mus- 
cles; and of the nerves which excite the contractions of these, as well as of the expira- 
tory muscles which are sj^m pathetically associated with them; — those, in fact, which 
are concerned in the act of coughing. The peculiar cough of pertussis resembles 
that excited by a foreign body direcdy irritating the glottis; in fact, it is properly 
called "/pertussis;" for it consists of an exaggeration of all the actions of an ordi- 
nary cough, and of nothing more; and there is no more reason for seeking its 
cause in the brain or spinal marrow, than there is for referring excessive vomitincr 
or dysenteric straining to this seat. It is unnecessary to go further than the respi- 
ratory apparatus, for an ex[)lanation of the phenomena of hooping-cough. The 
irritation which at first extends to the vessels and is more constant, becomes after- 
wards purely nervous; and, like other local nervous affections, — such as neuralgia, 
spasms, nervous colic, &c., — manifests its effects only occasionally, perhaps under 
the influence of some additional exciting cause. The various complications which 
so much increase the danger of hooping-cough, we would regard chiefly as the 
effects of the violent cough; sometimes assisted by predispositions to particular 
diseases, or by co-operating causes. Any one who has witnessed the severe pa- 
roxysms of hooping-cough, can scarcely wonder that it may produce in the head, 
in the lungs, and in the abdomen, serious congestions: which previous tendencies, 
or additional exciting causes, may readily convert into inflammation and its eflfecls; 
hydrocephalus, pneumonia, and intestinal disease. *"] 

Treatment of the Inflammatory Stage. — The treatment of hooping-cough is 
twofold; — accordingly as it respects the inflammatory or the spasmodic condition 
of the parts. The most important thing, by far, is to remedy the inflammatory 
state; — the bronchitis or peripneumonia. If it be found that there is a constant 
oppression of the breathing, with spasmodic attacks of increased difficulty, and oc- 
casionally a violent cough, and that there is an accelerated pulse, and pyrexia, to- 
gether with sonorous, sibilous, and crepitous rattle, — it will be evident that there is 
inflammation of the bronchia, or the substance of the kings; — the air-tubes, or the 
air-cells, or both. Of course that inflammation must be remedied in the usual way. 
We might give all the antispasmodics, all the narcotics, and all the other medicines 
tliat are supposed to have a direct influence over the spasm, and yet do no good. 
In fact, we should make the patient worse; and if nature were not to get the better 
of us, and cure the individual, there is every probability that great mischief would 

* " Dictionary of Practical Medicine;" Volume 2; Page 242. 

bDr. C.J. B.Williams. 

^ •' Library of Medicine;" Volume 3; Pages 97 and 98. 



784 FUNCTIONAL DISEASES OF THE LUNGS. 

be done. It is therefore highly important to ascertain the existence of inflamma- 
tion; and to remedy it, if possible, in the usual way; — by taking blood from the 
neighbourhood of the chest; occasionally by bleeding in the arm, if the patient be 
old enough; but particularly by local bleeding, and the exhibition of mercury, and 
of emetics. 

Emetics and Leeches. — In the greater number of cases, the inflammation is such 
as will yield to the application of a few leeches, and the exhibition of emetics; but 
it is of great use, at the same time, to clear out the bowels by calomel, — provided 
the inflammation is severe; and to give it steadily in small and repeated doses. 
The inflammation is frequently not so severe, but that an emetic every day, or 
night and morning, will be found sufflcient for all the purposes of remedying the 
bronchitis; still I would not trust to it in severe cases. 

In this, as in most diseases of children, the warm-bath is of essential service. It 
is thought by some, that the friction of tartar emetic ointment over the chest, is 
more useful than the application of blisters. I rather feel disposed to think, that 
this is the case; and that blisters are not of very great utility in the affection. 

Regulate the Diet. — It is of great importance not to allow children to overload 
the stomach; for the cough is generally much more troublesome after meals than 
before. When there is any inflammation, the food should (of course) be exceed- 
ingly light; — afl'ording scarcely any nourishment; and the patient should not be 
allowed to distend the stomach with liquids. During the whole period of the dis- 
ease, even when the inflammation is gone, the food which is given should be very 
compendious, — not bulky. It is also of great use, in this disease, to prevent chil- 
dren from moving about a great deal; for running will frequently excite the cough; 
and it is also of great use to keep the child quiet mentally; for a fit of passion will 
bring on a violent cough. The bronchitis will sometimes continue for a great 
length of time. The breathing will be difficult for some weeks; there will be more 
or less feverishness; and the child will waste away; but by the steady employment 
of antiphlogistic regimen, with a moderately open state of the bowels, many cases 
will do exceedingly well; — notwithstanding the bronchitis may contmue, though 
not in a violent degree, for some time. 

Treatment of the Spasmodic Stage.-^Next to the employment of emetics, nar- 
cotics are of very considerable use. Emetics will not cure the disease; because 
there is, in many cases, violent inflammation, and we must treat that in the usual 
way; but there is hardly a case of hooping-cough, that will not be much mitigated 
by the continued use of emetics. In the first instance, a large number of cases 
may be trusted to them, and to the administration of narcotics. Prussic acid is 
very useful in this complaint; not in subduing inflammation, but in subduing the 
tendency to cough. We may give it to the youngest child; but of course it should 
be in a small quantity. If the child be young, we may put one minim to one or 
two ounces of almond-emulsion; and one tea spoonful of this mixture will some- 
times be found as much as is proper. This is one of the most convenient modes 
of exhibiting it; and from the sixteenth to the fourth of a minim may be given, 
three or four times a day. After the disease has lasted some time, opium is more 
or less useful, given in a small quantity. "Dover's powder" is one of the best 
forms. The extract of conium and hyoscyamus may be given in small doses, 
rubbed up in mixtures or emulsions; but I think prussic acid is one of the best 
things. It will not cure the disease; it has no specific power over it, any more 
than any other narcotic; but it does remedy spasmodic irritation of the air-passages, 
exceedingly well; and very often better than other narcotics. 

Tonics. — After a certain time has elapsed, and no bronchitis exists, or so slight 
a degree of it that it requires no inflammatory treatment, — when there is debility 
and irritation of the air-passages, rather than any thing else, — tonics may be given. 
Various metallic tonics have frequently been employed. I do not know that any 
one is so good as iron; it seems to me to be the best we have. The sulphate is a 
form in which the medicine may be given to children very conveniently, dissolved 
in various mixtures; and, as they are fond of sweet things, the sesquioxide mixed 



PHTHISIS PULMONALIS. 7S5 

with treacle, may be very easily given them. I am not aware that it exerts a par- 
ticular power over the cough; but, when the disease has existed some lime, such 
remedies are very useful. 

Friction. — Some persons place great reliance upon friction, with some external 
application; and narcotics are frequently applied in this way. I believe that a very 
good remedy is a quack medicine, called "Roche's Embrocation." Any stimulant 
not sufficient to abrade the cuticle, and produce inflammation, if it have united with 
it a quantity of opium, will be found exceedingly serviceable. Friction along the 
spine is particularly recommended. 

Cold-Bath and Change of Air. — After a time, there can be no doubt of the use 
of the cold shower-bath; but one of the best things is change of air. Every old 
woman says so; and I believe she is perfectly right. I have known (as every one 
must) many cases, where the cough continued in spite of all the medicines that 
could be given, and all the physicians that could prescribe them, till the residence 
was changed; and then the cough speedily diminished. This will not do good at 
the beginning. It is only when the disease has existed some time, and is disposed 
to cease, that a change of air will cause it to disappear, better than any thing else. 

Inhalation of Tar or Chlorine. — The inhalation of tar-fumes has been recom- 
mended; but as these are acrid, it would be a wrong practice during the inflamma- 
tory stage; though when the disease becomes merely spasmodic, they may be of 
use. The mode of employing the tar, is to put it in a pipkin in the room, and to 
let the fumes ascend so as to impregnate the air. In doing this, great care should 
be taken that the fumes are not too strong; or they will cause irritation, instead of 
subduing it; but, with proper precautions, it is a remedy that is of great use. I 
dare say chlorine, used about the room in the same way, would be beneficial; but 
great care is required not to use these things to the degree of producing irritation. 

Hooping-cough is a very troublesome disease to treat. We may save life by 
subduing inflammation; but with regard to removing the complaint, we may find 
ourselves very much baffled. Much good, however, may be done, with respect to 
the spasmodic part of the aflfection, by good management; — by giving light food, 
and a very moderate exhibition of narcotics. Of all these prussic acid is the best; 
for although its exhibition is not very satisfactory, I am persuaded it is more satis- 
factory than that of any other narcotic. 



CHAPTER X. 

PHTHISIS PULMONALIS. 

I SHALL now describe an organic disease of the lungs, for which unfortunately 
we can do little or no good; and which causes more destruction in this country, 
than any other aflfection whatever. It is "consumption." I shall commence by 
describing, not the symptoms, but the changes of structure which takes place in 
the lung itself. 

Definition. — This disease is called, in common language, "consumption," or 
*'/)w/mowar?/ consumption;" and, in medical language, "phthisis pulmonalis," or 
simply "phthisis;" — "/)w/mona/is" being understood. The word '^phthisis'' is 
derived from 4)9tw, to consume. This disease is apparently of a scrofulous nature. 
The substance which is deposited is precisely that which takes place in those parts 
which are said to labour under scrofula. Some have made varieties in phthisis, as 
being tubercular or not; but by ''phthisis^' is now meant, not an ulceration of tlie 
lung, but a scrofulous disease of the lung; which may produce ulceration; and 
which will produce ulceration, if it continue long enough. But ulceration not con- 
nected with this disease, is not called "consumption." An abscess may be formed 
VOL. I.— 50 



7S6 PHTHISIS PULMONALIS. 

from common inflammation, rare as it is: but that is not called "phthisis;" — it 
would be called simply "an abscess in the lungs," or "a vomica." By ""phthisis'^ 
is meant a deposition of a scrofulous substance in the lung; and all the organic 
changes to which its presence, or the state which produces its presence, gives rise. 



SECTION I.— PATHOLOGY OF PHTHISIS. 

Deposition of Tubercles. — The deposition, in this disease, takes place in minute 
granules; which are grayish, semi-transparent, and pretty firm; lying close to each 
other, over a certain space in the substance of the lungs. Although at first they lie 
distinct from each other, yet they are close. They increase in size; and they like- 
wise increase in number, and, as they increase in this twofold manner, they of 
course approximate. The space between them diminishes; till they coalesce, and 
form a mass. When they increase in size and number, they possess less semi- 
transparency; — they become opaque and yellow. This change is first observed 
either at the centre, or on some part of the surface; and from the point at which it 
commences it gradually pervades the whole "tubercle," as it is called.* When the 
tubercles are few, they seldom exceed the size of an almond each; but the masses 
produced by their aggregation, may be very large. I have often seen the whole of 
one lobe of the lung, and I once saw the whole of one lung, converted into a solid 
tubercular mass. Laennec conceives that, in such a case as this, the tubercular 
deposition has taken place in a diffused manner; — that there has not been a forma- 
tion of distinct separate tubercles, but that the substance was difiused in the texture 
of the lung; and he calls this mode of deposition " tubercular infiltration."" Whether 
he is right or not, I do not pretend to say. 

Their Shape and Situation. — The shape of the tubercles is round, and rather 
oval; and this might incline us to suspect, that their situation is the air-cells. That 
they may be formed within the air-passages, is proved by the dissection of glan- 
dered horses by Dupuytren and Andral. The bronchial tubes were filled with 
granules, mixed with, pus and tubercular substance. Hence it is clear that these 
substances may be found in the air-passages; and Andral says, that he also found 
a tubercular mass in the minute twigs of the bronchia, where no ulceration existed; 
of course, therefore, the deposit may be formed in the air-cells. Many have said 
that this deposition takes place in the cellular membrane of the lungs; but when 
we consider its situation, and consider that it is found in the minute bronchial 
twigs, and not leading to ulceration, it is probable that it is formed in the air-cells. 
Cruveilhier says that, after injecting mercury into the bronchia of a living animal, 
he found each globule of the metal surrounded by a concrete substance, formed of 
white granules, in various parts of the lungs. By injecting the mercury into the 
bronchia, it reached the air-cells; and he afterwards found granules, formed of 
-tubercular substance, around the globules of mercury. Still it is to be remem- 
bered, that a similar effect is produced in the cellular membrane, by injecting mer- 
cury into an artery; and that flakes, precisely similar to those in the lungs, are 
seen in the spleen, and in the cellular membrane of various parts. I will not, 
therefore, take upon myself to pronounce, whether tubercles exist in the one or 
the other. They may exist in both; but there are arguments on both sides. 

Softening of the Tubercles. — After a longer or shorter time, the tubercular 
mass softens, — generally first in the centre: and the greater part becomes a fluid, 
resembling pus, in the midst of which are seen particles of the original solid and 
friable deposit. The membrane which is often found around the deposition, like- 
wise secretes pus. Long after the tubercle is gone, the membrane which sur- 
rounds it continues to secrete pus; and the cavity enlarges by ulceration. The 
openings of the bronchia, which had been lost by the deposit surrounding them, 

« See Page 190. 

'' See Dr. Forbes's Translation of Laennec's Treatise on Diseases of the Chest; Part 1; 
Book 2; Chapter 7. (Third Ediiionj Pages 278 and 283.) 



PHTHISIS PULMONALIS. 787 

blocking- them np, compressing them, and causing them to ulcerate, — are seen 
opening- into the cavity of the abscess, on all sides. Bands of pidnionary sub- 
stance, and blood-vessels (shrunk and obliterated), are seen leading- across the 
cavity, with tubercular deposit upon them; while a great number of blood-vessels 
are completely obliterated, and run flattened along the sides. 

Usually Commences at the Superior Part of the Lung. — While some tuber- 
cles are advanced to this degree in one part, others are less advanced; and others, 
again, are exceedingly minute (having been recently formed); both at a distance, 
and in the neighbourhood. We see them in all states, in the same lung: but it is 
an established fact that, in by far the majority of instances, the greatest deviations 
from a healthy structure, exist at the superior part of the lungs; and the first 
tubercles are, in the greater number of instances, deposited there. The reason 
why there is the greatest devastation at the upper part of the lung, is because the 
tubercles are first deposited there. In proportion to the duration of the tubercle, 
in general, is the change it has undergone; and if tubercles, therefore, be deposited 
in the upper part first, we may expect the third stage to be arrived at there, sooner 
than at the other parts. The reason of the tubercles being first deposited in the 
superior part, is not known; unless it be that the superior part of the chest is more 
exposed to the vicissitudes of temperature, than other parts. It certainly is a fact, 
with respect both to males and females, that the upper part of the lungs is less 
covered by dress than the lower. In ladies, and in women of all ranks, the neck is 
bare; and so is the upper part of the chest; and with regard to ourselves, we have 
the breast more open than the lower parts; except when close square waistcoats 
are worn. But whether this will explain the circumstance I have mentioned, I 
will not pretend to say. 

Some have made observations upon which lung is most affected with tubercles. 
Laennec sa'ys the rights but the majority of authors say the left; and therefore I sup- 
pose that one side is as much subject to them as the other. I have never made 
any observations on the matter. 

[The upper and back part of the lungs is the most common seat of tubercle, and 
the left side is more frequently affected than the right; — an observation first made 
by Stark, and corroborated by Carmichael Smyth from an examination of the cases 
recorded by Bonetus and Morgagni, and more recently by Louis from his own ex- 
perience. The last author found tubercles exclusively confined to the right side in 
two cases only, and in five to the left; of thirty-eight in which the upper lobe was 
totally occupied by large excavations and tubercles, sa as to be impermeable to air, 
he met with twenty-eight in the left and ten only in the right lung; and in eight of 
perforation of the pleura, he found seven on the left and one only on the right side. 
When to these observations we add the result of Reynaud's experience, — who, of 
forty cases of pneumothorax, found twenty-seven on the leftside, and thirteen only 
on the right, — I consider that there is sufficient evidence to confirm the conclusion, 
that the left lung is most frequently affected.*] 

State of the Lung around Tubercles. — The intervening portions of the lung, 
dividing the tubercular deposition, are not always healthy; — being frequently tur- 
gid with blood, and with a bloody serous fluid; and sometimes they are indurated, 
and of either a red or a gray colour. The bronchial membrane, on being slit up, 
is frequently found red; and evidently smeared with a far greater quantity of mucus 
than in health. Thus there is evidently peripneumonia, — inflammation of the 
substance of the lungs, in many cases; and likewise bronchitis. I think there can 
be no doubt, that by far the greater quantity of expectoration in phthisis, is derived 
from the bronchial membrane; — much more than from the abscess; and the fluid 
secreted by the bronchial membrane is, as m common bronchitis, of all degrees of 
consistency, and of all degrees of quality. 

Dr. Stark's Researches on Phthisis. — Admirably as the morbid anatomy of 
phthisis has been investigated by the French, I am bound to do justice, on this 

» " A Treatise on Pulmonary Consumption. By Sir James Clarke, Bart., M. D." 
Pages 128 and 129. 



788 PHTHISIS PULMONALIS. 

subject, to one of our own countrymen; as I formerly did* on the subject of the 
enlargement of the air-cells, to Sir John Floyer, and Dr. Baillie, — a truly eminent 
physician of the last generation. In the " Medical Communications,"" tliere is a 
very admirable paper on the Morbid Anatomy of Phthisis, by Dr. Stark; who was 
a very clever young man, and fell a victim to his ardour in investigating Morbid 
Anatomy. Dr. Stark, more than fifty years ago,'' pointed out that phthisis was 
essentially a tubercular affection; — a fact which, though known to Hippocrates, had 
been passed over by almost every other ancient writer; — Greek, Roman, and Ara- 
bian; and by many of the moderns. Sydenham himself considered tubercles and 
abscess, as rather the effect of disease, than the actual disease itself. Boerhaave 
was not acquainted with the subject. Dr. Stark, in his paper, traced the tubercles 
from their original minuteness and solidity, to their enlarged and softened state. 
He asserted that the chief seat of the affection, was the superior and posterior part 
of the lungs; and particularly, he says, the left lung; — agreeing therefore with a 
great number of writers, in opposition to Laennec.*^ He stated that the bronchial 
ramifications were never obstructed or obliterated, but opened into the cavity; but 
that the blood-vessels suddenly became constricted near the orifice; and even 
obstructed by a coagulum; so that an injection would not pass into the abscess from 
the large blood-vessels, or flow into the blood-vessels around the abscess. He found 
that the injection rendered the surrounding parts quite hard; so that the diseased 
parts which appeared firm before, became soft by contrast. He also mentioned, 
that the parts unaffected by the tubercles, but immediately around them, are gene- 
rally red and firm; so that he found, between the effects of the tubercles and this 
induration, that about one quarter only of the lungs, in extreme cases of phthisis, 
remained fit for duty. He ascertained that the tubercles generally have a capsule; 
and that adhesions of the costal and pulmonary pleura, generally exist where an 
abscess is within. Y/e find, on opening persons who have died of pKthisis, and 
Avhen the tubercles exist near the surface, — especially if they be softened down, — 
that there are adhesions on the outside of the surface of the lung, attaching il to the 
pleura. This is a provision of nature, to prevent the escape of the contents of the 
abscess into the cavity of the membrane. The care taken by nature to prevent 
sudden and speedy death, — which would take place, if the blood-vessels were not 
filled up by a coagulum, and flattened down upon the sides; and the equal care 
taken to prevent sudden death from inflammation of the pleura, occasioned by the 
escape of pus from any of these abscesses, — is certainly very striking; but both 
circumstances were pointed out long ago by Dr. Stark. The French are not aware 
of his existence; having, till of late, read but little of English literature. 



SECTION II.— SYMPTOMS AND PROGRESS OF PHTHISIS. 

The symptoms of phthisis vary, according to the progression of the tubercles. 
This is the case both with the general symptoms, and with those which are to be 
learned by the ear. When the tubercles are only in a solid state, and are not 
united together into groups, we can learn nothing of their existence from the ear. 
We can only /;reswme their existence, from the general state of the patient; and 
therefore cannot be sure that tubercles are formed. When they are sufficiently 
numerous to constitute groups, then, on striking that part of the chest, we hear a 
different sound from that which is audible, when nothing but air is present. When 
the part is softened, and a cavity is produced, various other sounds will be heard. 
The part will sound different from what it would, were there no cavity at all, and 
no unnatural state of the parts; but where the air enters a healthy part, and leaves 

» See Page 750. 

*"' Medical Cummunication?, by a Society for the Promotion of Medical Knowledge." 

c In 1788. ^ See Page 787. 



PHTHISIS PULMONALIS. 789 

it again. From what I have said respecting the morbid anatomy,* the cause of the 
different sj^mptoms I have to detail will be evident. There must necessarily be 
more or less pain, congh, expectoration, and at last hectic; and we shall see that 
the sounds in the chest must all perfectly correspond. 

General Symptoms: Hsemoptysis. — This is, for the most part, a very slow and 
insidious affection. Long before any other symptom occurs, it is very common 
for the individual to be seized with haemoptysis, — "spitting of blood." This, as I 
mentioned when speaking of haemoptysis (or " hsemoptoe,"^ as it is sometimes 
called), is usually from the bronchial membrane." The blood is of course frothy, 
scarlet, and mixed with air. Occasionally it is in considerable quantities; but, for 
the most part, it is not to any great amount. The patient frequently has several 
returns of this, before any other particular symptom of phthisis presents itself. 
When phthisis occurs, there is then, for the most part, little or no more spitting 
of blood. 

Cough, — Whether this has occurred previously or not, one of the first symptoms 
noticed is a short tickling cough; — such a cough as the patient denies even to exist. 
It is observed by his friends, while he himself for the most part complains little of 
•it; or, if questioned on the subject, denies it altogether. The cough is short, tick- 
ling, and hacking, rather than very severe. With this cough there is generally spit 
lip only a litde mucus; — either at the same time, or soon after its commencement. 

Stitch in the Side. — It is very common to hear the patient complain of "a stitch 
in the side," generally low down; and one would think it was a slight pleuritic 
affection; only that sometimes the stitch is undeniably felt beyond the chest in the 
parietes of the abdomen. I have known a very violent stitch, before any other 
symptoms of phthisis, low down in the abdominal muscles, out of the way of the 
chest; so that these pains, though they are occasionally pleuritic, are, I have no 
doubt, very frequently muscular. 

Cough increases at Night. — The cough is generally worse when the patient 
gets into bed; owing, I presume, to the coldness of the sheets; or when he rises 
in the morning; — from the coldness of the atmosphere of the room, compared with 
the warmth of the bed. There is felt a little shortness of breath on motion; — on 
any exertion, the patient finds that his breath is not so good as before; and he com- 
plains of languor. 

State of the Surface. — The flesh becomes soft; so that on taking hold of the arm 
of a patient, even at this time, we find it is flabby. The hair loses its strength; so 
that it cannot be kept in order as before. This occurs particularly in females. 
There appears to be a softness of the hair; which will not allow it to remain in the 
way in which it has been placed. 

Feverishness. — There is also observed, about this time, a little feverishness. 
The pulse is found to be quicker than natural; and this comes on particularly after 
the least exertion. An exertion which before would quicken the pulse only per- 
haps ten beats, will now quicken it twenty or thirty, in a minute. On falling 
asleep, it is very common for patients to find that they sweat in some one part of 
the body; — in the calves of the legs, for instance, or upon the chest. The power 
of resisting external temperature is diminished; so that the patient complains of 
chilliness. 

Character of the Sputa. — The expectoration, although only mucous originally, 
now becomes sanguineous. Perhaps the patient never had haemoptysis, but tlie 
complaint has begun with the general symptoms I have mentioned; but he tells 
ns, on one of our visits, that what he has spit up was brown, or tino^ed with blood. 
That is another form, in which a discharge of blood takes place. Very frequendy 
there is the haemorrhage which I before mentioned; but more frequently, perhaps, 
there is no such thing as any decided haemoptysis; but the mucus, after a time, 
becomes a litUe streaked with blood. 

» See Pa^es 785 to 788. «> See Page 763. 

b From aifAct^ blood; and tttuw, to spit. 



790 PHTHISIS PULMONALIS. 

Second Stage. — There is now more cough, more dyspnoea, and more debility 
than before; and the patient begins to find, that he lies more easily on one side 
than on the other. The patient finds his strength decrease; or, if he do not him- 
self allow it, yet it is evident to others. He cannot make the same exertion as 
before; and it is also pretty evident that he loses flesh. Occasionally there is a 
sharp pain in the side, of a pleuritic character; — so as to make it necessary to take 
away a little blood. There is clearly inflammation of the pleura. If the patient 
be a female, menstruation is almost sure to decline. The catamenial discharge 
loses its natural redness; becomes paler than it should be; and, as well as being 
thus impaired in quality, becomes more scanty in quantity; and, more frequently 
than not, ceases altogether. 

Incurvation of the Nails. — Generally, as these symptoms proceed, the ends of 
the fingers become enlarged. The last joints of the fingers look broader than they 
did before; the whole appear tumid, and the nail is particularly prominent. The 
eyes, too, become very clear. There is a whiteness and transparency of them, 
"which did not exist before; — the sclerotica looks of a more intense white than 
natural. The nails sometimes become very considerably incurvated. The whole 
nail is more convex than before; and, I believe, rather softer, — like the hair; and 
that part of the nail which is unattached to the cutis, is in many instances very 
much bent. The hair, which at first is only soft, and with difficulty kept in order, 
now generally falls cflf. 

Change in the Character of the Sputa. — The expectoration, from being mere 
frothy mucus, now becomes a Hide green, or a litUe yellow, and more abundant; 
and, instead of being long and stringy, — like the expectoration of health, — it be- 
comes short between the fingers. Now and then the expectoration becomes fetid, 
the strength very much declines, the sweating at night becomes very profuse, and 
the expectoration decidedly sinks in water; whereas, before, either the whole of it 
or the greater part swam. Shreds are seen in it, whiter than the rest; like curdy 
lumps, or fragments; and, in some few instances, we may observe earthy matter 
in it. The latter is, by no means, so frequent an occurrence as the former; but it 
occurs now and then. 

State of the Tongue. — The tongue will sometimes remain in a healthy condi- 
tion; but in most instances it becomes loaded with mucus, and is foul and yellow, 
on the one hand; or becomes red at the edges and tip, on the other. Sometimes 
it is of an intense redness all over; so that it looks like a piece of beef. 

Third Stage: Hectic— There is now an increase in the pulse at two periods, at 
least, in the day; — that is, in the middle of the day and in the evening; but deci- 
dedly in the evening. There is a great exacerbation of it, together with heat of 
the body, after every meal. The pink sediment of hectic* appears in the urine; 
and the pulse is constantly much quicker than it should be; perhaps seldom below 
ninety, and frequently above a hundred. The mind and the appetite remain unim- 
paired. Persons labouring under this disease, will frequently eat heartily to the 
very last; — have a perfectly good digestion; and their mind is as alive and active as 
it ever was; — perhaps more so. Patients generally have hope. They will not 
believe they are in a dangerous state; — they do not think that their case is consump- 
tion. On the other hand, when people are not active, and think they are labouring 
under phthisis, in nine cases out of ten there is no danger whatever. A remarka- 
ble feature in the disease is this hope. Even medical men, who have fallen victims 
to phthisis, have insisted, up to the day of their death, that they had not ulceration 
of the lungs; and that they should get well. This has been observed in intelligent 
men, as well as in those who were most stupid. It is not a matter of judgment, but 
of feeling; and hope is quite characteristic of this disease, though it is by no means 
an invariable circumstance. Now and tlien persons despond; — being quite aware 
that the disease is well established and confirmed; but, in a much greater number 
of instances, there is the roost lively hope. 

» See Faffe 268. 



PHTHISIS PULMONALIS. 791 

Colliquative Purging and Sweating. — In the greater number of cases, the in- 
testines suffer very mucli. Perhaps, at the beginning, the intestines are a little 
dormant; but as the disease proceeds, and especially at the last, the intestines fall 
into a state of diarrhoea; and the purging very frequently alternates with the sweat- 
ing. The purging is so severe, that it may be said to melt down the patient, and 
therefore is called ^'•colliquative purging;" and the sweating is so profuse, that it 
is called "co/%wafit;e sweating." The expectoration becomes more yellow and 
green than before; and it also becomes more abundant. The cough becomes more 
severe; the legs become oedematous; and the body wastes exceedingly. The 
hectic flush is seen, decidedly, upon the cheeks and palms of the hands;^ and the 
exhaustion is such, in some cases, that the patient frequendy faints. He feels ex- 
ceedingly languid. The patient is, at last, confined to his bed in all cases; but, in 
some instances, there is great tendency to syncope, and dyspnoea from debility; so 
that stimulants are required. Just before death, the brain is sometimes affected; 
so that there is frequendy delirium, three or four days before death. 

Varieties in the Symptoms. — The progress of all these symptoms, is exceed- 
ingly various. Sometimes only a few weeks, but in other cases, many years 
elapse before the patient sinks under the affection. I am convinced that I have 
seen cases, where there were no symptoms of phthisis; and yet the patient has 
died from ulceration of the lungs, in the course of three months. I recollect one 
instance of this particularly. On account of some anomalous symptoms in the 
abdomen, the patient was frequendy examined by me. He was two or three 
miles from London; and, on carefully examining his chest, I found that he was free 
from cough, and from all the symptoms of phthisis generally; as well as from those 
symptoms which can only be learned from auscultation. He then began to expec- 
torate, showed signs of phthisis, and died. On the autopsy we found ulceration. 
All this occurred in the course of two months. The public at large are aware of 
tJiis state; and they give to such cases as these, the epithet " galloping consump- 
tion.'''' On the other hand, the disease will last, there can be no doubt, for very 
many years; that is to say, persons will have cough, and expectorate; yet it will 
not increase, but decline from time to time; and so they will go on, till at last they 
expectorate a great deal, and die in the usual way. Dr. Gregory, of Edinburgh," 
used to say that he knew a case, where a person was in a state of consumption for 
fifty years; but it is impossible to say that the patient laboured under phthisis all 
the time; it might have been only bronchitis. But it is a fact, that there is very 
great variety as to the duration of the disease. It is generally quickest in those 
who have the finest skins, and are nearest the period of puberty; or who are not 
very much beyond that period. The disease is frequendy suspended, on the other 
hand, by pregnancy, and by suckling; and now and then it has been suspended by 
other diseases, as by ague or insanity. These, however, are only occasional cir- 
cumstances. 

Auscultatory Signs. — We are now prepared to understand those symptoms, 
occurring during the progress of this disease, which are acquirable by the ear. At 
the first period of phthisis, there is nothing (in my opinion) to be learned by the 
ear. It is from the general appearance of the patient, and from the general symp- 
toms of which he complains, that we suspect the presence of phthisis. At the 
onset, it is at most only a matter of suspicion. We cannot be certain of it. It 
is easy to perceive that this must be the case, when we consider that, in the first 
instance, the tubercles which constitute this disease, are exceedingly small and 
exceedingly few; — leaving a large portion of pulmonary structure perfectly healthy. 
It is only when the tubercles increase to a certain size, and approximate, — so as to 
form a mass, or when a considerable portion of the pulmonary structure is beset 
with tubercular deposit, that we can expect to discover any audible change. 

Percussion in the First Stage. — The parts in which the symptoms acquirable 
by the ear may be noticed, in the first instance, are below the clavicles. This may 

* Sse Page 06, » See Note to Page 339. 



792 PHTHISIS PULMONALIS. 

be observed before the tubercles have softened; but when they become sufficiently 
large and numerous to occupy some space, on striking over the part where such 
deposit exists, we do not find the hollow sound of health, but a greater degree of 
dulness than there was before. In proportion to the size of the tubercular deposit, 
is the dulness of the sound; and we may save ourselves a great deal of trouble, by 
beginning our examination at the clavicle, and immediately under it. Still, if we 
have any suspicion, and yet the parts below the clavicle sound well, we should 
examine other parts; because now and then the deposition, instead of taking place 
there, occurs^n other situations. In the great majority of cases, however, — -I may 
say in nine cases out of ten, — the change takes place just below the superior por- 
tion of the lungs; and therefore we should commence our examinations there. 

Stethoscopic Signs iyi the First Stage. — Besides this dull sound on percussion, 
if we listen with the stethoscope, and make the patient speak, we find the voice 
resound there in an unnatural manner. The solid substance of the tubercles, is so 
much better a medium of conveying sound, than the loose structure of the healthy 
lung, that the sound is louder where these tubercles exist than elsewhere. The 
voice will not come through the tube, as if the patient's mouth were at the other 
end of it, speaking to us; but we hear the sound echo; and it is louder than natural. 
There is no pectoriloquy; but we have what is called " bronchophony;" — the same 
sound that is heard on putting the stethoscope over the large bronchia.* But it is 
to be remembered, that the voice naturally sounds louder under the clavicle than 
elsewhere, on account of the large tubes being there; and therefore we should not 
depend on this symptom alone. It should be united with the dead sound on per- 
cussion, in order to satisfy us that there is bronchophony dependent upon tuber- 
cular deposition. It is well to compare the sound on each side; for the deposition 
generally takes place more on one side than on the other; and frequently it occurs 
only on one side; and our suspicion will be increased, as to the really unnatural 
loudness of the voice, if we hear it louder on the one side than on the other. The 
diflference of the two is frequently very manifest. 

Pectoriloquy. — But when the tubercular mass softens, and a portion is discharg- 
ed, — so that the cavity is emptied, or nearly so, — a new symptom occurs. The 
bronchial tubes, we know, enter this cavity; and as the air enters it, the same slate 
of parts exists there as in the trachea; — that is to say, there is a large space, into 
'Which, on inspiration, the air enters; and consequently, when the patient speaks, 
the same sound is heard that occurs on putting the stethoscope over the trachea. If 
we place the stethoscope over the trachea, we have the voice traversing the tube, as 
though the mouth were at the other end; and just the same occurrence takes place, 
when we put the stethoscope over a cavity in the lungs; — we have the phenomenon 
called "pectoriloquy."* If we make the patient cough, a mucous rattle is heard; — 
the same sound as if air were forced through soap-suds. It is a gurgling sound, 
arising from air agitating a viscid fluid.'' But as the contents grow less and less 
viscid, — as the curdy matter of the scrofula is more and more spit up, and mere 
mucus forms more and more the contents of the cavity, the gurgling is heard louder, 
and is found to be freer. Then, if we make the patient breathe quickly, and at 
the same time rather deeply, we hear the same sound that we do if we make him 
breathe quickly, and put the stethoscope over the trachea. In the latter case, we 
have the sound of the air evidently going through a large space; and the same cir- 
cumstance occurs in the former instance; — merely arising from the part being of 
the same description as the trachea. We have the same phenomena with respect 
to simple respiration, the same phenomena with respect to the voice when the 
patient speaks, and the same phenomena when we make him cough, that we have 
when we place the stethoscope over the trachea; — that is to say, we have pectori- 
loquy. We may, however, have the same symptom of pectoriloquy in the most 
perfect health, if we listen over a certain part of the chest; — especially in thin 

• See Page 713. " See Page 703. 



Phthisis pulmonalis. 793 

persons. On placing the stethoscope between the clavicles of a person who is thin, 
we have pectoriloquy; because the large bronchia going to the lungs, emit the 
sound of a tube, even if the individual be healthy. We must not, therefore, pro- 
nounce a person in a state of phthisis, simply because there is pectoriloquy between 
the clavicles; but when it is heard decidedly in other parts of the chest, then there 
can be no doubt as to the nature of the case. 

Percussion in the Second Stage. — When the disease has reached this stage, 
we no longer have the dull sound on percussion, that we had in the first instance.* 
The tubercular solid mass, which gave the dull sound on percussion, no longer 
exists; and consequently there can no longer be the phenomenon which it pro- 
duced. That phenomenon was a dull sound, from the part being solid. The part 
is now hollow; and, on striking over it, we find the sound as hollow as in health, 
and perhaps more so. 

Pectoriloquy does not indicate the nature of the Cavity. — It is to be remem- 
bered, that though we have pectoriloquy, and thus have a large space which ought 
not to be there, yet the phenomenon does not show the nature of the cavity; and 
it is only from the general symptoms, that we are satisfied it is the cavity of 
phthisis. In gangrene of the lung, a part of the latter is sometimes separated and 
discharged; leaving a cavity which may give rise to pectoriloquy. But then we 
know that it arises from gangrene by other circumstances; — sucli as the great 
debility of the patient, and the fostor of the expectoration. In chronic bronchitis, 
the bronchial tubes may be very much enlarged at one spot; — as large as the 
bronchia themselves, or approaching to their size; and in that case we shall have 
pectoriloquy; but then there will not be present the general symptoms of phthisis, 
and thus we may suspect the nature of the case. No reliance, then, is to be placed 
on the ear alone: the symptoms which are audible, are only to be taken in con- 
junction with those which are general. Persons find fault with auscultation un- 
justly, who suppose it is employed to the exclusion of attending to other symptoms. 
No person who uses his ear, is justified in making so absurd an application of it. 
He ought to be careful in adopting all the means of making observations within his 
power. A person maybe labouring under ulceration of the lungs; and yet he may 
not afTord the sign of pectoriloquy. If the cavity be near the surface of the chest, 
and the walls of the cavity be very thin, and if the bronchial tubes that open into 
the cavity, have mouths so small as to bear no proportion to the cavity itself, we 
raay have a large cavity, and yet no pectoriloquy at all. Here, again, is an in- 
stance of the fallacy of the observations made by the ear alone, to the exclusion of 
the other symptoms. Like every body else who has attended to these matters, I 
have over and over again opened patients, and found a large cavity after death; 
where, before the fatal termination of the case, there had been no pectoriloquy at 
the affected spot. The walls of the cavity must be a certain thickness, for the 
phenomenon of pectoriloquy to be produced; and the bronchial tubes opening into 
the cavity, must bear a certain proportion to it; for when the cavity is near the 
surface of the lung, and the substance of the lung has been entirely destroyed, so 
that there is merely pleura forming the parietes of the cavity, we cease to have 
pectoriloquy. If, however, we had seen the patient before the cavity became so 
large, as to be out of proportion to the bronchial tubes opening into it, and the 
walls became so much diminished, then we should have had pectoriloquy. But 
we may not have been called in before the patient arrived at this state; and there- 
fore may not have had an opportunity of observing the successive changes. 

Metallic Tinkling. — When an excavation is very large indeed, we sometimes 
have another phenomenon; — which is called " metallic tinkling." By this is meant 
a sort of silvery, ringing, metallic sound, when the patient coughs, speaks, or 
breathes; but particularly when he coughs; — a clear metallic ringing, which can 
hardly deceive us. But the sound is not peculiar to this affection; for when the sur- 
face of the lung is ulcerated, and air escapes into the pleura, that being a very large 

« See Page 792, 



794 PHTHISIS PULMONALIS. 

cavity, it jnst gives us the same phenomenon. When air enters into the pleura, 
we have metallic tinkling, from the presence of the air and fluid together; but if it 
so happen that there is a large cavity in the lung, that will come to the same thing; 
and the air and fluid entering into it, will give rise to the same sound. The cavity, 
however, is seldom so very large as to produce it. 

Value of Auscultation in Phthisis. — We seldom examine a patient at that point 
when much information is to be derived from the ear. In the first stage of the dis- 
ease, there is nothing to be learned from it; and as the disease proceeds, the case is 
generally perfectly clear, without the use of the ear; but if a set of symptoms do 
present themselves to the ear, they are as worthy of being observed as those that 
present themselves to the eye; and the mere trouble of examining them, can be no 
excuse for not observing them. Unfortunately, in the great number of instances, 
the case is too severe to render such examination necessary; but cases do occur 
wKere the disease is not so severe; and some will say that the affection is bron- 
chilis, while others assert that it is phthisis. Persons are said every day, by those 
who do not use the ear, to be in a state of phthisis, when they are not; and vice 
versa. Now if the ear be used after a certain time, and we ascertain the existence 
of a cavity; this, in conjunction with the other symptoms, will render the case clear. 
The examination must not be too late; or the phenomenon of pectoriloquy may 
have ceased. It is of great importance to be able to say that there is pectoriloquy; 
for a practitioner may iiave said that it is not phthisis at all, and he will stick to it; 
but if, on listening, we hear pectoriloquy, we may be sure that he is wrong; and 
may be able to convince him of it. It is a fact that some practitioners who have taken 
a predilection for other organs, — particularly the liver, or the viscera of the abdo- 
men, — may declare that there is no such thing as phthisis present; while it is evi- 
dent enough that the patient's lungs are rotten. Now if, in a case like that, we can 
induce a person to listen to us, and can show him the difference between the sounds 
in health, and those in this disease, we may open his eyes, and bring forward such 
an argument as cannot be resisted. It would be unphilosophical not to know these 
things; and not to attend to them if they do exist. 

Complications. — Besides those morbid appearances and those symptoms which 
I have now mentioned, as occurring in phthisis, a variety of others occur in dif- 
ferent patients. Some have very great disturbance of the digestive organs; some 
have tenderness of the epigastrium, tenderness of the abdomen where the small 
intestines lie, and tenderness likewise of the liver. Some have very little appetite; 
but a large number have an excellent appetite; and eat and digest well, to the last 
moment of their existence. It is very common for a fistula to form by the side of 
the rectum; and it is very common to find, after death, a considerable inflammation 
of the mucous membrane of the intestines. It is by no means uncommon to find the 
intestines ulcerated; to find a scrofulous deposit in the mesenteric glands; and to find 
the liver more or less diseased. The French have attended very minutely, to the 
proportionate occurrence of these different morbid affections of other parts. We 
find in the work of M. Louis (a physician now living in Paris), the most accurate 
information on this point.* It is very common to find the trachea ulcerated; — to 

* We subjoin the following summary, from Louis's admirable work on Phthisis (trans- 
lated by Dr. Cowan), of the various complications which occur in phthisis, and their relative 
frequency: — 

" Tubercles and pulmonary excavations were, in one-tenth of the cases, coincident with 
recent inflammation of a portion of one or both lungs, of the pleurae; or with the effusion of a 
notable quantity of limpid fluid in the thoracic cavity. 

The trachea presented ulcerations, often of considerable size, in rather less than one-third 
of our [M. Louis's} observations. Its mucous membrane was merely reddened, sometimes 
slightly softened or thickened, in one-fifth. The larynx was ulcerated in rather more than 
one-fifth, and the epiglottis in a nearly similar proportion. 

The pericardium contained a marked quantity of clear fluid in one-tenth of the cases, and 
presented traces of chronic or recent inflammation in many others. The heart was pretty 
frequently softened; the aorta was red in the majority of young patients, and its structure 
more or less modified after the age of forty. 

In one-twelthof the patients the stomach was dilated, and situated lower down than natural. 



PHTHISIS PULMONALIS. 795 

have a scrofulous deposit in various parts of the trachea; particularly about the 
larynx. In some instances there is soreness, violent cough, and every other mark 
of chronic disease of the larynx; whereas, in other cases, there is no hoarseness, or 
other sign of affection of the larynx or trachea; except a little inflammatory irrila- 

Its mucous membrane was red, sometimes mammillated, a little softened, and thickened an- 
teriorly, in nearly the same proportion. In one-fifth it was more or less extensively thinned. 
We found it in the same proportion very red, softened, and sometimes thickened in the great 
cul-de-sac; it was ulcerated, of a more or less grayish tint, and mammillated in many others, 
&c.; so that it was only healthy in one-fifth of our examples. 

In the small intestine there were ulcerations, varying in number and extent, in five- 
sixths of the patients. They were nearly as frequent in the large intestine; of which the 
mucous membrane, often red, and in one-half of the cases thickened, was either wholly or 
partially of the consistence of mucus; so that we have only three times seen it perfectly 
healthy. 

The tuberculization of lymphatic glands was less frequent in the neck, loins, mesocolon, 
and axilla, than in the mesentery; where it existed in various degrees in oile-fourth of the 
cases. 

The liver had become adipose in one-third of the examples. The parietes of the gall- 
bladder were occasionally thickened and ulcerated; and when this was the case, as also in 
some other circumstances, it contained calculi. 

Tiie spleen was softened, and under or above its natural volume, in a great number of 
instances. It was tuberculated in one-sixth. This last alteration was nearly equally fre- 
quent in the kidneys, where we sometimes discovered cysts. 

In many individuals the prostate was tuberculated; in one of these there was an example 
of tubercular exhalation in the interior of the vesiculse and seminal ducts. We have once 
seen the internal surface of the uterus converted into tuberculous matter. 

From one to six pints of clear serous effusion in the abdomen existed in one-fourth, and a 
small quantity of pus, or some false membrane in the pelvis, in four of these instances. We 
have seen several cases of tubercular peritonitis. In one the great omentum and the meso- 
colon presented a mixture of gray, bluish, semi-transparent and tuberculous substance. 

The cerebral arachnoid was often partially thickened; presenting more or less numerous 
granulations in its upper portion, especially near the falx. In two cases it was lined by a 
yellowish and soft false membrane. The tissue uniting it to the " pia mater" was infiltrated, 
and the ventricles distended by a very appreciable quantity of serum, in three-fourths of our 
examples. The same fluid was found in the inferior occipital fossae; but less frequently, and 
not so abundant. In one-seventh the brain was injected; in one-twentieth, its consistence 
was generally diminished, and in one instance to a remarkable extent. Its partial and pulpy 
softening was observed in the same proportion. All the serous membranes were thus very 
frequently the source of effusion; and it is in the lateral ventricles of the brain that this was 
most generally observed. The same membranes were also liable to acute inflammation, 
coming on towards the close of life; and this was most frequently the case for the pleura. 

In some instances, many of the morbid states just glanced at, — as the softening and thin- 
ning of the gastric mucous membrane, and the ulcerations of the intestines, — were sufficient 
of themselves to have caused death, independently of the lungs. The period to which the 
commencement of these different alterations could be referred, was very variable. Pneu- 
monia, pleuritis, softening and redness of the great cul-de-sac of the stomach, pulpy soften- 
ing of the colon, peritonitis, arachnitis, partial and pulpy softening of the brain, could all 
originate a few days previous to death. The greater part were the result of inflammation; 
— plainly proving that weakness, so far from being an obstacle, is (on the contrary) favour- 
able to inflammatory action. The other alterations, dated much further back, sometimes to 
the very commencement of phthisis; as, for instance, softening with diminished thickness 
of the mucous membrane of the stomach; and, in some cases, the large intestinal ulcera- 
tions. 

These various morbid changes admitted also another division; some were peculiar to 
phthisis, others were not so; but were present in different degrees, after a variety of other 
chronic affections. 

Among the first class may be enumerated ulcerations of the larynx, and more especially 
of the trachea and epiglottis; ulcerations of the one or both intestines (principally of the 
small); and the adipose state of the liver: so that by seeing an ulceration in either of the 
organs mentioned, &c., we should be able to assert, independently of all farther investiga- 
tion, that the patient had died of phthisis. These ulcerations, wherever they were situated, 
in their mode of production presented many points of resemblance. When the mucous mem- 
brane was destroyed, the sub-mucous layer gradually thickened, and became uneven; after 
a time, it ulcerated, and then the muscular coat in its turn began to thicken: this was, like 
the former, subsequently destroyed (though iis total destruction was extremely rare); so that 
in proportion as one of the coats of the intestine became ulcerated, the succeedin^: one thick- 
ened; and, by thus opposing greater resistance to its destruction, protracted the fatal termi- 
nation. 

The last morbid alteration peculiar to phthisis, were tubercles, wherever they might be 



796 PHTHISIS PULMONALIS. 

tion, indicated by an excessive secretion of mucus. Now and then, scrofulous 
tubercles are found in the brain, or at least under the "pia mater;" but, for the most 
part, the head remains perfectly free. 



SECTION III.— DIAGNOSIS AND PROGNOSIS. 

Diagnosis. — With regard to the diagnosis of the disease, it must be made out 
by general observations respecting the patient; — general observation as to predispo- 
isition, and as to constitution. Then, again, as to (he progress of the disease, if a 
person has had, for a great length of lime, cough, which has generally increased; 
if there has been a falling away in flesh; and the individual has not passed the mid- 
dle period of life, but is between eighteen and thirty; — if these symptoms occur, 
and there has been phthisis in the family, we have still greater reason to suspect 
the formation of tubercles. If, in females, there be a suppression of the menses; 
if, in males or females, the ends of the fingers become enlarged, and there are fre- 
quent attacks of haemoptysis, together with a continual cough, — the case will be 
rendered still more suspicious. By means of the stethoscope we may ascertain, 
after a time, whether there is a cavity or not; but the diagnosis of this disease is 
too easy, after the affection has once formed. 

Prognosis. — The prognosis, in these cases, must always be unfavourable. If 
one part of a lung be beset by tubercular deposition, it is possible that the substance 
may soften, be expectorated, the part heal, and the patient do very well. It is 
possible that, notwithstanding the presence of pectoriloquy, and other signs of con- 
firmed phthisis, yet the patient may recover. Such things, however, are exceed- 
ingly rare. I doubt whether it is a common thing for these excavations to heal; 
but it is a far more uncommon thing for the patient to get well; because, in general, 
the disease is constitutional; and if one excavation should heal, a crop of tubercles 
occurs in some other part, and goes through successive changes; and under these 
the patient will sink. On opening a patient who has died of phthisis, we almost 
almost find tubercles in various stages; and if we could heal one lung entirely (as 
it has been proposed to do, by making an opening into the chest, and causing the 
lung to collapse) I doubt whether we should do much good; because the other lung 
is generally beset with tubercles, which will regularly go through their stages in 
the same way. 

Cicatrization a rare Occurrence. — Laennec says, that he has frequently seen a 
cicatrix in the lungs; — that a cavity had existed and healed; that the sides had 
come together; and the part become solidified and hardened; — just as is the case 
with a cicatrix on the surface of the body. The appearance spoken of by Laen- 
nec, as indicative of a healed cavity, is a depression, or a puckering, on the surface 
of the lung; just as in a cicatrix on the surface of the body, when there has been 
an abscess below. If there be merely superficial ulceration, we know that a scar 
is left; but in proportion to the depth of the ulceration on the surface of the body, 
and in the parts immediately below the surface, so is the depth of the cicatrix 
and of the puckering. This appearance is sometimes seen on the surface of the 

found. We [M. Louis] have never observed them in a single instance in any organ, with- 
out their existing in ihe lungs; so that their presence in these last viscera, seems a necessary 
condition for their development in other parts. Another fact which strengthens the idea of 
this dependence is, that, with one single exception, we have always seen the tuberculous mat- 
ter more advanced in the lungs than elsewhere; and when tubercles existed at the same time in 
different parts of the body, these were always at the same degree of development; and it would 
be difficult to conceive this uniformity, in parts so distant from each other, and so various ia 
structure, unless we admit the influence of one and the same cause, acting simultaneously 
on a great number of organs; thus milking tuberculous deposition quite independent of those 
occasional causes, which we are apt to suppose active in certain cases. 
I As our object, however, is not to support one opinion more than another, we [M, Louis] 
will remark, that we have found one exception to the law we have established. It was in a 
case of typhus. No tubercles existed in the lungs; and yet there was a small quantity of 
tuberculous matter in the mesenteric glands." (Pages 115 to 118.) 



PHTHISIS PULMONALIS. 797 

lung; and Laennec says that, on cutting down on such a part, we find below it 
induration, to a greater or less depth. My reason for doubting this is, that we see 
exactly the same appearances upon the liver. Almost every month, if we open 
many bodies, we find a puckering on the surface of the liver; — a depression, with 
a puckering all around it; and, on cutting into it, the substance of the liver appears 
unnatural as to colour. But there is no ulceration; in fact, there could have been 
no ulceration, — no suppuration; for there are no signs of there having been any 
matter. The peritonaeal surface of the liver will fall into a state of chronic indu- 
ration; here and there it will become indurated and hard, and it is commonly puck- 
ered; and there we have the appearance of so many scars. The same thing will 
take place in the lungs. They may seem puckered, and the pleura may be very 
hard there; but that is not a sufficient reason to my mind, for believing that there 
is a cicatrix. It is common, when there has been a slow thickening of the pleura, — 
to say nothing of inflammation, — to find the lobes glued together, and the pleura 
between the lobes thick, and almost cartilaginous. Sometimes there is a pucker- 
ing on the surface; and, on cutting down, we find a cartilaginous hardness to 
some depth; — from cohesion of the different lobes. Independently of that, the 
pleura will fall into the same sort of disease as the peritonaeum over the liver; and 
will produce just the same appearances. On reading Andral, I find that he has 
come to the same conclusion as myself; and I have no doubt that others have done 
60 likewise. It is said that, now and then, a cicatrix may be produced; but I am 
sure it is a rare occurrence. 

Evacuation of the Tubercular Deposit. — But sometimes people, without any 
cicatrix, get rid of this tubercular deposit. When it has occurred only at one spot, 
an open cavity remains; and the patients live for a long time. It is so common, 
however, for tubercle after tubercle to take place in the lungs, and go through suc- 
cessive changes, that people generally do not live. It certainly does happen, 
sometimes, lliat the lining membrane of these cavities becomes hard, secretes a 
quantity of mucus, and so remains during the rest of life. No further mischief is 
done; pectoriloquy is always heard; and the patient is only troubled with cough 
and expectoration. But this is comparatively rare. 

Terminating in Pneumato -Thorax. —Now and then, — but this likewise is an 
uncommon occurrence, — death will take place from ulceration extending outwards 
through the pleura. In cases of this description, the patient is generally seized 
with a sudden difficulty of breathing. On striking the chest, there is a very clear 
sound; and (as may be supposed from the air escaping from the lungs to the pleura) 
the lungs become more and more collapsed. If it occur on the left side of the 
chest, the force of the air will be such, as to drive the heart to the right side. This 
is called "pnewmo-thorax;" but, as I shall afterwards point out, it should be termed 
"jOMewma^o-thorax." I shall describe this more particularly, when I come to dis- 
eases of the pleura; but it is to be remembered that, now and then, ulceration is 
not confined to the lung itself; but that the pleura becomes ulcerated, or is rendered 
so thin, that it gives way; and then we have air and fluid in the pleura. In gene- 
ral, nature prevents this, — however near to the surface the cavity may be, — by 
causing adhesions. I mentioned* that when a tubercle is near the surface of the 
lung, the pulmonary and costal pleurae (one or both) throw out lymph, and be- 
come glued tegether; so that ulceration may go on within, and yet neither air nor 
fluid can escape into the pleura. But now and then nature fails. A tubercle exists 
near the surface; the ulceration goes on; no adhesions take place; a perforation is 
produced by the ulcer; and the phenomenon of air and fluid in the pleura occurs. 



SECTION IV.— CAUSES OF PHTHISIS. 

Hereditary Predisposition. — There can be no question, that the die^position to 

• See Page 788. 



1^ 



798 PHTHISIS PULMONALIS. 

this disease is frequently constitutional, and frequently hereditary. Those who 
are most subject to it, are usually fair persons; with light hair, a sanguineous tem- 
perament, soft skin and hair, and long pointed fingers. Their flesh is flabby, — not 
firm; and the pupils of their eyes are large. They are frequently thin and tali; but 
whether they are tall or not, persons of this description are slender, with a long 
neck. Frequently, too, such persons have been subject to haemorrhage from the 
nose when young. There is another description of persons subject to phthisis; — 
comprehending those who are not tall, but short; and who have not light hair and 
a fair skin, but are rather swarthy, and have dark hair and dark eyes. These also 
have large pupils, and their skin is rather soft; and, instead of having long, they 
have short fingers and nails. Like the others, they are of a lax fibre; — their mus- 
cles being flabby; and persons of this latter description generally have a tumid 
upper lip. There are, therefore, two descriptions of persons most liable to phthi- 
sis. Both, in general, have a soft skin, soft hair, a flabby fibre, and a pale look; 
but those of one set, if they be not tall, are slender; and generally have light hair 
and a florid complexion; and are disposed to haemorrhage; whereas the others are. 
short, with dark hair, a tumid upper lip, and short truncated fingers. This form 
of body is (of course) constitutional; and it likewise may be hereditary. 

Jli^e. — A certain age is more liable to the disease than any other. In this coun- 
try, scrofula is more likely to occur, in the lungs, between the age of eighteen and 
thirty, than at any other period. When it occurs later than this, it is perhaps 
more frequently the result of unfavourable external circumstances, acting upon 
constitutions moderately disposed to it, than of the mere intensity of the predis- 
position. 

Food, Temperature, and Clothing. — There can be no question that it is greatly 
predisposed to by bad food, bad lodging, and bad clothing. Many would escape 
the disease, were it not for their being exposed to wet and cold, being badly pro- 
tected in the way of lodging or of clothing, and not fortified with the means of 
resisting wet and cold, by good food. The latter keeps up a good fire within; and 
compensates, in a great measure, for the unfavourable state of the atmosphere. 
Hence the disease is much more frequent in countries which are wet and cold, than 
in others; and it is more frequent in countries which have cold and wet alternating 
with warmth, than in those which are simply cold. For example:" I believe it is 
not so common in Russia, as in many other warmer parts. 

Alternations of Temperature. — Alternations of temperature, especially cold and 
moisture (united) alternating with a warm temperature, seem to have the greatest 
efl*ect in exciting the disease; and to be the great predisposing cause, — next to 
hereditary, constitutional disposition; or the want of food, clothing, and lodging. 
It is far less frequent in tropical, than in temperate climates. Indeed, it is said 
that real strumous phthisis is unknown in the tropics, or is confined to European 
settlers; who bring the disposition to it from unfavourable climates. It is a disease 
seen, more or less, in all parts of the world, or nearly so; either occurring among 
the inhabitants, or among those who come from countries where it is very common. 
Some ascribe the comparative rarity of the disease (I only say ^'comparative 
rarity") in Russia, to the circumstance of the people having good clothing: — being 
clad with furs and other warm materials, and eating plenty of animal food. All the 
inhabitants of cold climates, eat a large quantity of animal food; while those who 
inhabit warmer regions, care little about it, and live principally on vegetables. The 
diets of Italy and Russia are completely different. To show the eff'ect of cloth- 
ing upon the disease, it is said that it was unknown in Scotland, before the people 
changed their dress from woollen to cotton. I suppose that is an exaggeration. It 
is alleged, that formerly, in Scotland, the people were all dressed in woollen, — as 
the Romans were; but that since they have changed it for cotton, the disease has 
become very prevalent. The disease is said to be the least prevalent among 
butchers, fishermen, and fishwomen (in Scotland, called " fishwives"). The cause 
is said to be, that these people eat plentifully of animal food. 

When the predisposition is very strong, the most favourable external circum- 



PHTHISIS PULMONALTS. 799 

stances can scarcely keep away the disease. AVe see a family, brought up with 
every care in guarding against cold, — having good food, good clothing, and good 
lodging, and attention paid to the slightest indisposition; and yet, one after another, 
— especially if they be females, — they become the victims of this disease. On 
the other hand, where the disposition is not so strong, by taking great care to avoid 
vicissitudes of temperature, to dress very warmly, and to be vvell nourished, people 
escape it. If persons who have this disease in their respective families, who thera- 
selves are disposed to it, and perhaps afterwards (one or both) die of it, intermarry, 
the affection is almost sure to be transmitted to the offspring. Every one must 
have seen instances of the death of children, whose mother died some years before 
of the same disease. Where two first cousins marry together, the predisposition 
derived from this unfortunate mixture becomes so powerful, that a very phthisical 
offspring is generally the result. Whoever belongs to a phthisical family, should 
endeavour to " cross the breed," by marrying some one that is not phthisical; 
because, although it is delightful to marry a lady delicately beautiful to all appear- 
ance, — having white teeth, a fine skin, soft hair, and so on, — yet misery is almost 
sure to be the consequence. The disease is almost certain to begin; and the off- 
spring perish one after another. 

Exciting Causes: Cold and Wet. — The immediate exciting cause of the dis- 
ease, when one is apparent, is generally that of any common inflammation, — any 
common cause of catarrh. Exposure to cold, more particularly cold and wet, 
especially when applied partially, and (again) especially when the body is over- 
heated, is the most common exciting cause. Persons with a strong predisposition, 
catch cold from the slightest causes; — from something that would be insufficient 
to give another individual cold; and what would be mere catarrh in one person, 
becomes in the other the commencement o{ phthisis. Sometimes tubercles have 
already existed in the lungs; and these merely produce inflammation in the organ. 
In other cases, inflammation is induced in the air-tubes; and, the disposition being 
strong, the debilitating effects of the inflammation lead to the production of the 
tubercles. 

Mental or Physical Exhaustion. — Whatever exhausts the body, many produce 
the disease. When persons are predisposed to it, they will have it come on with- 
out catching cold at all; but simply from over-exertion of the body, or over-exertioa 
of the mind. But where there is mental exertion, there is almost always anxiety. 
It is seldom that a person is occupied mentally without anxiety; and therefore 
anxiety may, in a great degree, be the cause of the disease. There can be no 
doubt that the depressing passions will produce the disease. I have seen a case 
where, in a predisposed family, an individual has become the victim of phthisis, 
decidedly from the very time that some great source of grief occurred to him. 

Powdery Substances. — Powdery substances in the atmosphere, have excited 
this disease; — not simply in cases where tliere was a strong predisposition to it;— 
but where the powdery dry substance is of a hard nature, (sucli as portions of 
metal, or of stone,) the disease is produced with scarcely any discoverable predis- 
position. There are certain occupations, in which fine particles of stone are dif- 
fused through the atmosphere; and others in which fine particles of steel are so 
diffused; and the persons exposed to these, very frequently die of phthisis; so that, 
in some parts of tlie country, where these trades prevail, ^q\\ men, who work at 
them, live beyond forty; and many die much before that time. 

Contagion? — It has been supposed that the disease will arise from contagion; 
but it is in foreign countries that this idea prevails. It is believed in Languedoc, 
Spain, and Portugal; and the clothes of patients who have died of this complaint, 
are there burned by the civil authorities. Morgagni was so frigfitened at the con- 
tagiousness of this disease, that he never opened the body of a person who died of 
it; but that was evidenUy the result of a little nervousness, rather than of his better 
judgment. It is mentioned as being contagious by Morton, a writer on tliis dis- 
ease in our own country; but it was not so considered either by Hippocrates or 
Celsus. I do not believe that it is in the slio^htest degree contagious. Like others 



soo 



PHTHISIS PULMONALIS. 



practising medicine, I have seen hundreds and hundreds of cases of the disease, 
but I never saw an instance, in which there was a shadow of probabiHty for the 
doctrine of contagion. I have seen husbands nurse their wives, and wives their 
husbands; and I am quite sure that where the survivor has become phthisical, the 
proportion has not been greater than we might expect, where a disease is so preva- 
lent as phthisis. It is not uncommon for persons in the same family to fall into it, 
where there is great anxiety. I hardly recollect a case where the husband has died 
of phthisis, and the wife has fallen a victim to it immediately afterwards, where 
there has not been a predisposition to it. I have seen so many hundreds of exam- 
ples of the reverse, that I do not think the proportion is greater than it would be, 
if it were a matter of absolute certainty that the disease is not contagious at all. 

The Presence of other Diseases. -^The presence of other diseases will excite 
this. It is very common for phthisis to come on after inflammation of the lungs, 
and after severe bronchitis, peripneumonia, or pleuritis; but it is certainly very 
often the case, that the inflammatory disease which has preceded it, has been the 
result of a general predisposition to disease in the region of the chest. 

Sedentary Occupations, — Sedentary occupations, of all descriptions, must be 
unfavourable in this disease; because, in sedentary occupations, there is a want of 
fresh air, as well as of due exercise. In such occupations, too, there are generally 
many persons collected together; and unhealthiness, of all descriptions, must be 
engendered. 

Great Respiratory Exertion. — With some, the exciting cause has been great 
respiratory exertion;— such as excessive public speaking, excessive reading aloud, 
excessive blowing of wind-instruments; and some have had symptoms of phthisis, 
which have declined after giving up the flute, or some other wind-instrument. 

Mercury. — The disease has frequently been excited by mercury. It is very 
common for us to see persons who have been in the foul wards of an hospital, and 
undergone a considerable administration of mercury, fall into a state of phthisis. 

Excessive Venery. — Excess in venery is likewise, by no means, an unfrequent 
exciting cause. I have seen many young men die of phthisis, a twelvemonth after 
their marriage; although they have shown no signs of it before. 

We sometimes have an abscess of the lungs; — sometimes an abscess of the liver, 
making its way, and producing an adhesion to the diaphragm, and of the dia- 
phragm to the lungs, and so on; but all this is not phthisis. Where, however, there 
is a great predisposition to the disease, this may be the exciting cause. 

Statistics. — It is said by Dr. Young, in his work on Consumption,* — and I dare 
say we may depsnd pretty much upon his estimate,— that one-fourth of the inhabi- 
tants of Europe die of phthisis. Dr. Young's Treatise is a sort of Bibliographia 
Phthisica; for the author refers to every work on the subject written previously to 
his own. Years ago it was calculated, that fifty thousand persons died of the com- 
plaint, in Great Britain, every year. The mortality in this country is greater than 
in Paris. Whereas one in /o?/r dies of this complaint in Great Britain, only one 
in Jive dies in Paris, and at Vienna, only one in six. 



\ 



SECTION v.— TREATMENT OF PHTHISIS. 

The treatment of the disease must be totally difl^erent in different circumstances. 
Very little can be done, in general, after it has gone on to a certain length. We 
can then do something to alleviate suffering, it is true; but before it has occurred, 
unless the predisposition be very strong, I think we can do much in preventing it; 
— provided the person's situation enable him to follow our directions. 

Prophylactics. — The great mode of preventing phthisis, when there is a predis- 
position to it, is by invigorating the body as much as possible; — by taking care 
that the individual shall have plenty of fresh air; — shall go out every day; have 

'^ " A Practical and Historical Treatise on Consumptive Diseases. By Thomas Young, 
M. D., F. R. S." 



PHTHISIS PULMONALIS. 801 

just exercise enough, without producing- fatigue; have a good portion of rest at 
night, and never be deprived of it; eat plenty of animal food of the best quality; 
and take mall liquor, or a certain portion of wine, if it can be borne. Malt liquor 
is the most invigorating; vvhde, for the most part, wine merely stimulates, and in 
most cases does harm. The state of the mind is also of very great importance; 
and the utmost care should be taken to commit no excess m study, exercise, 
venery, or any thing else; so as to do nothing that can do harm, and yet maintain 
all the functions of the body. 

Warm Clotliing. — The utmost attention should be paid to clothing. A large 
number of females, in this country, fall into consumption chiefly through their own 
fault. The poorer classes cannot dress well, — cannot be expected to take that 
care of themselves which they ought; because they have not the means; but the rich, 
and the middle classes, do every thing they can to fall into consumption. They 
do not wear sufficient petticoats. They wear silk stockings, and the thinnest 
shoes, and so walk out; or if they do not walk out thus attired, they stand on the 
steps of the door, and often go some yards on the pavement, before they get to their 
carriage. They will go from the hottest rooms without any thing about their feet. 
They take little sleep; have party after party every night; and then, at last, fall 
into a state of consumption. Neither themselves nor their friends will believe, 
that this want of rest and this extreme excitement have been the cause of it; but I 
am quite sure they have. I think I have saved the lives of several young ladies, 
by insisting on their following my advice of wearing plenty of flannel; — flannel- 
drawers, flannel-waistcoats, and high dresses. I have seen several who appeared 
to have every disposition to phthisis; but who, by wearing flannel next the skin, 
from their collar-bones to below their knees, have passed that age at which phthisis 
(in all probability) would have begun; and they have ultimately done well. I have 
taken care to add to this good living. Many wish to make themselves look slender 
and genteel; and therefore they starve themselves, as well as dress in thin clothing. 
They should take meat once or twice a-day; and an allowance of malt liquor. 

Cold Shower-Bath. — If we can do all this, we may in many cases prevent 
phthisis; especially if, in addition, we can make patients use the cold shower-bath. 
Many cannot bear a cold shower-bath, at first; but they can bear a shower-bath 
iepid\ and by degrees they can bear it cold. I saw a young gentleman, whose 
brother died of phthisis. He expectorated blood at the same time as his brother; 
and they appeared equally disposed to phthisis. In one, the disease ran on very 
fast; and he died, 'i'he survivor was spitting blood continually; and the pupil of 
his eye was large. I prevailed upon him to begin the use of the shower-bath; and 
he has done so all the winter. The result is, that he has lost his cough, spits no 
more blood, and is now a strong young man. No doubt, if he take care of him- 
self, and commit no excess of any description, he will go on well. I do not know 
any means so powerful in " hardening" the body, as the use of the cold shower- 
bath; but it is to be remembered, that we cannot " harden" every person, and that 
we may kill many in the attempt. Some ladies, in order to strengthen themselves, 
will go out of doors in the most frosty weather; and by that means often injure 
themselves. We may make the most delicate hot-house plant hardy, by lowering 
the temperature gradually; but what will harden one, will kill another; and what 
will not " harden" one person at all, would be quite sufficient to " harden" another; 
and therefore the greatest ciire should be employed. Some try to "harden" them- 
selves by having the window open; and they glory in having snow on their cover- 
let. Some can bear it; but a great number never could bear any thing of the kind. 
Still, 1 am sure, it is proper treatment to *' harden" people as much as can be 
borne. 

Some persons are so disposed to an inflammatory state, that it is not at all admis- 
sible to give them wine, beer, and meat. The utmost we can do is to clothe them 
well, make them guard against catching cold, and order the shower-bath. Some 
persons are so disposed to heemorrhage, — haemorrhage from the nose, and then 
haemorrhao-e from the lungs, — that nothing stimulating can be allowed. There are 
VOL. I. — 51 ^ 



802 



PHTHISIS PULMONALIS. 



such cases; but I know that, in the greater number of instances, by fortifying the 
constitution well, and adjusting the means used to fortify it to the stale of the con- 
stitution, we may do great good. 

Maintain a Uniform Temperature. — When the predisposition is very strong, it 
is not only necessary that the patient should most carefully avoid catching cold, by 
wearing warm clothing when he is out of doors, and by avoiding all danger arising 
from wet feet, but the temperature of his room should be prevented from falling too 
low. In many cases it is necessary that the bed should be warmed; but others, 
not so delicate as that, should have a fire in the room, either when they go to bed, 
or when they get up, — once in the twenty-four hours, — for the purpose of tho- 
roughly wanning it. Some persons are so delicate, — so disposed to phthisis, that 
we can hardly allow them even to go out during the winter; and a certain degree 
of artificial temperature must be maintained in their rooms; but these are cases 
where the predisposition is extreme, and the debility very great. 

Removal to a Warm Climate. — It is also of great use where there is a strong 
predisposition, to send patients to a warmer climate than our own, — to a thoroughly 
warm climate. One of the best places to which they can be sent is the West or 
East Indies. If that be too far, one of the best places is the south of Spain, or the 
south of France. Many parts to which people are sent, are very objectionable. 
Lisbon, for example, is very cold in the winter; and both Venice and Naples have 
high mountains in the neighbourhood; and therefore are not good. If we cannot 
send patients to the East or West Indies, the south of Spain and the south of 
France are certainly among the most proper places. But many cannot go even 
there; and for them the warmer parts of England are the only situations left. I 
need not mention, that parts of Cornwall and Devonshire are the most suitable; 
and 1 believe Penzance is particularly so. Nearer to London, one of the best 
places is Hastings. Many persons have an idea that if, instead of living in London, 
they go to Brompton, they are more protected from the disease; but I do not 
know whether there is any thing in that opinion. I have heard practitioners found 
fault with, for allowing their patients to live in London, and not sending them to 
Brompton. 

But all this must be done before the disease is fully formed; for when it is once 
established, to send patients away from home, and thus expose them to all the 
misery of the journey, is not only very absurd but very cruel. It is horrible to 
see the grief it occasions; and the patient dies of consumption after all. It is much 
better, when the disease is once formed, to allow patients to remain at their own 
home, where there is every comfort around them. 

Iron. — [In a letter addressed to the Royal Academy of Medicine, M. Coster 
announces that (from certain experiments) he hopes to prove that: — 1. It is possi- 
ble, even in the face of predisposing causes, to prevent the development of a tuber- 
cular diathesis. 2. Even where the formation of tubercles has commenced, their 
progress may, in a great number of cases, be arrested. 

The following are a few of the experiments upon which M. Coster has built his 
hopes: — Two years ago he placed a number of dogs, rabbits, &c., in the circum- 
stances most favourable for the development of the scrofulous diathesis. Thus, 
many of the unfortunate animals were shut up in dungeons, without light, incapa- 
ble of moving; and exposed to a moist cold, by means of wet sponges which were 
hung up in the cages. Some of the animals placed in these conditions, were fed 
on their ordinary diet; others were fed with ferruginous bread, containing half an 
ounce of carbonate of iron to the pound. All the former became ill, — the greater 
part tuberculous; but not one of those fed on the bread containing iron, presented 
a trace of tubercles."] 

Jintiphlogistics. — When the disease has formed, the treatment must be very 
different in different circumstances. We generally have to subdue or mitigate 
inflammation. There are frequent attacks of pleuritis, bronchitis, and peripneu- 



» Brailhwaite's "Retrospect of Medicine;" Volume 1; Page 19. 



PHTHISIS PULMONALIS. 803 

monia. The pleuroe, or the lungs (including the air-cells and bronchia), or both, 
are commonly found in a state of inflammation. Persons are continually seized 
. with violent "stitches in the side;" and it is necessary to take away a little blood; 
four or six ounces, sometimes more; or to cup the part, or to blister it. We find 
the blood buffed, and have to treat the case, for a time, as one of inflammation of 
the chest, but conjoined with little power of the constitution. In these circum- 
stances, of course it is necessary that the diet should be low. If patients be seized 
with haemorrhage, it is often necessary to treat them in the same way. It is gene- 
rally necessary to bleed the patient, to some little extent; and to keep him on low 
diet. When there have been attacks of inflammation or of haemorrhage, it is neces- 
sary, for some days, to pursue antiphlogistic diet; but these may all subside, and 
we may have recourse to nutritious diet again, or now for the first time, if we have 
not resorted to it before. It is right, however, not to take alarm at every pain 
which a phthisical patient may have in the side; for many such attacks will go 
away, without any strong antiphlogistic measures; and many will go away from 
the application of a blister, or of a mustard-poultice, which is one of the best things. 
If, however, that will not remove it, it is requisite to bleed; and to treat it in the 
common antiphlogistic manner. 

Diet. — -Supposing, however, that there is no inflammation or haemorrhage to 
subdue; and tliat the patient is free from pain, and has been so for some time, — 
then we have to support him as well as we can, and to lessen the irritation. It is 
often indispensable to give meat and malt liquor. Many persons in phthisis, are 
the better for having meat. Wine (as I saiel before^) has a tendency to stimulate; 
and therefore should not be given; but ale will often be proper. In a great num- 
ber of cases, we have to consider that the patient is just in the same situation as 
an individual having a large abscess in the extremities; which abscess, from pour- 
ing forth an immense quantity of fluid, has exhausted him. In that case, we must 
allow meat and beer, in order to support the patient; and we must administer opium, 
to lessen the irritation; and, in phihisis, the treatment must be conducted precisely 
in the same way. 

Tonics. — In this state of things it is very useful, when there is no inflammation, 
— no haemorrhage, to give tonics; and of all tonics iron is by far the best. The use 
of what is called "Griffith's Mixture,"** is well known. There was a Dr. Moses 
Griffiths, who made a mixture of iron and myrrh; which is a very good form. 
But the myrrh is nauseous; and, after making a number of trials, I am satisfied 
that the iron will do as well tvithoiit the myrrh, as with it. The sulphate of iron 
answers exceedingly well; and when it is recollected how often in this disease 
there is cough, out of proportion to the regular irritation that takes place, we may 
see that the iron may relieve the cough, even to a greater extent than it supports 
the constitution. I mentioned before, that many cases, which have been supposed 
likely to end in phthisis, have given way to the exhibition of iron.'' If the sulphate 
purge the patient too much, or excite the pulse, we may give the sesquioxide; 
which is rather the milder form of the two. If we exhibit two or three gains of 
the iron, three times a day, patients will gain strength up to a certain point; and 
their cough will diminish. The relief, it is true, is only temporary; but we do 
good for a time; and it is our duty to protract life, without considering whether it 
is usefvd to the patient or not. We are to follow the invariable rule of saving or 
protracting life, whenever it is in our power to do so. 

Sponging or Bathing. — Though we may not be able to use the shower-bath, 
we may do great good, and produce great comfort, by sponging the patient well 
with vinegar and water, cold or tepid. We may even thus check the hectic sweats, 
better than by any other means. When the disease is fully formed, a tepid bath 
is frequently borne, though patients cannot bear a cold bath."* Tepid sponging is 
very beneficial; and it is said to be better, if vinegar be mixed with the water. 

a See Page 801. 

* Answering to the " Mistura Ferri Composita" of the Pharmacopoeia. 

^ See Page 736. ^ See Page 801. 



804 PHTHISIS PULMONALIS. 

Many persons, when they have expectorated pns, have, from tepid spong-ino-, come 
to bear cold sponging; ?\m\ have found the greatest relief from it. That is to say, 
when hectic heat is upon them, they find it very comfoitable; and the feelings of 
the patient should always be consulted. 

Anodynes, — Among the means of lessening irritation, opium is one of the very 
best. 1 need not say, there are other things used for that purpose; — such as hyos- 
cyamus, conium, and extract of lettuce; all of which do a certain portion of good, 
and are very oflen even more eligible than opium; because the latter may disagree. 
I believe the best preparation opium, is muriate of morphia, for it has seldom more 
than one unpleasant efl'ecl; namely, constipation; and even that is often a good ihinjr 
in phthisis, because there is generally a disposition to relaxation of the bowels. A 
quarter of a grain of muriate of morphia, is equal to a grain of opium; and is more 
certain in its operation, than any other form of that drug. A solution of it is very 
cheap. 

Inhalations. — We may sometimes lessen the irritation, by making the patient 
inhale the vapour of various drugs; — by having a vessel three parts filled with 
warm fluid, and making a patient inhale through it. There must be two tubes to 
the vessel, — so that the air may pass through the body of the fluid by means of 
one, while it is drawn out by means of the other. The tube which admits the air 
must go the bottom of the liquor, — so as to convey the atmosphere through it; and 
the tube to be inhaled from, must be fixed above the liquor.* The agents which 
have been chiefly tried are, first, a very minute quantity of iodine, mixed with 
hydriodate of potassa; and, secondly, chlorine. I have seen more mitigation 
from the chlorine than from the iodine; but I have never seen a case cured. I 
have used them both perseveringly; but I never saw a case of phthisis cured by 
these means; and 1 do not believe that a case ever 7vas cured. I have known a 
single drop of tincture of iodine, put into a pint of fluid, produce great irritation; 
but chlorine is borne much better. The mitigation afforded by it, however, is but 
temporary. The mode of using it is this: — into three-folirths of a pint of water, 
drop four or five minims of a saturated solution of chlorine. It is best to begin 
with one or two minims, and to increase the quantity gradually, as the patient can 
bear it; but if we at last arrive at a quantity which he cannot bear, we must then 
desist, and go back to what he can bear. Some have recommended the exhalations 
of tar. Tanners, as well as butchers, are said to escape the disease; and I have 
employed the liquor from tan-pits, in which there is an infusion of oak-bark. I 
have made people inhale it; and some have found considerable relief. Oihers, 
however, have found the smell so unpleasant, that they could not go on with it. 
I have not used it long; but as to its curing the disease, I should imagine that is 
out of the question. 1 believe that no means whatever will effect so desirable a 
purpose. 

Removal of Urgent Symptoms, — The great indication, when phthisis is once 
established, is to subdue inflammation if we can; — whether it occur in the form of 
pleuritis, or bronchitis, or peripneumonia. Besides this there is an indication, on 
the other hand, to support the strength by nourishing food and tonics; and a third 

" The particularity of this description is by no means uncalled for; and a medical man, 
when he orders a patient to inhale vapours, must give his personal auention to the manner 
in which it is performed, if he wishes to have his intentions efficiently carried out. On one 
occasion, in a lar<?e hospital, when a patient with ulcerated sore-throat had been ordered to 
inhale steam, 1 found him with the tin-inhaler comfortably tucked under the bed-clothes, 
with a cork stuffed into the air-tube. The consequence of this was, that the patient was 
obliged to remove his mouth from the instrument after every inspiration; and, after all his 
laborious efforts, the supply of steam was very insuflicient. The nurse (in every respect 
an excellent one), on being questioned as to the use of the cork, very naturally replied that 
it was "to keep in the steam;" and added, that she had been in the hospital eleven years, and 
never saw an inhaler used in any other way. There is nothing surprising in all this. Nurses 
are not expected to understand the principles of pneumatics. On instituting an inspection 
of the other inhalers in the hospital, every one of ihem was found duly provided with a 
«ork. — Dr. Rogers. 



PHTHISIS PUIj^ONALIS. 805 

imlication is to subdue irritation by narcotics. It is necessary to attend to another 
indication; — the removal of urgent symptoms of various kinds. 

We continually find a person sweating so profusely, that his strengtli is thereby 
gready diminished; and this may often be subdued by washing him all over with 
tepid vinegar and water, several times a-day; or by the exhibition of sulphuric acid: 
and sometimes, again, by acetate of lead. We also frequently have to subdue 
another evacuation; which is purging. This, of course, is to be accomplished 
chiefly by astringents and opium. Unfortunately, the more we subdue one evacu- 
ation, the more we increase the other. Frequently, when we check the sweats, 
the purging becomes more intense; so that while lessening the sweating by tepid 
ablution (with vinegar and water, for example) it is safe to give astringents, lest 
diarrhoea should suddenly begin. Diarrhoea is one of the most tiresome symptoms 
in consumption; and very frequently astringents and opiates do not succeed in ar- 
resting it, — on account of the inflammatory state of the mucous membrane; and 
yet the patient is too weak to bear leeches; and suffers so much altogether, that it 
is very painful to apply blisters. In many cases, fomentations or poultices of bran 
applied to the abdomen, will be as good means as can be adopted. Frequently the 
largest doses of opium (such as will produce great stupor), and the largest quantity 
of astringents (such as almost overload the stomach), have no tendency to check 
the diarrhosa. For a long time they may succeed; but at last, in most cases, the 
diarrhcea becomes so severe and obstinate, that they lose their efTect. A remarkably 
large quantity of astringents and opium may be given, with little or no benefit. 
However, we must do our best; and astringents and opium are certainly the best 
modes of checking the diarrhoea. Frequendy there is ulceration of the intestines; 
and, among the astringents, sulphate of copper answers better than any other. It 
has a tendency to produce sickness; but that may be subdued by hydrocyanic acid. 
If we exhibit sulphuric acid, it is generally necessary to guard it by laudanum; for 
its acrimonious qualities, when given by itself, tend to increase the affection of the 
bowels. 

Empirical Remedies. — Certain remedies have been boasted of as being capable 
of curing consumption; but there is no reliance to be placed on any of them. We 
are continually asked about the propriety of Iceland-moss, and things of that de- 
scription. There is no harm in them. On the contrary, they are good so far as 
they are nutritious and bitter; and are very proper things to be given; but there is 
no hope of saving a patient by them. It has been stated, that a large quantity of 
vinegar has cured the disease. Some persons ffive, in the course of twenty-four 
hours, about seven ounces of vinegar mixed with seven ounces of water, and 
sweetened with two ounces of refined sugar; but fair trials have been made with it 
without success. The balsams have also been recommended; but sometimes they 
heat the system exceedingly, and increase the inflammatory state. Myrrh has been 
recommended by some; but I believe it does no more good than any other tonic. 
We have also had the sulphate of copper strongly recommended; and it does alle- 
viate the symptoms. I think I have seen it, when guarded by opium, not only 
check the diarrhosa, but diminish the copiousness of the expectoration; but it has 
no specific virtue. Some have recommended us to give a person an ague; but so 
many persons who have ague die of consumption, and consimiption is so com- 
mon in aguish parts, that there is no reliance to be placed on this; and it would be 
great cruelty to give a person another distressing disease (such as ague), for the 
mere chance of doing good once, [)erhaps, in ^ thousand cases. Little more can be 
done than to lessen inflammation, support the strength, lessen irritation, and subdue 
urgent symptoms; for, after all that can be done, persons generally die of the com- 
plaint. The disease goes on progressively, and we can lessen suffering; but that is 
all; although, as I have already said," the disease may, no doubt, be prevented by 
great care. 

Elongation of the Uvula. — Symptoms arising merely from elongation of the 

» See Page 800. 



806 



PHTHISIS PULMONALTS. 



nvula, have very often been mistaken for real phthisis. This is a little point worth 
knowing. When the uvula is elongated,—- hanging from the pharynx, — it some- 
times produces constant cough; and this leads to a constant expectoration of mucus, 
and in some cases to emaciation. It happens, now and then, that extreme emacia- 
tion has been the consequence of an elongated uvula. Patients, from the constant 
cough and expectoration, have become emaciated; the tongue has become white; 
flying pains have taken place in the chest; loss of a|)petite has occurred; the pulse 
has become small and unequal; a pain has been felt in the larynx, from constant 
efforts being made to expel the mucus; — all of which symptoms have arisen from 
an elongated uvula: and therefore, whenever we are consulted by a patient labour- 
ing under these symptoms, it is right to look into the pharynx. 

Treatment. — The complaint may be promptly remedied by snipping off the 
lower half of the uvula, with a pair of scissors. The pain is but momentary; there 
may be a litde bleeding; but the operation is perfectly safe. 

It is very seldom that such severe symptoms will occur as to be mistaken for 
phthisis; but sometimes such a circumstance has taken place. Very often, how- 
ever, persons have a tiresome cough, which has been mistaken; so that blisters 
have been applied to the chest, when the symptoms have arisen from nothing more 
than an elongation of the uvula. With regard to local applications, the best are 
those which unite astringent with stimulating properties; but in cases where these 
fail, the operation of curtailing the uvula should be had recourse to. 

[There are few subjects within the range of medical science, that modern investi- 
gation (powerfully aided by the stethoscope) has more strenuously sought to eluci- 
date, than that of which we have just completed Dr. Elliotson's masterly exposition. 
The fearful ravages of pulmonary consumption; the insidious nature of its approach; 
the rapacious cruelty with which, as if in bitter mockery of our dearest sympathies, 
it loves to select the young and the beautiful for its victims; and the little avail 
hitherto attending our exertions to wrest the prey from the merciless spoiler; — all 
this has combined to impart to its investigation no ordinary share of interest.* Nor 
have the difficulties attending the pursuit caused the zeal of its followers to relax; 
for obstacles in the path of the real votary of science, instead of paralyzing exertion, 
only lead to greater effort. It is a heartless apathy, equally unworthy of the phi- 
lanthropist and the physician, that can look at the mass of disease yet unsubjected 
to the control of medicine, without humiliation at its extent, and anxiety for its 
diminution! And who shall say that its diminution, nay its final extinction, may 
not ultimately be accomplished? There are depths in science, and in medicine 
too, of which our present means of investigation only serve to show the profundity; 
hut who will venture, either in the. one case or in the other, to set bounds to the 
future advancement of knowledge? With the recollection of what has been already 
done, is there one in the whole range of diseases, against which the power of 
medicine shall be declared for ever unavailing? A conquest so noble as this, how- 
ever, is not to be attained at once. It must be the result of patient and laborious 
investigations; of multiplied and varied experiments; of impartial and repeated 
observations. We must be content to ascend the steps, if we would ever attain the 
summit. It is on this account that every devoted student of medicine must hail, 
with pleasure, the light which has been thrown on this and kindred subjects, bjj 
the French school; and to those who have devoted their lives to an unflinching 
warfare with disease and death, and to the grateful task of soothing the pangs of 
suffering humanity^ will be adjudged, by every properly constituted mind, a higher 
meed of applause, than to heroes and conquerors the most sucecessful and re- 
nowned.'']] 



* Various points of interest relative to this subject, are discussed by Dr. Graves, in two 
lectures wiiich form part of one of his clinical course>;— courses distinguished no less by 
attractive vivacity of style, than by intrinsic excellence of matter. Seethe " London Medi- 
cal and Surgical Journal," for March, 1833. (Nos. Gl and G2j Volume 3; Pages 230 and 262.) 

•» Dr. Rogers. 



DISEASES OF THE PLEURA. 807 

CHAPTER XL 
DISEASES OF THE PLEURA. 

SECTION I.— ACUTE PLEURITIS. 

I NOW proceed to consider diseases of the pleura; and, in the first place, the 
most comnnon affection of it, — inflammation. 

General Symptoms. — When the pleura is inflamed, there is (of course) pyrexia. 
If the inflammation be idiopathic, — if it be consequent on some local irritation, it 
usually begins with shivering; and is followed by quickness of the pulse, and all 
the symptoms of pyrexia. The pleura is a serous membrane; and therefore, in 
most cases, we have a firm hard pulse; — not invariably, but generally. Then, as 
to the local symptoms, we have almost always severe pain, — an acute, stabbing, 
sharp pain; — the least attempt at a deep inspiration augmenting this pain exceed- 
ingly. This pain is not increased on the least pressure. We may press the 
integuments down upon the ribs, without aggravating it; and we may press mode- 
rately between the ribs; but if we press very firmly between them, and still more 
firudy upon the ribs themselves, we (of course) press upon the pleura, and then the 
pain will be increased. In severe cases there is extreme pain, so that hardly any 
pressure can be borne; and I have known persons unable to lie on the side, on 
account of the pressure exerted by the part against the bed. 

Distinguished from Rfieumatism. — A case must be very severe, for pain to be 
felt on slight pressure. In truth, we may generally distinguish pleurilis from rheu- 
matism of the muscles of the chest, among other means, by this; — that in the latter 
case the least touch causes pain and soreness; — such a pressure as will not affect a 
patient labouring under pleuritis; — pressure on or between the ribs, and at the back 
or front of the chest. In acute rheumatism, for the most part, there is profuse 
sweating; — such as there is not in pleurilis; but there is not, in rheumatism, that 
general disturbance of the constitution, which occurs in pleuritis. In pleurilis, the 
whole constitution is very much disturbed; and there is not, by any means, that 
severe pain which there is in rheumatism. In general, we can make out the differ- 
ence of the cases very well. The pain, in pleuritis, is only felt at the lowest part 
of the chest; — or, at least, low down in the chest; — not in front, nor at the back; 
but towards the side. I suppose the disease has had its name (''pleuritis'') from 
the pain being observed to be situated in the side [Hisv^a)', and not from the pleura 
being inflamed. 

The respiration is rapid in this disease, because the patient cannot make a deep 
inspiration; and, to compensate for the want of depih, he breathes the more quickly. 
The pain is increased by coughing, and by speaking. Sometimes, on account of 
its severity, patients cannot speak at all. In general, we make out the nature of 
the disease sufficiently, without listening to the chest. This affection is one of the 
best marked of any with which I am acquainted. There can be no difficulty, 
except in distinguishing it from rheumatism; and, in general, by attending to. the 
points just referred to, no difficulty will be met with, even on that head. 

Varieties in the Symptoms. — The seat of the pain will sometimes vary in the 
course of the disease. It wUl sometimes cease on one side, and be felt by the 
patient on the other; and it is said that, now and then, the pain is not felt in the 
part which is found inflamed after death. The pain is felt in the opposite side 
during life; and opposite to that in which we find marks of inflammation after 
death. It is said, though I do not recollect j^eeing such a case myself, that some- 
times no pain has been felt at all; and the practitioner has been surprised to find, at 
he autopsy, violent marks of inflammation. Usually the patient lies best on the oppo- 



808 



DISEASES or THE PLEURA, 



J;(,|i; 



i 



;!;r* 






m 
iiil 
PI 



site side; but sometimes he can lie more easily (or lie onli/, indeed) on the affected 
side. The cough which attends this disease is usually dry, and not very frequent; 
and sometimes it is altogether absent. 

Auscultatory Signs. — On listening to the affected part, we generally find less 
respiration there, than there should be. The part is not much expanded in respi- 
ration. The ribs, at that part, do not move so much as in other parts of the chest 
that are healthy. Less respiration occurs there; and, on that account only, there 
would be less respiratory murmur; but there is sometimes considerable effusion of 
lymph, or of serum; and that, of course, will obscure the respiratory sound. After 
a time, effusion takes place in a decided manner; and then we have a dull sound 
upon percussion, and no respiratory murmur is heard at the part. There is no 
crepilous rattle heard, as in pneumonia;* and no sonorous or sibilous rattle, as in 
bronchitis;'' and therefore — with this absence of sound, and the acuteness of the pain 
— there is in general no difficulty in saying, that the patient is labouring under inflam- 
mation of the pleura. Now and then, pleuritis is united with pneumonia and bron- 
chitis; so that we have the crepitous rattle as well as acute pain; or we may have 
a sonorous and sibilous rattle; but the acute pain, which is unknown in pneumonia 
and bronchitis, sufficiently shows that those affections are complicated with inflam- 
mation of other parts. 

^gophonism. — When effusion takes place, we may always ascertain it to a 
certainty by the presence of aegophony. Sometimes the patient loses his pain, and 
may even say he is a great deal belter; but notwithstanding that, on listening to 
the chest, we may ascertain that he is in considerable danger. Indeed, in such 
cases, we may be satisfied, — from the quickness of the respiration, or the difficulty 
of it, — that all is not going on well. But if, in every case of pleuritis, we make a 
point of examining the chest by the ear, we may ascertain to a nicety when effusion 
takes place, and to what extent it has occurred. In cases unattended by danger 
altogether, this effusion may occur; although a person who does not use his ear, 
would not know that it existed. When effusion is present, there is a dull sound on 
percussion, and a want of respiratory murmur; and besides that, if the effusion be 
inconsiderable, we have in most cases a peculiar phenomenon; which is called 
"aegophonism"'' (from ^wv»;, sound or voice; and ac|, a goat); — the sound of a 
goat. When once heard, this sound can never be mistaken. It is a sound which 
but few persons have heard; because, in general, people do not listen to the chest 
in this disease; and when it is heard, it is only in a moderate^ not in great effu- 
sion. The symptoms at large are not severe at the moment it is heard; and there- 
fore those who are not in the habit of using their ears, in this particular disease, do 
not think it worth while to examine the chest at that period. We hear it best by 
applying the stethoscope firmly to the chest; and then applying our ear lightly to 
the stethoscope. The voice does not run through the tube, as in pectoriloquy. It 
does not, by any means, lake place to the same degree. It rarely, indeed, enters 
the tube at all. There is no difficulty in learning these signs. Laennec says he 
noticed it in every case of pleuritis that he examined, for five years preceding the 
publication of his second edition.* Where the effusion is very moderate indeed, 
then it is not sufficient to produce the sound; and if it be excessive, the pheno- 
menon cannot lake place at all. Laennec says he has observed it, where there did 
not exist in the chept above three or four ounces of fluid.** It will occur, not merely 
when there is serum effused in the pleura; but also when the serous membrane 
pours forth pus; as it sometimes will. Altogether it is a variable symptom; because 
it can only occur when the effusion is moderate. 

Cause of^gophonism. — This phenomenon is explained, by Laennec, to be owing 
to the compression of the bronchial lubes by fluid, conjointly with the transmis- 
sion of the sound of the voice through a thin layer of fluid. If the layer be very 
thin, it is not sufficient; for the sound must pass through a certain body of fluid; 



• See Page 753. " See Pa?re 739. 

d Laennec, on Diseases of the Chest; translated by Forbes. 
ter 4; Section 2; Subdivision 3. (Third Edition; Page 42.) 



" See Page 713. 
■ Prelinninary Essay;" Chap- 



DISEASES OP THE PLEURA. 809 

and, indeed, a very thin layer of fluid would not be sufficient to compress the 
bronchial tubes. It must reach a certain amount, both in order to compress the 
bronchial tubes, and to be the medium of this sound; for if there be ffreat effusion, 
the bronchial tubes are so compressed, that there is but little air in them; and then 
the sound cannot be heard. Whether Laennec's explanation is correct, I will not 
pretend to say. By changing the level of the fluid, we change the seat of the 
aegophonism. If the patient be upright, it will be of course over the highest por- 
tion of fluid; but if the patient be lying down, then it is heard where the layer of 
fluid is the thinnest. 

Morbid Appearances. — If we inspect the part after death, we find nothing more 
than I mentioned, when speaking of inflammation of serous membranes in gene- 
ral.* Sometimes there is diffused redness; sometimes there is a striking redness, 
and an effusion of lymph on or within the pleura; and sometimes there is serum, 
occasionally quite clear, but for the most part turbid, and of a yellow colour, with 
more or less flakes of lymph swimming in it. 

Causes. — The disease arises, in almost every instance, from cold and wet. It 
will sometimes arise from a local source of irritation; for example, from wounds, 
from the effusion of substances into the pleura, or from idceration of tlie part; but 
by far the most common cause is the application of cold. 

Treatment — Upon the treatment I need not dwell. It is nothing more than 
that for any common inflammation.* Bleeding, mercurializing, starving, and pur- 
ging, will cure it; — ^^just as easily as any other inflammation. 

Blood-letting. — [The most desirable object is to destroy the inflammation at its 
very onset, before the signs show that the effusion is considerable. For this pur- 
pose, the most effectual remedy in severe cases is a full general bleeding, carried 
(if possible) to such an amount as to remove all pain on full inspiration; or, if 
there be little or no pain, until all hardness of the pulse ceases. This should be 
followed by free leeching or cupping of the aflected side. We" think leeches 
generally preferable; but they should not be applied sparingly; and they should 
be immediately followed by a large warm poultice covered with flannel, or by a 
succession of warm dry napkins. These depletory measures must be repeated, if 
within a few hours the pain return, or the pulse resume its hardness. Of internal 
remedies, those are the most useful, in the first instance, which assist the blood- 
letting in producing an impression on the circulation; es{)ecially brisk purgatives, 
containing mercury and antimony; which act fully on all the secretions. Calomel 
and James's powder, followed by an active draught consisting of salts and senna, 
generally answer best. Tartarized antimony is less effectual in this than in other 
inflammations of the chest: it may do harm if it excite vomiting; but in doses 
short of that effect it may prove useful. 

Mercury. — It commonly happens that such measures take off the edge of the 
disease without destroying it entirely; or, at least, without removing its products; 
which must be a work of time: and although the pain, dyspnoea, and cough be 
much relieved, they are not removed; and the physical signs show, that effusion 
lias taken place to a greater or less extent. In these circumstances, the proper 
means are those which promise to fulfil both indications; — to reduce the remaining 
inflammation, and to promote the absorption of the matter already eflused. The 
most powerful of these is meicury; which may be combined with ipecacuanha and 
opium; — to lull the pain, and to prevent the calomel from passing off too freely by 
the bowels. These remedies should be given in pills every three or four hours; 
and to them may be added digitalis or colchicum in a saline mixture, with an ex- 
cess of alkali; — to keep down the action of the heart and arteries, to determine to 
the kidneys and skin, and to lower the inflammatory condition of the blood. The 
beneficial influence of mercury is sometimes apparent when it does not aflect the 
gums, especially in young subjects; — its operation being only manifest on the hepa- 
tic and alvine secretion; which is green, dark, or high-coloured, — from diflerent 

aSeePaselOS. b See Page 118. 

c Dr. C. J. B. Williams. 



810 



DISEASES OF THE PLEURA. 



conditions of tlie bilious matter in it: but in most cases the gums exhibit the efTect 
of mercury before these secretions are producecl. 

Leeches and Blisters. — Venesection can seldom be repeated with much advan- 
tage after the first few days; unless on the occasion of a fresh access of pain, or 
other symptoms which denote the renewal of acute inflammation. Occasional 
leechinofs continue to be useful; but, after the inflammatory fever has been rethiced, 
the most effectual external remedies are bUslers; which shoulil be large, and not 
left on too long; from six to eight hours is generally time enough to make iheni 
vesicate without inflaming the tissues too deeply, or irritating the system by the 
absorption of their serous discharge. Where the effusion is abundant, a succes- 
sion of blisters will be necessary; or they may be varied by a suppurating counter- 
irritant; — such as the tartar-emetic ointment or solution. 

Diet and Regimen. — The diet must be of the most spare kind, in the early 
stage of acute pleurisy; and the patient should remain as quiet as possible in bed. 
But when the inflammation is subdued, sitting up, and (if the strength wdl permit 
it) using a little exercise about the room, will be beneficial in promoting the ab- 
sorption of the fluid. 

In limited varieties of pleurisy, — such as those of a mild or partial kind, those 
excited by tubercles, and those which occur in combination with typhoid or asthe- 
nic symptoms, — the anliphloijistic measures above described must be reduced to 
suit the nature of the case, and the amount of the general strength. Circumscribed 
pleurisies may sometimes be removed by cupping or leeching only; and in condi- 
tions of the system depressed by febrile or other morbid poisons, or reduced as in 
phthisis, blisters, or sinapisms may be the only antiphlogistic means which can be 
borne. In contiimed fever, besides these external means and the usual salines, 
mercury in combination with opium is, according to our* experience, the most ap- 
propriate remedy."'] ^ 



SECTION II.— CHRONIC PLEURITIS. 



Pleuritis is sometimes a chronit affection; and here it is that the particular sign 
called '• aegophonism"'' is essentially serviceable. When pleuritis occurs in a chro- 
nic form, it is every day mistaken for phthisis. I have seen instances of this over 
and over again. Sometimes the acute form of the disease degenerates into the 
chronic; but more frequently the latter is a very insidious affection; and creeps 
upon the patient slowly. 

Symptoms. — The general symptoms so much resemble consumption, that the 
patient is supposed to have gradually fallen into that affection; for this chronic 
form of the disease is frequently attended by no pain, or only by obscure pain; and 
yet the patient has pyrexia, cough, and expectoration. He will become hectic, and 
waste away; the pulse will be constantly quick, and he will die. On opening the 
body, a large quantity of pus will be found in the pleura; while the lungs them- 
selves, perhaps, are entirely sound. Very frequently, when chronic pleuritis exists, 
tubercles exist in the lungs at the same time; but irequenUy they do not; and, at 
any rate, if they do, it is very common for pleuritis to have been the sole cause of 
death; — none of the tubercles having proceeded to ulceration. 

Adhesions; Effusion. — In this chronic form of pleuritis, adhesions are not 
formed to any great amount. In the acute form, the effusion leaves adhesions. 
Sometimes the whole side is adherent; — the " \)\e\.ua pulmonalis^^ to the " pleura 
costalis;'^ but in this chronic form the collection is often altogether, or the greatest 
part of it, pus; and any adhesions that form, are frequently slight portions of 
lymph that have been effused. They are so soft, that they are not capable of be- 
coming organized; but, as they are mixed with serum, we find (after death) that 

* That of Dr. C. J. B. Williams. 

»» " Library of Medicine;" Volume 3; Pages 133 and 134. 

«SeePages713, 808, andSU. 



PI^EASES OP THE PLEURA. Si 1 

the two substances are united; or, at least, that the one is mingled with the other. 
This fluid — this turbid serum, or puriform serum, or this absolute pus — augments 
daily, till the lungs are compressed towards the spine, and towards the mediasti- 
num; and sometimes they are so reduce<i, that, on a careless examination, they 
have been said to have disappeared altogether. 

Empyema. — Sometimes the affected side of the chest grows large; and if it be 
the left side in which the disease resides, the heart is pushed to the right; — so that 
it beats on the right, instead of the left side. The disease is then called "empye- 
ma," if the fluid be pus; but it makes no diff'erence whether it be pus or serum. 
In these circumstances, the ear may not be necessary in order to recognise the dis- 
ease; for the side is visibly increased in size. It appears, to the eye, to be larger 
than the other; and, on measuring it, we find one side of the chest half an inch, 
perhaps, or an inch, larger than the other. Sometimes we can discover fluctuation, 
— just as in other instances of a collection of pus; but now and then there is no 
enlargement of the chest, and no fluctuation to be felt. 

Signs afforded by Auscultation. — When eff'usion takes place, there is a dead 
sound on percussion; and no respiratory murmur is heard. This is the natural 
result of the part being no longer filled with air, but with pus; which has driven 
the lung aside or upwards, and compressed it below. When a lung has become 
solid from air, we have this same auricular phenomenon. If the lung become solid 
from inflammation,— if the substance be converted into something like liver, so far 
as the solidity is concerned,* — we must have a dead sound on percussion, just as if 
fluid were there. No more air exists in the lung when it has become solid, than 
when fluid abounds in the chest; and in these circumstances we have equally no 
respiiatory murmur; because the lung, being solid, is unfit for its functions. But 
when a lung thus becomes solid from inflammation, it becomes so solid throughout, 
that there is no respiratory murmur at the root of the lung; for that part is equally 
inflamed with the rest; whereas when the dull sound of the chest, and the want of 
respiratory murmur, arise from a collection of fluid, it rarely so compresses the 
lung, but that we may hear respiration at the posterior part; that is to say, along 
the sides of the spine, about three fingers' breadth from the vertebral column. Re- 
spiration also continues there when fluid is collected. However great the eff'usion 
may be, — even if the lungs be so compressed as to be found with difficulty after 
death, — still I believe that the respiratory murmur is heard at the back and root of 
the lungs, in the situation I have just stated. This murmur, too, is heard before 
the eff'usion is very considerable; and it is heard for a length of time under the 
clavicle, at the highest part of the chest; — before the collection of fluid mounts so 
high. When the want of a hollow sound on percussion, and the want of the re- 
spiratory murmur, arise from the lung becoming solidified through inflammation, 
we may very rapidly cease to hear the respiratory sound under the clavicle. The 
inflammation may so quickly solidify the lungs, that we may hear no respiratory 
murmur on either side of the spine; because all parts of the lungs may be inflamed. 

jEgophonism. — iEgophonism certainly does now and then occur; but still it is 
to be remembered, that if the fluid fill up the side of the chest, or nearly so, we 
cannot expect this phenomenon. It is only in a moderate collection that this sign 
is present; and therefore a person may have the pleura full of pus without it; but 
if we have attended the patient from the beginning of the complaint, and have been 
in the habit of noticing all the symptoms to be learned by the ear, in conjunction 
with the general symptoms, it is easy to find that regophonism has appeared and 
disappeared; and we know it has disappeared, not from an absorption of the fluid, 
but from an a^tgmentation of it, because percussion of the chest gave a dull sound, 
just in proportion as the aegophonism declined. 

The part of the chest where we should first listen for segophonism, is from about 
one to three fingers' breadth from the lower angle of the scapula, towards the nip- 
ple. The reason why it is most frequently heard there is, that the fluid generally" 

• See Page 753. 



812 DISEASES OP THE PLEURA. 

accumulates below that part; and if the whole lung be covered with effusion, still 
the thickness of the body of the fluid is always less at the posterior part. We can 
hear this phenomenon here, when we can hear it nowhere else; because the fluid 
cannot accumulate so extensively in this situation, as in other parts. After the 
phenomenon has declined in the front of the chest, from the great accumulation of 
fluid, it may still be heard at the back, in the particular part I have indicated.* 

Displacement of the Liver. — In mentioning that the accumulation of fluid in the 
left pleura, sometimes pushes aside the heart, — so as to produce the extraordinary 
phenomenon of the heart beating on the right side,'' — I might have stated, that 
before auscultation was known (but after percussion had been introduced to the 
medical world, and treated with neglect in this country), I saw a case that puzzled 
me completely. In a case of this disease, the liver was so pushed down, that it 
was felt below the navel; and I, being young in practice (though, however young 
a practitioner might be now, he could not make such a mistake), had no idea of the 
nature of the disease; but supposed that the man had an enormously enlarged liver; 
and so did every body else that saw him. The man had a very enlarged abdomen. 
After death, the liver was found perfctly healthy; but, like the heart in other cases, 
it was not in its " right place." A vast accumulation had taken place in the right 
pleura; which actually pushed down the diaphragm, and the liver along with it; — 
so that the case was completely misunderstood. If auscultation had been then 
devised, — if all the phenomena that are known now, had been known then, the 
matter would have been very clear. We should have ascertained that there was 
no enlargement of the liver, from this circumstance; — that there must have been a 
dull sound on percussion, all up the right side of the chest; and, on listening for 
respiration on the right side, there would have been none heard. It would have 
been perfectly clear, that the right side of the chest was occupied with something 
else instead of air; and if the case had been observed throughout, of course there 
would first have been noticed segophonism; and afterwards it would have disap- 
peared; — so that no mistake could have been made. An operation might have been 
performed, and the man might have recovered; but, as it was, he died. There 
was a large collection of liquid in the right side of the chest; and every one was 
quite surprised to find it there. I was not at the inspection; but such was the 
result. An accumulation in the right side of the chest, therefore, may push down 
the liver in an extraordinary manner; — ^just ^s accumulation in the left side, may 
push aside the heart. Even now, cases of chronic pleuritis are every day mistaken 
for phthisis. 

Dyspnoea not very great. — In this chronic form of the disease, as the accumu- 
lation takes place slowly, respiration is not so difficult as might be imagined. The 
other side of the chest gradually does more and more duty; and the patient feels the 
inconvenience increase so gradually, that it is not such a source of distress, to him 
as we should imagine. In acute pleuritis, when the effusion is very considerable, 
respiration is necessarily rapid;" and there we have infinitely more difficulty of 
breathing, than if the same quantity of fluid were effused in a chronic form. 
There is nothing more than an instance of a general fact; — that when any thing 
peculiar comes on slowly, and is increased moderately, it is not productive of half 
the excitement, that it would be if it came on quickly. 

Effect of Compression on the Lungs. — When the fluid has thus compressed 
the lung, although nature may cause its absorption, or although a medical man may 
occasion its escape by an operation, it is possible that the lungs may never expand 
again; and this want of expansion may occur, either from the great compression 
they have undergone, or from the production of such firm adhesions, that they are 
effectually bound down. Inflammation may not only have induced the accumula- 
tion of fluid; but may have produced such an effusion of fibrin, as to form firm 
bands, — binding down the lungs; and, from either of these circumstances, the lung 
may never recover its elasticity. Laennec declares that, on inspection, he has 

» See the last Paragraph but one. ^ See Page 811. « See Page 807. 



DISEASES OF THE PLEURA. 813 

Uniformly found these firm adhesions; and he calls them " fihro-cnrtilag'ino'js;" — 
liol " fibrous," as we generally see adhesions; hut " fibrn-cai^ti/aginoits.'^ How- 
ever, as the lungs have been known to expand again in some degree; and as the 
chest, which was sunk in, in consequence of the compression of the lungs, has in 
some degree recovered its form, — we can hardly suppose that the lungs, in every 
case, are prevented from expanding merely by adhesions. Of course, if the lungs 
do not expand, the chest wdl become flattened on the sides, from the pressure of 
the air; but it has been known that the chest, after it has become flattened, has 
enlarged again, — from the lungs having recovered their powers; and if the want of 
expansion in the lungs, for a great length of time, arose from fibro-cartilaginous 
bands, it is not likely that they would ever have yielded, so as to allow of the ex- 
pansion of the luuffs again. The extreme compression of the lungs, seems to me 
to be quite a sufficient cause for the want of their subsequent expansion, without 
having recourse to the supposition that, in every case where they do not expand 
again, there must be firm adhesions. The whole lungs are so compressed, — so 
squeezed together, and become so fixed, that they resemble muscles: — muscles 
with fibres too minute for detection. The colour is either red or gray. 

Conlraction of the Chest. — If the lung has been so compressed that it will not 
expand, and the fluid has been absorbed or let out, and no more has formed, the 
ribs on that side fall, and lie more closely together than they should do. The 
shoulder, on that side, falls below the other; and the muscles (especially the pec- 
toral) waste, — both as to breadth, and as to length. The muscles waste in propor- 
tion as the side becomes contracted; and they are found, on actual measurement 
after death, to be diminished; and still more do they appear to the eye to be dimi- 
nished. Even the spinal column at length inclines, in some cases, to the opposite 
side. Most practitioners must have seen instances of persons, with their ribs lying 
closely together on one side; with the shoulder depressed, and the spinal column 
bent to the other side. The nature of such cases, however, was not understood, 
nor were the general phenomena of the case itself well described, before the appear- 
ance of the first edition of Laennec's celebrated work.* I recollect, very well, 
having had an individual pointed out to me, as a decided proof of the power of 
hydrochlorate of lime in scrofula and phthisis. After suffering very long from 
pectoral complaints, and b 'ing put under the long exhibition of muriate of lime, 
the man recovered his health; but one side of the chest was manifestly smaller than 
the other; and he was shown to every body as a man who had long had phthisis; 
but in whom all the ulcers had healed up, in consequence of his having taken the 
remedy just mentioned. It was considered that the lung had wasted away from 
ulceration; and the contraction of the side of the chest, was thought a sufficient 
proof of it; because he had continually expectorated from irritation of the bronchia. 
I supposed, not knowing better, — for nobody knew better in those days, — that 
this was actually the case; and therefore did not attempt to deny it. There is no 
doubt, however, that this was not a case of phthisis at all; but that it was a case 
of chronic pleuritis, in which great effusion had taken place; which effusion had 
afterwards been completely absorbed, by the power of nature; and the lung had never 
been able to recover itself from its compressed condition. There is, in Laennec's 
work, a drawing of an individual, with one side of the trunk lower than the 
other;'' — through the falling in of the chest, in the manner I have now described. 

Cause of Contracted Chest. — Laennec considers, that when a case of this de- 
scription is well marked, it arises from that form of pleuritis, which is attended by 
bseiuorrhage into the pleural cavity." I mentioned, when speaking of heeniorrhage, 
that mucous and serous membranes will sometimes produce an effusion of blood;* 

• See Note to Pa^e 706. 

•> See Plaies 6 and 7 in Dr. Forbes's Translation. 

* Laennec on the Chest; tran:^laled by Dr. Forbes: Part 1: Book 3: Chapter 1: Section 6. 
(Third Edition; P;.ge 459.) 

«» See Pages 136 and 137. 



814 DISI;ASES OF THE PLEURA. 

though we cannot tell the reason; but sometimes it is tlie case. This sometimes 
happens in the case of the pleura. There is, however, no proof that it always 
resuhs from haemorrhagic pleuritis. Sometimes it arises from that source; but 
sometimes the fluid, when let out, has proved to be mere pus, without any admix- 
ture of blood; and yet contraction of the chest has occurred; — just as where blood 
has been let out in conjunction with the pus. If it occur more frequendy (as 
Laennec says") after hsemorrhagic pleuritis, and if the dense fibro-cariilaginous 
bands (formed by a cohesion of the fibrin in the blood effused upon tlie costal 
pleura) were always discovered in contraction of the chest,* still I should not re- 
gard the thickness of these bands of fibrin as the cause of the contraction; but as 
effects, no less than the contraction itself, of the inability of the compressed lung 
to expand again. 

Bloody fluid, just like pus, is not so rapidly absorbed as mere serum. When 
blood is effused, the lung is irrecoverably compressed, by the duration of the 
pressure; and, from the slow manner in which the elasticity of the chest, and the 
pressure of the atmosphere, — resisted as they are by the natural structure of the 
chest, — can bring down the side to the flattened lung, a space probably exists, 
greater or smaller, for some time. Laennec, indeed, seems to contradict himself; 
for he says he is of opinion, that contraction of the chest rnay be found, in an 
€qual degree, after the disease has produced merely cellular adhesions; so that, in 
some parts of his work,'' he seems to give up the opinion, that the inability of the 
lungs to recover always arises from these firm fibrous cartilaginous bands. He also 
allows, in another part of his work,'' that the contraction is owing, not to the adhe- 
sions themselves, but to their slow formation. The more slowly these are formed, 
the less chance will the lung have of expanding. He says'' that if the effusion be 
copious, and consequently the resolution of the pleuritis slow, the contraction is 
evident long before the complete absorption of the fluid; but he says," that the 
more rapid the absorption, the less chance is there of contraction; since the longer 
the lung is compressed, the greater is the loss of its natural elasticity. In short, 
Laennec himself does allow," that the continuance of the compression, through the 
effusion, is the cause of the inability of the lung to recover itself. I myself have 
frequendy opened persons, in whom the lung has never recovered itself; and yet 
there have heen no fibro-cartilaginous bands, or bloody fluid; so that the long con- 
tinuance of the compression, appeared sufficient to explain the immobility of the 
lung. 

Period at lohich Contraction Co7nmences. — When the chest contracts, in chronic 
pleuritis, the diminution may begin at an early period of the effusion; but may not 
be perceptible for months. Of course it can only be a certain degree of contraction 
of the chest that is observable; and those persons who are not in the habit of ex- 
amining patients with the eye and with the hand,— who consider those as mechani- 
cal means, fit only for the surgeon; — those who are not in the habit of making 
patients undress, and are not accustomed to handle them, except to feel the pulse; 
— such persons will, of course, be ignorant, for a great length of time, of contrac- 
tion of the chest. It may go on till the patient makes the discovery, and announces 
it to his medical attendant. 

Auscultatory Signs of Contracted Chest. — When the chest is contracted, — 
when fluid no longer exists, but the lung is compressed, and the thorax goes down 
upon it, — then there is a dull sound upon percussion;— just as when pleuritis 
existed; and sometimes we have not only a dull sound, but a irue Jfeshy sound; — 
the same sound as if we struck the shoulder or the thigh. But notwithstanding 
this dull sound, the respiratory murmur is heard a litde. Probably, there will be 

* See Pages 136 and 137. 

1) See Dr. Forbes's Translation; Part 1; Book 3; Chapter 1; Section 6. (Third Edition; 
Page 462.) 

c See Dr. Forbes's Translation; Part 1; Book 3; Chapter 1; Secdon 6. (Third Edition; 
Page 463.) 



nS-EASES OF THE PLEURA. 815 

no respiratory murmur at the lower part of the chest, where the effusion had taken 
place first, and must have ceased the last; — for, of course, it is to the lower part of 
the chest that the fluid will gravitate at first, as well as at last; but respiration may- 
be heard Taintly at the upper part. 

Usual Termination of Chronic. PJeuritis. — When the inflammation has ceased, 
and the effusion to which the inflammatory state gave rise has ceased, the walls of 
the chest are flattened down proportionately to the contracted dimensions of the 
lunor; and nature has effected a cure, exactly in the same way that a surgeon effects 
a cure of hydrocele;— by adhesion. In the case of a hydrocele, there is a serous 
membrane; and when it is inflamed by an injection, fibrin is poured forth, and also 
serum. The serum is at last absorbed, but the fibrin blocks up the cavity alto- 
gether; and that is exactly the state of the parts in the cavity of the chest. When 
nature has effected a cure, in the way that I have now described, the person is 
more or less deformed for life; but suffers little inconvenience. The general health 
may be excellent. Laennec mentions the case of a distinguished surgeon at Paris, 
whose chest was contracted after pleuritis, which took place in youth; and in 
whom percussion, when Laennec wrote, gave a dull sound at the lower and lateral 
parts of the affected side of the chest; and the respiratory murmur was weaker 
there, than on the opposite side; but this surgeon had a strong voice; and contrived 
to lecture once, or eveii twice a-day, for an hour at a time, without any inconve- 
nience.* 

7Weatment of the Empyema. — In this particular form of the disease, the making 
of a correct diagnosis is very important; because we may render a patient essential 
relief. We may save life; and in those cases in which we cannot save it, we may 
protract it. It was only a few years ago, that I had a case of this description, in 
a young child almost at the breast. The heart was pushed so much to the right 
side, that it was pulsating there; and, the nature of the case being perfectly clear, a 
lancet was plunged into the left side of the chest two or three times; and the child 
fortunately recovered, and is alive now. An operation is always safe in these 
cases. If the collection should point at a particular part, that is the spot at which 
we should make the opening; but if it do not point, then we should puncture be- 
tween the eleventh and twelfth ribs. If there be any doubt about the case, I should 
advise the use of a needle invented by Dr. Thomas Davis. He had a large needle 
made with a groove; which we may introduce without any danger. When it is 
plunged in, if fluid exist, a drop will form near the end of the needle. Whether 
there be water present, or pus, it will escape to a certain extent; and if a drop of 
fluid come, we may be sure of the nature of the case. A small trocar may then be 
passed in; and we may thus draw off the fluid. It will be right not to draw off 
much at a time; — to draw off only what we consider to be a third or a half of what 
is there, — according to the size and age of the patient; and we may continue to 
draw it off at different times, till the chest is completely emptied. It was the 
custom of the late Dr. Thomas Davis, ^ I know, to pass in a piece of hollow bougie; 
and to let it remain there. The end of the bougie must be bent down, and fastened 
by straps of adhesive plaster; so that it may not find its way into the chest. Some- 
thing must be put into the end of the bougie, to prevent the fluid from escaping too 
suddenly. The plug may be taken out every day, and a liiile fluid allowed to 
escape. When the lungs were sound, this treatment has been successful. I have 
not seen many cases of this description; but Dr. Davis had several; and he could 
count up a considerable number, where life has been saved eniirely by this method. 

Besides the surgical treatment of such a case, — letting out the fluid, — it is neces- 
sary to support the strength, and to lessen the irritation by means of opiates; — to 
use the same constitutional means that we should employ in the case of a large 
abscess. 

" See Dr. Forbes's Translation; Part 1; Book 3; Chapter 1; Section 6, (Third Ediiion; 
Page 459.) 
•> Physician to the London Hospital. 



816 DISEASES OF THE PLEURA. 



SECTION III.— HYDROTHORAX. 

Pathology. — It sometimes happens that an effusion of fluid takes plane into 
the pleura, without much inflammation. A quantity of serum is effused there; 
sometimes quite clear; sometimes more or less turbid, and of various characters; 
but it is not pus, nor is it the result of inflammation. This is commonly called 
*' hydrothorax."* When speaking of dropsical effusion, I mentioned'' that effusions 
in a serous membrane were sometimes puriform, sometimes purulent, sometimes 
bloody, and so on; and I mentioned that sometimes they arise from violent inflam- 
mation, sometimes from moderate inflammation, and sometimes, apparenfly, with- 
out any inflammation at all.*^ Now the pleura is in the same predicament as all 
other serous membranes. It is frequently in the state I have now mentioned from 
inflammation; but sometimes it contains a quantity of thin fluid, where there was 
scarcely any inflammation at all, — where there was no necessity to employ anti- 
phlogistic means; and sometimes it contains a large quantity of serum, without 
our being aware (not only during life, but likewise after death) that inflammation 
has occurred; — in fact, without the least sign of inflammation. Effusion may take 
place in the pleura, as in other parts, without any signs; — just as a person may 
sweat, and pour forth fluid, without any inflammation whatever. 

Idiopathic Hydrothorax very Rare. — A genuine idiopathic case of hydrothorax 
(water in the pleura) is a very rare thing. Some people who never examine the 
chest during life, but who open bodies after death, speak of hydrothorax as the 
most common thing in the world; but when it does not arise from inflammation, 
hydrothorax is a rare disease. When there is any other disease in the chest, it is 
common for effusion to take place; but for it to take place, except as a consequence 
of inflammation, or some organic disease in the chest, is very rare. I do not recol- 
lect half a dozen such instances. 

Auscultatory Signs. — When hydrothorax occurs, whether it is the result of a 
very slight kind of inflammaiion, or is produced by bronchitis, or peripneumonia, 
or disease of the heart, or any other disease, the symptoms discoverable by the ear 
are just the same as those that occur when the fluid is puriform or purulent, and 
the result of decided inflammation. There is, of course, a dull sound on percus- 
sion, from the presence of fluid; and there is no respiratory murmur at the lower 
part, although we may still have it at iheupper part (unless the chest be completely 
filled), below the clavicles; and also on each^ide of the spine, where the fluid does 
not compress the roots of the lungs. 

General Symptoms. — The general symptoms are difficulty of breathing, defi- 
ciency of urine, swelling of the legs, cough, and a sudden starting from sleep; but 
all these things, when they do occur with a certain degree of effusion into the chest, 
are more frequently the result of other diseases in the chest than of hydrothorax. In 
almost every case of hydrothorax, we find, on examination, other disease sufficient 
to explain the symptoms. In most cases there is disease of the heart, or chronic 
disease of the lungs; and in those affections we have exactly the same symptoms; 
although there may not be the same quantity of fluid effused into the pleura. I 
have frequently o|)ened patients, who have been supposed to have died of hydro- 
thorax; whereas death arose from disease of the heart Cases are frequently sej 
down as hydrothorax; — where the legs are swelled; where the breathing is so diffi- 
cult that the patient is unable to lie down; where he has orthopncea and deficiency 
of urine; and where there is a collection of symptoms which are pronounced to be 
hydrothorax; whereas, on listening to the chest, we hear respiration all over it; and 
we hear the usual sound on percussion; but on listening to the heart, we hear dis- 
ease of that organ; or on listening over the chest, we find sonorous and sibilous rat- 
lies; — showing that there are other diseases present. The fluid that occurs in the 
chest, when it is not puriform, is usually the result of some other disease in the 

» From uJaoj, water; and flw^a^, the chest. * See Page 153. 

• See Fages 149, 152, 172, and 173. 



DISEASES OF THE PLEURA. 817 

chest. In cases of effusion into the chest, we have, in nil circumstances, the same 
auscultatory phenomena; — not only the want of a respiratory murmur; — not only 
the want of a hollow sound on percussion; but, if the fluid be not considerable, 
there is also segophonism. No matter what the disease is, the phenomena are the 
same. 

Treatment. — If we can ascertain that there is really hydrothorax, to an amount 
sufficient to explain the symptoms: — that there is a dull sound all over the chest 
on percussion; that the respiratory murmur is not heard anywhere except just below 
the clavicle, and at the root of the lungs; and if we see the general signs of dropsy, 
and the absence of disease of the heart; — we then may presume that the extreme 
difficulty of breathing, the swelling of the legs, and the scantiness of the urine, arise 
from a collection of fluid in the chest; — especially if osgophonism be present; and 
if we observe that the dulness of sound, and the want of respiratory murmur in- 
crease, — reaching higher and higher. In such a case we ought to let out the fluid. 
Exactly as in other cases, where the presence of a collection is doubtful, we may 
use the needle which I spoke of,* to ascertain whether fluid exists or not. It would 
be well to do it in every case; because it gives no pain to the patient, and is per- 
fectly safe. 

Diuretics. — But before these measures are taken, it would be right to give the 
common remedies for dropsy, where there is no inflammation; — to give diuretics. 
Digitalis answers an excellent purpose, and also squills; more especially if united 
with a small quantity of mercury, which appears to increase the diuretic efl'ect. A 
great deal of good may be effected by these remedies, in all cases of chronic diffi- 
culty of breathing, — whether there is efl*usion of serum or not; because there is 
continually a great collection in the air-cells, and perhaps also in the cellular mem- 
brane of the lung, which impedes respiration. When there is not hydrothorax, 
properly speaking, we continually find that diuretics are very useful, by causing an 
absorption of the fluid which is oppressing the cellular membrane of the lungs, or 
filling the air-cells themselves. I mentioned, when speaking of dropsy, that diure- 
tics answer more purposes than one.* 



SECTION IV.— PNEUMATO-THORAX. 

Etymology. — The pleura is sometimes distended by air. This disease is called, 
by Laennec, "pnewmo-thorax;"" but very improperly so. It should be "■pneumato- 
thorax." Such compound words are always made from the dative singular; — the 
final letter being changed into o, if it be any other vowel. We thus have ''utero- 
gestation," "cere&?'o-spinal," ^'h9smafo-ce\e.^^ The genitive and dative of at'^ua, are 
atfiato^, aiixatc. The genitive and dative of Ttvsvua, are TtvEVfidtog, Ttvsvfidtt,; and 
the compound word should be "j9ne?^m«/o-thorax." In truth, we already have 
*' pneumatomphalos," to signify a flatulent umbilical hernia; and, what is still 
closer, we have "pneumato-ce/e." Laennec, therefore, is wrong in the name which 
he has given to the disease; which consists of air being present in the pleura. 
This, however, is unimportant; and one is not disposed to dwell upon words; only 
when a new term is invented, it is right to make it legitimate, according to other 
words. With words that have been long established, we must be contented, and 
not be over nice. 

Signs. — When air exists in the pleura, it of course gives rise to the same effects 
of distension, that the existence of pus or serum does. The intercostal muscles 
swell out a little; and the diaphragm and liver, in the case of the right side, are 
pushed down. We may predict what will be the signs to the ear. The air that is 
inclosed is not the air of respiration; but exists externally to the lungs; and there- 
fore it does not give any respiratory murmur; but there is this great difference; — 

» See Page 815. b See Pages 172 and 173. 

c See Dr. Forbes's Translation of his Treatise; Part 1; Book 3; Chapter 4. (Third Edi- 
tion; Page 199.) 
VOL. I. — 52 



818 DISEASES OF THE PLEURA. 

that if we strike the chest, notwithstanding there is no more respiratory murmnr 
than in the abdomen, yet we have a fine clear hollow sound. Here is an instance 
of the importance of not trusting either to percussion or to the stethoscope sepa- 
rately; — beintr a case in which the combined use of percussion and auscultation is 
necessary. If we merely strike the chest, in these instances, we find nothing 
•wrong;^ for it gives a fine hollow sound; — perhaps a clearer sound than in health. 
Again, if we only listen to the chest, without striking, we shall say — "Here is a 
lung solidified;" or — "Here is a pleura filled with liquid, — with pus, or with 
serum." But, by using both, the nature of the case is clearly seen. We ascer- 
tain, by the fine hollow sound, that air is there; but, by the want of respiratory 
murmur, we perceive that the air has nothing to do with the lungs. 

When speaking of liquid in the pleura, I mentioned that, however large the col- 
lection might be, we should still hear respiration about three fingers' breadth from 
each side of the spine;"* — that the roots of the lungs were never so compressed, but 
that we might hear respiration there; although, in extreme inflammation of the 
lung, the lung becomes so solid, that no respiration can be heard. Now it is ex- 
actly the same when the pleura becomes distended with air. When the lung is 
compressed by air in the pleura, still the compression is never so great, that 
respiration cannot be heard at the roots of the lungs; — at least, it must be an ex- 
tremely rare occurrence. The lung still resists sufficiently to maintain its function 
at the roots; and, consequently, at the sides of the spine we may hear the respira- 
tory murmur. 

Diagnosis from Emphysema. — There is one case in which the auscultatory 
phenomena resemble those which are noticed in pueumato-thorax; and that is one 
that I have already mentioned, under the head of " chronic bronchitis."'' It is 
when the air-cells are greatly distended, and perhaps broken one into another. 
When the disease improperly called " emphysema of the lungs"'' takes place, there 
is a great cavity in the lungs, filled with air. I say ''improperly" so called; be- 
cause "emphysema" is the existence of air in the cellular membrane; and in this 
case it is contained in the air-cells of the lungs. I mentioned,^ that there is a very 
clear sound on percussion; but that, on listening to the respiratory murmur, we 
scarcely hear any thing. The cases are very similar in their nature; that is, cases 
where air exists in the pleura; and cases where some of the air-cells are very much 
enlarged, and partly broken down; so that a body of air exists in the substance of 
the lungs, and does not pass and repass as it ought to do in respiration. There is, 
however, a mode of distinguishing between the two cases; and it is this. When 
air exists in the pleura, we hear no respiratory murmur at all at the front of the 
chest; — it is stagnant: but in the case of dilatation of the air-cells, the air, although 
nearly stagnant, is never quite so; — it is partially expired and inspired; and there- 
fore we do hear a faint respiratory murmur. Another mode of making the diag- 
nosis is this. When the case is one of dilatation of the air-cells, it is consequent 
upon a long-continued catarrh, or bronchitic affection. It only takes place when 
the disease has existed a long time; and we hear the mucous, sonorous, and sibilous 
rattles of bronchitis; so, that, altogether, we may very clearly make out the nature 
of the case; whereas when air exists in the pleura, it is, for the most part, a very 
sudden afTection. There are no signs of bronchitis; and it is not only sudden, but 
generally very violent; and usually confines the patient to his bed. 

SECTION v.— HYDRO-PNEUMATO-TIIORAX. 

Its Nature. — A compound case sometimes happens;— one made up of the two 
afli'ections of which I have last spoken; — of " Ai/t/ro-thorax,"*^ or empyema, from 
the fluid existmg in the pleura; and of "jf?newm«/o-thorax,"* in which air exists 

» See Page 811. *> See Page 751. « See Page 749. 

d See Page 81G. ^ See Page 817. 



DISEASES OF THE PLEURA. 819 

in the pleura. We somelitnes see patients with both air and fluid in the cavity of 
the pleura. This affection is termed " hydro-pneumato-thorax." It is a long 
word, but very expressive. It shows, at once, the nature of the case; — '' bvdro- 
thorax," the name for liquid in the chest; and "jO?ie?/ma^o-thorax," the name for 
air in the chest. There is nothing puzzling in the name. 

Symptoms. — On reflection, we may (as in many other cases of affection of the 
chest) say beforehand what will be the symptoms of this disease perceptible by 
the ear. The air, of course, must be at the I'.pper part of the chest, — unless there 
be adhesions there; and the liquid will be at the lower; and therefore, on percus- 
sion at the superior part, we have a dearer sound than natural; but on striking at 
the inferior part, there is a dead sound. The contrast is very great indeed. On 
listening with the stethoscope, during respiration, to all parts of the side of the 
chest, we hear no respiratory murmur. The air above, and the liquid below, im- 
pede respiration; and therefore there is no respiratory murmur, either in the one 
situation or tlie other. But there is this difference between simple hydro-ihorax, 
and pneumalo-ihor2ix; — in the former case there is a dead sound, from the presence 
of the liquid: while in the latter there is a clearer sound than natural, from the 
presence of the air; and in a compound case there is a dead sound below, and a 
clear sound above. Again: if we alter the position of the patient, we alter the 
situation of these phenomena. If the patient under examination be sitting or stand- 
ing upriglit, the symptoms will be what I have stated. But suppose we make him 
lie down. The hollow sound, instead of being at the superior part of the chest, 
will then be altogether at the anterior; and the dead sound, on percussion, will be 
quite by the side; — simply by altering the relative position of the air and the fluid. 

Fluctuation. — There is, however, another circumstance which takes place only 
in this disease. If we suddenly shake the patient, — take him by the shoulder and 
jolt him, we frequently hear fluctuation. We cannot hear fluctuation in empyema 
alone; neither can we hear it in hydrothorax; not is it audible where only air 
exists in the chest. It is only pei-ceptible in hydro-pneumato-thorax. We may 
hear the fluctuation with the naked ear applied to the chest; or by means of the 
stethoscope. It is well, in all cases of this sort, to put the ear on the patient's 
chest, and let some one move him rather suddenly; and then we hear fluctuation 
within, and the patient will be aware of it himself. Sometimes the patient has 
discovered this, before the medical attendant has thought of the nature of the rase. 
In a volume of the " Dublin Transactions," there is reported a very remarkable 
case, which occurred before Laennec's time. The patient did not say, like the 
woman in Scripture, that he had spent all his substance on physicians; but he had 
been to all the doctors within his reach; and, moreover, he had been sent to the 
Continent; but it was all in vain. Nobody knew the nature of his malady; and 
he discovered it at last himself. ^He found that when he was sitting up, or jolted 
himself in any way, he heard fluctuation within his chest. He pointed the atten- 
tion of his medical attendant to it; and then the latter, for the first time, listened to 
his chest. This phenomenon is mentioned by Hippocrates, or in some of the 
works ascribed to him; but, unfortunately, it is there said that it takes place only 
when pus exists in the chest. This is incorrect. It takes place only when there 
is both liquid and air ni the chest; the reason of which is very evident. Those 
who attended to what Hippocrates, or the writer of this passage said, endeavoured 
to verify it by dissections; but they found that the observation was inaccurate, and 
therefore it dropped to the ground; and medical men neglected to apply the ear to 
the chest, (although Hippocrates had done so,) and stigmatized the plan as mere 
nonsense. Unfortunately the observation was not sufhcienUy minute. The sound 
was ascribed solely to the existence of pus; and so the mistake was made. 

Metallic Tinkling. — Another symptom which exists when there are these com- 
pound contents (air and liquid) in the pleura, is "metallic tinkling."* This sound 
may be heard, most frequently, by putting our ear to the patient's chest, and then 

* See Paffe 714. 



820 DISEASES OP THE PLEURA. 

suddenly raising him, or causing him to be raised upright. It is supposed that a 
portion of the pus then drops from the upper part of the chest, down inu) the lower 
part; and thus produces the sound. At any rate, the way I have stated is one of 
the best modes of hearing it. We may hear it by this means, v^hen we cannot 
hear it in any other mode; but in one particular case of air existing in the pleura, 
it may be heard when the patieni is speaking, coughing, or even breathing; and 
that case is where the air has got into the pleura through the lungs. It appears 
that air may sometimes be secreted in the pleura; sometimes it is the result of a 
decomposition of puriform fluid; and sometimes it enters the pleura through a 
rupture of the surface of the lu!ig. If a communication be established between 
the lung and the pleura, — whether by the ulceration of a tubercle, by rupture, by- 
gangrene of the surface of the lung, or by a wound, — then this clear silvery sound 
is heard when the patient is speaking; — perhaps when he is coughing, or when 
he is breathing. An aperture of this description, most frequently takes place from 
an abscess of the lung, — from a tubercle bursting; so that both air and pus are 
effused into the cavity together; and in this case there is always a clear *' metallic 
tinkling." 

Case. — I may here mention a patient, in whom there was a most beautiful me- 
tallic sound. On striking the chest v/hen I first saw him, I found a perfectly dead 
sound all over the lower part of the chest; and, being told that it was a case of 
consumption, of course I did not know the reason of it. But, on listening above, 
I found no respiratory murmur: and the nature of the case, in my estimation, was 
then clear. When he spoke, there was a fine, clear, ringing sound all over the 
chest; and when he coughed, it was exactly the same. After a time, it entirely- 
disappeared; and then, I presunrie, a small cavity which had existed in the lung, — 
fortning a communication between the lung and the pleura, — had healed. In about 
a fortnight, there was no ringing sound to be heard; and the patient, after going 
into the country, was apparenUy a great deal better. After a time, when I saw him 
again, there was still no respiration to be heard over nearly the whole of the chest; 
and there was a dead sound on percussion; — not merely at the inferior^ but also at 
the superior part of the thorax. There was no more metallic tinkling; and it was 
clear that what had been filled with air, was now filled with a liquid. An opera- 
tion was performed; and a quantity of liquid was let out, day after day, till it 
amounted to many quarts, — gallons, I believe. I forget how much was evacuated; 
but it was an immense quantity. Unfortunately, however, there was too much 
disease of another kind for the operation to cure him. 

Amphoric Buzzing. — When air exists in the pleura, in consequence of such 
an opening as I have now described, before the silvery sound is heard, we may 
occasionally hear a particular sound, from air going in and out of the opening; and 
it is so much like the sound which we make when blowing air into a bottle, that 
it has been called " amphoric buzzing." I do not recollect ever having heard it. 

Diagnosis from Abscess of the Lungs. — I mentioned,^ that when the air-cells 
are dilated, and a caviiy filled with air exists in the lungs, the symptoms in some 
measure resemble those arising from air existing in the pleura; because the one is 
a great cavity, and so is the other. Now if it so happen that a great cavity exists 
in the lung, filled half by pus, and half by air, the circumstance is very much the 
same, as when the occurrence takes place in the pleura. Just as a cavity in a 
large dilated air-cell, resembles a cavity in the pleura, and gives rise to nearly the 
same symptoms, so a large abscess in the lung, filled half with air and half with 
fluid, resembles the pleura when in the same condition; and therefore we have the 
same phenomena; — that is to say, "metallic tinkling." If the symptoms take 
place from a large abscess (containing both air and fluid) existing in the lungs, on 
raising the patient suddenly, a drop will descend from the upper to the lower part, 
and cause a silvery sound. But if the case be not very clear, it can be made out 
from this circumstance; — that, when a cavity exists in the lungs, we shall have 

« See Pa^e 818. 



DISEASES OF THE PLEURA. 821 

pectoriloquy, or the air going through the tube, as if the person's mouth were at 
the other end of the stethoscope; whereas, in cases where the pleura is affected, 
as there is no great communication between that and the bronchial tubes, we do 
not have this phenomenon. Where an abscess in the lung, containing partly air 
and pardy fluid, is large, it will give a sense of fluctuation, upon suddenly shaking 
the patient. 

Causes of Pneumato-Thorax. — With respect to the cause of pneumato-thorax, 
far more frequendy than otherwise, it takes place suddenly; and I believe that, 
most frequently, it happens to phthisical patients; in whom, unfortunately, a tuber- 
cle has existed close to the surface of the lung; and nature has not formed an 
adhesion of the surface of the lung to the costal pleura; so that ulceration has 
gone on to the pulmonary pleura, which has become thin, and at last has ulcerated 
through. It has frequently happened, that when a patient labouring under phthisis 
has made a violent effort, rupture has taken place. The general symptoms are 
extreme dyspnoea; and a person who does not use his ear, might perhaps be led to 
suppose that it was merely an attack of inflammation; — especially if the patient 
had been running out of doors in the evening. One might then suppose, that the 
patient had caught a violent cold; and he might be bled and blistered all to no 
purpose;— -the nature of the case simply being, that air had escaped into the pleura. 
The importance of listening to the chest, in such a case, is evident; for we may 
make out the nature of the case, clearly enough, by striking the chest. There is 
a perfectly clear sound; and yet, on listening to the respiration, we hear no respi- 
ratory murmur. 

Treatment by Operation. — In such circumstances, an operation should be per- 
formed. The parts should be punctured, and the air let out. An interesting case 
of this description occurred to Dr. James Johnson.* It happened to a medical 
practitioner, who ran to a case of midwifery; and was seized with difficulty of 
breathing, and the symptoms I have just mentioned. Several practitioners were 
called in; one of whom said that he had had a similar case the preceding winter, 
and that the patient was cured with hyoscyamus; but nobody had the least idea of 
the true nature of the affection, except Dr. James Johnson; and he was so satis- 
fied respecting it, that Mr. Guthrie, (I think,) at his request, made an opening into 
the chest; and out came a rush of air, and the patient felt immediate relief. This 
was a great object effected; — ease after pain. The patient died afterwards, be- 
cause he was phthisical; but had there been no other disease than this accidental 
escape of air, no doubt he would have done well. If the collection of air occur 
on the left side of the chest, it will push the heart to the right side; — ^just in the 
same way as a collection of liquid. Of course the operation would not be required, 
merely because we hear air in the chest. It need only be performed where there 
is such difficulty of breathing, as to make it necessary to do something for the 
relief of the patient. So in a compound case, — -one of hydro-pneumato-thorax, 
where there is both air and water in the chest, — no operation would be required, 
imless there were extreme dyspncea. It is best to make the opening large enough 
to let out the liquid; so that, after the air has escaped, the liquid rnay also be eva- 
cuated. 

General Treatment. — The general treatment would be that of phthisis, or a 
large abscess; — supporting the strength, &c. These are rare cases comparatively; 
but it is very necessary to know them. Every now and then, in practice, we 
meet with such a case; and by knowing the nature of it, we may lessen the pa- 
tient's sufferings, and sometimes even cure him. When air exists in the pleura 
from gangrene of the lung at that spot, and the separation of the eschar, — a cir- 
cumstance which will occur when the gangrene is quite partial, — the operation, in 
such a case, might be followed by complete success. If the air were disengaged 
merely from a quantity of fetid pus underneath, it is possible that the operation 
might be the means of saving the patient's life, — by putting an end to the dysp- 

* " See the Medico-Chirurgical Review;" Volume 10. 



822 DISEASES OF THE PLEURA. 

iioea, which would perhaps have killed him; and then the other disease ma)' be 
made to subside. Phthisis is rarely cured; but these other affections sometimes 
are. It may happen, tiierefore, — unless the patient have phthisis, — that the dis- 
ease may be permanently cured. 

[The measures calculated to relieve the symptoms of pneumothorax with per- 
foration, vary considerably; — according to the period of the lesion, and the condi- 
tion of the system. In the first instance, the perforation and access of air and 
matter to the pleural sac, are often attended by considerable prostration of the 
system, with rapid feeble pulse and faintness; together MMth the pain and cough, 
which are then the result of irritation, rather than inflammation. Considerable 
doses of opium or morphia are necessary to allay this irritation; they maybe ad- 
vantageously combined with calomel and anlimonials; and sinapisms or warm 
fomentations may be applied to the affected side. More active antiphlogistic 
measures cannot be used until the reaction takes place; which generally begins in 
a few hours; — bringing with it heat of the skin, strength and hardness of the pulse, 
the great soreness as well as pain of the whole affected side; then blood-letting, 
chiefly local, must be used, with aperients and salines; — according to the strength 
of the patients, and the degree of fever present. These may be followed by blis- 
tering, or tartar-emetic counter-irritation, in proportion to the continuance of the 
inflammatory symptoms. But it is not to be forgotten, that perforation of the 
pleura and its consequences are almost always added to a previously existing dis- 
ease, — tuberculous phthisis; and the degree of advancement that this may have 
reached, must much limit the propriety and efficacy of the measures for this acci- 
dental inflammation that has been excited. The same considerations are to be 
kept in view when, in consequence of the smallness of the perforation, or its val- 
vular condition, air accumulates in the chest, and becomes the cause of oppressive 
dyspnoea. The immediate indication in this case is, doubtless, to give exit to the 
air by puncturing the chest; and this has been done in several instances, with great 
temporary relief. But before this operation is prescribed, it should be considered 
whether, as the relief from it will be but temporary, the condition of the patient 
be such as to make this likely to outweigh the pain and risks of the operation. 
These certainly are not great; but, when added to the dubious view in which the 
friends of the patient may regard an operation which proves but imperfectly suc- 
cessful, they are sufficient to deter us in many cases from recommending it. The 
case is different when the accident occurs before the consumptive disease has ad- 
vanced far; — when there is much flesh and strength, and when the physical signs 
have shown that there is a large proportion of sound lung. The operation may 
be repeated if the air accumulate again. As it is impossible to avoid the continued 
introduction of air into the chest, the mode of performing the operation is a matter 
of much less consequence than in empyema. It is more desirable to puncture 
below the level of the liquid; — to allow this, as well as the air, to escape.*] 



SECTION VI.— ORGANIC AFFECTIONS OF THE PLEURA. 

Tubercular Disease of the Pleura. — There are certain other diseases of the 
pleura, of an organic nature; upon which I will not dwell long. Occasionally 
the pleura is attacked by the same disease which, when it exists in the lungs, forms 
phthisis. The pleura is sometimes, though not very frequently, in a state of 
tubercular deposit. Sometimes, in phthisis, we find one pleura, or both, studded 
with tubercles of various sizes; — generally small, but sometimes of a large size. 

Symptoms. — The deposition of tubercles in the pleura, may be attended with 
scarcely any symptoms whatever; because phthisis may exist at the same time; 
and the symptoms of the greater disease, may swallow up those of the small one. 
But sometimes, if the disease exist alone, and is of any considerable amount, there 

f " Library of Medicinej" Volume 3j Pages 133 and 134. 



DISEASES OF THE PLEURA. 823 

will be all the signs of a pleuritic effusion into the chest; — all those symptoms 
which I just now mentioned; and it may not be easy to make a diagnosis, in a 
case of this description. On making a post-morlem examination, we are often sur- 
prised at finding tubercles in the pleura. But if the disease be considerable in any 
one spot, we shall iiave marks of pleuritis. Inflammation will take place around 
the tubercle; and suppuration will occur. But it is not easy to distinguish inflam- 
mation from such a source as^hat, from inflammation of a simple nature. When 
the tubercles suppurate, pus may be discharged into the pleura; or, without sup- 
puration, there may be an efiusion into that cavity, from excessive secretion; and 
the secretion may be either serous or purulent. In fact, we may have pleuritis, and 
all the consequences of pleuritis; so that air may pass in, and all those other 
changes will take place which 1 mentioned as occurring without tubercles;^ and the 
patient will become hectic. 

Treatment. — The treatment of the case will depend entirely upon the presence 
of air, the presence of liquid, the presence of inflammation, and so on. It is only 
necessary to know, that all the changes which I have mentioned,* are sometimes 
connected with tubercles in the pleura itself; and that sometimes very minute tuber- 
cles will exist there, and give rise to scarcely any symptoms at all. Tubercles are 
frequently observed there, when they are seen in various other parts of the body. 
More frequently than not, perhaps, when pleuritis is chronic, — when the patient 
has a fixed pain of an inflammatory nature in the pleura, and wastes away, it is a 
scrofulous affection; and is attended by this tubercular deposition. The tubercles, 
most probably, are situated in the cellular texture, immediately under the serous 
membrane. 

Ossijication of the Pleura. — I have seen the pleura ossified to a great extent. 
Here, again, it is not the pleura (properly speaking) that is ossified, — at least origi- 
nally: but it is the cellular membrane under it. The cellular membrane is fre- 
quently converted into bone, in various parts of the body; or bony deposit takes 
place in the cellular membrane. Perhaps the latter is a more accurate mode of 
speaking. But the pleura above the bone will sometimes disappear, — waste away; 
so that, on looking into the cavity of the pleura, we perceive the bare bone. I re- 
collect once meeting with this occurrence, to a great extent, in an old man who 
died of ascites and liver-disease; and who was not aware that he had disease in the 
pleura; — at least, he never attracted our attention to it. I recollect remarking how 
well he could lie down, notwithstanding the fluid in his abdomen. I found the 
pleura covering several ribs, in a state of ossification. 

Scirrhus^ ^-c. — Other affections may occur in this situation. We may have 
scirrhus, and melanoid disease; but these are comparatively rare affections.** 

• See Pages 816, 817, and 818. 

•' We cannot take leave of Diseases of the Lungs, without directing the attention of our 
readers to " A Treatise on the Diagnosis and Treatment of Diseases of the Chest. By 
William Stokes, M. D." In this, the most able work we possess on the subject, one of the 
first stethoscopists of the day, has given us the result of great talents and ample opportuni- 
ties, brought to bear, for a long series of years, on this, his favourite department of medical 
investigation. 



BOOK IV. 
DISEASES OF THE HEART 



CHAPTER I. 

PERICARDITIS. 

Pericarditis, the first disease which I purpose to consider, would never be 
selected to show the advantages of auricular examination; which, in the acute form 
at least, is (for the most part) of only negative utility. But the consideration of it 
will prove the injustice of those who assert, that auscultators both regard ausculta- 
tion as a universal light, and neglect the general investigation of symptoms. 

Frequent in Occurrence. — The acute inflammation which occurs in the region 
of the heart, is usually situated in the pericardium; and pericarditis is a very com- 
mon disease. 

Anatomical Characters. — The anatomical characters are little different from 
those of inflammation of other serous membranes.^ There is either a partial red- 
ness, — patches, sometimes as if the membrane were injected, at others as if dyed 
red, — or groups of red points. The redness is seldom deep; and, in the most 
violent cases, is often very faint. The membrane was never, in a single instance, 
observed by Laennec to be thickened:* though Dr. Baillie declares this to be fre- 
quently the case;" but upon it lies a quantity of fibrin, thicker and more consistent 
than in pleurisy; and differing from the fibrin of pleurisy, also, in being generally 
irregular on its surface; — sometimes with minute pores, sometimes with depressions 
so large as to give it the appearance of the second stomach of the calf, sometimes 
knobbed like butter spread upon two slabs (to use Laennec's comparison''), first ap- 
proximated and then suddenly separated from each other. Dr. Baillie says that the 
fibrin never adheres firmly;"*' Laennec that it adheres more firmly than in pleurisy.** 
Although the redness is partial, this exudation is most frequently general, and often 
very abundant when the redness is slight. It is of the ordinary pale colour. 

The serum effused is in far less proportion to the fibrin than in pleurisy; — sel- 
dom amounting to a pint, though it has amounted to four; and sometimes scarcely 
any is found. It is of the common whitish lemon-colour; rarely limpid; some- 
times very turbid, containing larger or smaller flocculi of lymph, or absolutely cur- 

a See Page 108. 

* See iiis Tr'^atise on Diseases of the Chest, translated by Dr. Forbes; Part 2; Book 2; 
Chapter 22. (Tnird Edition; Page 671.) 

c "Morbid Anatomy;" Chapter 1; Section 1. 

•1 See his Treatise on Diseases of the Chest, translated by Dr. Forbes; Part 2; Book 2; 
Chapter 22. (Third Edition; Page 672.) 



PERICARDITIS. 825 

died; — as if only one kind of effusion had taken place. Sometimes it is bloody, 
sometimes puriform: Dr. Baillie once saw a quart of pus in a pericardium violently 
inflamed, but free from ulceration.* 

In the chronic disease, the redness is more jntense and more diffuse, and the in- 
flammation is almost always general. If any fibrin exist, — and it seldom does, — it 
is thinner and softer. There is always the turbid serous effusion. 

As time elapses after the acute attack, the liquid effused is absorbed, the fibrin 
grows to the cardiac and parietal portions of the pericardium, and adhesions (more 
or less partial or general) of cellular or serous membrane are produced, — usually 
thinner and stronger, like those of other serous sacs, the older their date. The 
adhesions are sometimes very thick and fibrous, — as it were fleshy; and sometimes 
cartilaginous or bony. I have frequently seen the whole cardiac and parietal peri- 
cardium coherent, and even the proper auricles concreted to the ventricles; so that 
no pericardial cavity existed; — the serum being entirely absorbed, and the fibrin 
nearly so. Such cases have occasionally been mistaken for instances of the absence 
of the pericardium. 

Both when the pericardium is very coherent, and when it is only thickened, the 
morbid action may be more intense in particular spots; for we often find, at dif- 
ferent parts, knobs of cartilage, some of which dip deeply into the substance of 
the heart. Sometimes the fibrin effused becomes cellular; and, contracting no ad- 
hesions, lies pale (like lace) upon the surface of the heart: sometimes merely an 
opaque white patch, which can be peeled off, remains; and sometimes, instead of 
smooth patches, we have opaque white granulations. If the inflammation has been 
severe, lymph is often found (in more or less quantity) on even the external surface 
of the pericardium; — uniting it by bands to the pleura. The reason is not ob- 
vious, why the fibrin within the pericardium sometimes adheres, and sometimes 
contracts no adhesions. The degree of serous effusion and consequent propor- 
tionate separation of parts, affords no explanation; because, first, we often see one 
portion of lymph adherent, while another by its side is not; and, secondly, there is 
often a total absence of adhesion, without sufiicient serous effusion to account for it. 

The substance of the heart after pericarditis may be unchanged, or redder or 
paler than usual, yellowish or brown, hardened or softened. After the ctironic 
disease, it has been found hypertrophied. It is usually when the organ is sof- 
tened, that we observe the effused serum to be bloody. In "softening of the 
heart," I have almost always found bloody serum in the pericardium. Not only 
the substance of the heart, but its lining membrane, — especially at the valves, — is 
also frequently affected; sometimes in the acute form,* but generally in the chronic, 
if very long continued. 

We shall find, presently, that the majority of cases of diseased heart, both as to 
its substance and its valves, arise from, or (at least) are coetaneous with, or spring 
up during, inflammation of the pericardium. 

Causes. — Pericarditis is occasioned by all the causes of the inflammation of 
serous membranes in general. But the most frequent is either exposure to cold, 
— especially after a warm temperature, and if rheumatism is also induced; or 
sympathy with the fibrous membranes of joints attacked by rheumatism. It will 
occur simultaneously with thhb rheumatism; or not till the rheumatism has existed 
for a longer or shorter period, has even gradually declined, or altogether ceased for 
some time; and, though the metastasis is comparatively rare, when the rheumatism 
suddenly disappears. 

Its Connection ivith Rheumatism. — Pericarditis is usually not very violent, but 
is disposed to assume the chronic form; — frequently stealing on, as a chronic dis- 

a " Morbid Anatomy;" Chapter 1; Section 1. 

b In the " Medico-Chirurgical Transactions" (Volume 7, Page 323), Mr. Stanley describes 
a case of pericarditis, that occurred with pain of an extremit}', evidently rheumatic. The 
pericardium contained several ounces of turbid fluid, wiih flakes of lymph; and was covered, 
in various situations, with a reticulated layer of lymph. The substance of the heart was 
almost black with congested blood, was very soft, and was studded with little collections of 
dark pus. 



826 PERICARDITIS. 

ease, from llie abuse of fermented liquors. In this case, the valves and (finally) the 
substance of the heart, as I have mentioned,* become diseased. From these cir- 
cumstaiices, the connection between rheumatism and affection of the heart was first 
noticed in the stage of organic disease; and rheumatism was said to produce, not 
inflammation, but disease of the heart. Occasionally the pericardium may not be 
affected, and occasionally but in a secondary manner: but I am certain, that nearly 
all the cases of affectiims of the heart, after rheumatism, are originally pericarditis; 
and that, when the inner membrane is thus affected from the first, so also is the 
pericardium. Among tfie cases of organic disease of the heart connected with 
rheumatism, published by Dr. Wells, in the year 1812,'' those which proved fatal 
displayed a complete abolition of the pericardial cavity, or strong or abundant par- 
tial adiiesions; and those which did not prove fatal, were marked by decided 
symptoms of pericarditis. In nearly all*" tliose mentioned by Sir David Dundas, 
in the First Volume of the " Medico-Chirurgical Transactions,"*^ the pericardium 
was adherent. Every dissection that I have made in cases that proved fatal during 
the early period of the disease, has proved the case to be violent pericarditis; the 
history of every chronic case that I have witnessed, could be clearly traced back to 
pericarditis; and every affection of the heart (however slight) that I have seen take 
place during rheumatism, has been marked pericarditis. The pleura, particularly 
of the left side, is occasionally inflamed at the same time; and the subsequent 
chronic organic disease of the heart, is of every possible variety. 

First observed by Dr. Fitcairn. — Dr. Pitcairn, of St. Bartholomew's Hospital, 
was the first who noticed, about the year 1788, the connection of rheumatism with 
disease of the heart; and Dr. Bailhe, in 1797, was the first who published on the 
subject.^ They considered the disease to be a morbid growth of the heart. Sir 
David Dundas published upon the subject, many years afterwards,^ without refer- 
ence to the observations of these physicians; and even asserted his belief, that no 
account of the matter was to be found in any medical writer;^ though, as Dr. 
Wells remarks,^ "there is great difficulty in supposing him ignorant of what had 
been mentioned twelve years before, in so popular a work as Dr. Baillie's Morbid 
Anatomy." Sir David mentions the disease as dilatation of the heart, and chiefly 
of the left ventricle; with paleness and softness of its substance, and adherence of 
the pericardium.^ But, from the imperfection of morbid anatomy in this country 
at the time he wrote,' his description is very loose. However, in one of Dr. 
W^ells's cases, — which proved fatal early, and was opened by Sir Benjamin Brodie, 
— nothing but pericarditis was discoverable;^ and Dr. Wells, no less distinguished 
for his sagacity than his independence, evidently regarded the rheumatic affection 
of the heart as inflammatory, by advising copious bleeding in the outset.^ 

The French do not appear aware of the connection of pericarditis with rheuma- 
tism, except as an ordinary instance of internal inflammation, upon the sudden 
retrocession of an external disease. 

However, I think it is pretty certain that disease of the heart is not connected 
with rheumatism, except so far as the effect o^ pericarditis is connected with rheu- 
matism. We every day see the latter occurrence; and whenever a case of disease 

° See Page 825. '• 

^ In the " Transactions of a Society for the Improvement of Medical and Chirurgical 
Knowledge;" Volume 3; Page 373. 

'^ That, is, in five cases out of the six which were examined. A seventh fatal case was 
not examined. See the " Medico-Chirurgical Transaciions;" Volume 1; Page 40. 

•» Page 37. 

^ In his "Morbid Anatomy of some of the Most Important Parts of the Human Body." 

MnlSOS. 

e "Medico-Chirurgical Transactions;" Volume 1; Page 37. 

^ ''Medico-Chirurgical Transactions;" Volume 1; Page 40. 

i In 1808. 

^ " Transactions of a Society for the Improvement of Medical and Chirurgical Know- 
ledge;" Volume 3;" Page 400. 

1 "Transactions of a Society for the Improvement of Medical and Chirurgical Know- 
ledge;" Volume 3; Page 409. 



PERICARDITIS. 827 

of llie heart connecteil with rheumatism occurs in a younfr person, and the patient 
dies, we find marks of the preceding- inflammation within the pericardium; and, on 
inquiring into the history of the case, we learn that there were origiiially symptoms 
of pericarditis. It is quite clear that the rheumatism is connected with the inflam- 
mation of the pericardium. I will not say it produces it; because all the symp- 
toms result, perhaps, from the same state of the system: but the first thing 
connected w'lih. the rheumatism, is pericarditis; and then when that has existed any 
considerable time, the organic changes of the heart take place. We may easily, I 
think, satisfy ourselves of this, by reading all the cases that have been published of 
diseases of the heart, as consequent upon rheumatism. We find strong proofs of 
inflammation of the pericardium; and if the original history of the case be detailed, 
we shall see strong symptoms of pericarditis. In affections of the heart connected 
with rheumatism, we continually find that inflammation has taken place first, and 
that organic disease is consequent upon that. This is a very happy circumstance; 
because inflammation of tlie pericardium may be controlled, as easily as inflamma- 
tion of any other part; whereas organic disease of the heart, for the most part, is 
an affection which we can only palliate. But it is not disease of the heart which 
is connected primarily with rheumatism, but /;er«c«rc/i/i5.^ This is nothing more 
than might be supposed; because young persons, who are chiefly the subjects of 
this disease of the heart, are not subject to organic diseases, except scrofula. They 
are subject enough to inflammation; and we know that inflammation of any part 
whatever, will leave organic disease. The great source of organic disease, is in- 
flammation; and it is quite capable of producing every organic affection whatever; 
— that is to say, of producing all common, and all structural diseases, and a predis- 
position to any -peculiar disease. The debility produced by inflammation of an- 
other part, easily makes the patient the prey of a specific aflection. But it is in 
yoimsr subjects that this affection occurs; — young subjects being particularly liable 
to inflammation of every description; and not to organic diseases of any kind, 
except scrofula. 

Duration. — This disease would appear sometimes to remain very long mere 
pericarditis, or at least merely an inflammatory affection; for it is sometimes cured 
after a lapse of time, and sometimes continues for many years with no signs of 
organic disease; — proving troublesome oifly when cold is accidentally caught, and 
a fresh attack of rheumatism in the joints induced. 

t^ge at ivhichit Occurs. — Most instances of rheumatic pericarditis commence in 
persons from about the age of puberty to near thirty. We occasionally see it in the 
younger; rarely for the first time in the older. I once saw it in an infant. With 
neither of Dr. Baillie's remarks, — that pericarditis is not very common, and that it 
chiefly attacks persons who have been some time adults," does my experience at all 
agree. 

Symptoms. — Acute pericarditis is, of course, attended by more or less pyrexia. 
There is a pain in the region of the heart, — sometimes severe and lancinating: 
generally darting through to the left scapula, upwards to the left clavicle and shoul- 
der, down the arm a certain way, and (what is remarkable) rarely extending quite 
so far as the elbow. I lately had a case, in which the pain extended down the 
forearm; but it did not quite reach the wrist. The pain is increased by pressing 
forcibly upon or between the ribs and cartilages over the heart; and by pressing, 
with the points of the fingers, upwards against the diaphragm, under the cartilages 
of the lei't false ribs; frequently even by pressing the epigastrium and left hypo- 
chondrium in the usual manner. The pain is often increased on inspiration, and 
by lying on the left side. I think patients in general lie most easily upon the back. 
The respiration is rapid; but less so than in affections of the lungs. 'J'here is some- 
limes a cough, which is dry. Nearly always palpitation, frequenfly violent, at 
least upon exertion. Sometimes, though more rarely, a disposition to syncope. 
The pulse varies exceedingly. It is necessarily quick; and often, but not always, 

^ See Page 825. ^ "Morbid Anatomyj" Chapter 1; Section 1; Paragraph 1. 



828 PERICARDITIS. 

small, in proportion to the heart's action; and only sometimes intermittent and irre- 
gular; neither is it always hard, or even very full. The countenance is described as 
anxious, and the features contracted: but this, I imagine, happens only when the 
pain is acute; and it is equally the case in pleuritis. 

Auscultatory Signs. — On examination by the ear, the ivhole heart is found act- 
ing more forcibly, and with a clearer sound, than in health. But this is all. Aus- 
cultation, however, appears to be of negative use. We do not discover the loud 
murmur of the sonorous or sibilous rattle of bronchitis, the crepitous rattle or obscure 
respiratory murmur of pneumonia, or the eegophony of pleuritic effusion, unless 
these diseases are combined with the pericarditis. Neither have we the partially 
excessive or defective impulse or sound, or preternatural sounds, of organic diseases 
of the heart. In all uncombined cases, therefore, light is thrown on the disease. I 
remember having once found auscultation of great use, in the diagnosis of a disease 
which might have been considered clearly pericarditis. The patient was a poor 
Irishman; and the Irish are by no means happy in their attempts at a lucid history 
and description of their diseases. He complained of pain (increased on pressure) 
in the region of the heart, palpitation, and dyspnosa; and declared he had been ill 
but a few days. The case appeared to be pericarditis. The pulse was full, and 
the constitution good. There appeared every reason to bleed him freely, and to 
put in force the whole antiphlogistic plan. But, on listening to the heart's action, 
the left ventricle gave a violent dead noiseless blow against the chest; and the case 
was evidendy one of hypertrophy of the left ventricle. I insisted to the man that 
he had long been ill; and it was ascertained, from his own mouth and from his 
wife, that he had suffered palpitation and dyspnoea for a great length of time; and 
that the error of his history arose from his having been compelled to leave off work 
only a few days before. He died in a fortnight; and great hypertrophy of the left 
ventricle was discovered. 

M. Collier says, that die action of the heart is accompanied by a sound resem- 
bling that of new leather. Laennec does not mention it; but remarks the occasional 
occurrence of a sort of click, which some persons mistake for a "bruit de soufflet."* 

QAt an early stage of the disease, inflammation of the pericardium often gives 
rise to considerable serous effusion. In consequence of this, the impulse of the 
heart diminishes, and the sounds become feebler and more distant. Percussion also 
yields a dull sound, over a larger space than natural, in the regiOii of the heart. 
This dulness may commonly be detected at a pretty early stage; and although at first, 
perliaps, dependent upon mere turgescence of the heart, soon becomes more marked 
in consequence of the effusion, of which it marks the limits. Frequently, also, by 
careful examination, we may discover a circumscribed fulness or elevation of the 
chest in the same region, where at the same time the respiratory murmur is no 
longer heard. Of course, in those cases where lymph only is effused, or where the 
amount of serum is quite small, the above combination of physical signs is not met 
with, and the impulse of the heart may remain strong throughout, accompanied by 
a corresponding strength and hardness of the pulse. The compression of the heart, 
on the other hand, by a considerable quantity of fluid, suflficiently accounts for its 
feeble and irregular action in certain cases, as well as the corresponding characters of 
the pulse and general symptoms, the faintness, dyspncea, &;c. — T. S.] 

Diagnosis. — The diagnosis of pericarditis is thought by many to be extremely 
diflacult. Laennec declares that he has frequently suspected it where it was not 
found, and found it where he had not suspected it.'' By close inquiry into the 
existence of all the marks just mentioned," I have never found the diagnosis difii- 
cult. I would particularly lay stress upon the extension of the pain from the region 

* The contraction of the ventricles yields a greater shock, and sometimes a more marked 
sound, than usual; and, at intervals, feebler and shorter pulsations are perceived; which cor- 
respond with the intermissions of the pulse. — '•Porbes's TraMslation of Laennec' s Treatise on 
the Chest;" Part 2; Book 2; Chapter 22. (Third Edition; Page 67G.) 

b See his Treatise on Diseases of the Chest, translated by Dr. Forbes; Part 2; Book 2; 
Chapter 22, (Third Edition; Page 675.) 

« See Page 827. 



PERICARDITIS. 829 

of the heart to the scapula, shoulder, and a certain way down the arm; — symptoms 
which patients will not always mention, unless questioned respecting them: and its 
increase on strong" pressure upon or between the ribs and cartilages over the heart, 
and upwards under the cartilages of the left false ribs. These two points I do not 
remember to have seen mentioned anywhere; and the others are not dwelt upon in 
some of the best books. In Andral's " Clinique Medicale," pain of the epigastrium 
on pressure is said to have occurred in some cases; but the point is not spoken of as 
if inquired into: in one case only is the extension of pain to the arm mentioned; 
and its extension even to the shoulder does not seem to have formed an object of 
inquiry. 

I am certain that, by a scrutinizing examination, the existence of pericarditis 
will very rarely be mistaken: and from this conviction, and the frequency of its 
occurrence during acute rheumatism, 1 make it as invariable a rule to examine the 
cardiac region by the touch and hearing in every case of acute rheumatism, as the 
usual seats of hernia are examined by us all in cases of colic and intestinal inflam- 
mation. Were this rule universally observed, practitioners would not be occasion- 
ally surprised by the death of patients, in what had been considered merely acute 
rheumatism. 

Treatment. — When the disease is acute, there is nothing peculiar in its treat- 
ment; — being the same as that for active inflammation in other parts of the body. 
Only it is to be remembered, that this inflammation is seldom violendy active; and 
is generally disposed to become chronic. When acute inflammation is not very 
intense, the best v^ay of attempting to remedy it, is by local bleeding; so in this 
case, I have observed free local bleeding to be more serviceable than general deple- 
tion. Mercury is of equal efficacy in acute pericarditis, as in other acute inflamma- 
tions; over which, wherever they may be situated, a very extensive experience of 
many years has fully satisfied me, — conformably with the observations of so many 
able physicians, — that it possesses far more power than any other medicine. 
Bleeding and other ordinary measures cure cases of severe inflammation every day; 
and, in cases of little danger, may be relied upon. But they frequently fail in 
cases of intensity; and they know that if, in addition to suitable bleeding, mercurial 
ptyalism is quickly induced, active inflammation will very rarely destroy; and not 
only is fatality almost always prevented, but far less bleeding is required. This 
has been my practice, from the commencement of my professional life; and I have 
never met with a necessity for those frightful bleedings of quart after quart, recorded 
from time to time in our publications. I have given tartarized antimony (in quantities 
of a scruple and half a drachm every twenty-four hours), hydrocyanic acid, and other 
medicines recommended by the Italians; but found them all greatly inferior to mer- 
cury. Among the best, unquestionably, is colchicum; and its power over active 
gout and rheumatism of the extremities, is universally acknowledged to be very 
great. After the violence of acute pericarditis is subdued, it appears of use in 
restraining the morbid irritability which sometimes sdll continues in the heart; and 
several chronic cases, of which I had despaired, have gradually recovered under 
perseverance in its use for many months. 

Dropsy of the Pericardium. — The quantity of fluid at a certain period of acute 
pericarditis, and in chronic pericarditis, is occasionally (but not often) so considera- 
ble, that " hydrops pericardii" exists. Inconvenience could scarcely arise from 
a less quantity than half a pint. Unless it is considerable, it is indicated with no 
more certainty by percussion and auscultation, than by the ordinary symptoms. 
But if the quantity be large, there is a dull sound to a great extent, on striking the 
carchic region; the heart's action may be perceived very f^iintly, and perhaps in a 
diffused manner; so that the epigastrium pidsates or vibrates, and may appear fuller 
than in health; patients have experienced a sense of weight in the cardiac region, 
a'.id even fluctuation has been detected. In cases of copious efli'usion of blood, pus, 
or serum, into the pericardium, these symptoms have suddenly appeared; and good 
examples of the occurrence of some of them may be found in Andral. 

A fluid occasionally collects in the pericardium, — as in the pleura and perito- 



830 PERICARDITIS. 

neiim, arachnoid, and " tunica vaginalis," — by a slow process, not amounting' to 
inflammation. The membrane is not red, but perhaps opaque; and even thickened, 
and of a satin-whiteness. This condition is, I believe,' — where no redness of 
inflammation is visible, — the common cause of ascites, chronic hydrocephalus, 
hydrocele, and idiopathic hydrothorax; and though, like the state which gives birth 
(as I shall presently mention'') to one kind of adhesions in serous membranes, it 
may be the result of a change allied to inflammation, it hardly merits the title of 
*' inflammation;" — from the absence of inflammatory symptoms, the absence of 
redness in the membrane, the pellucidity of the fluid, and the inutility of anti-in- 
flammatory measures. 

Adhesions.-— The adhesions within the pericardium left after pericarditis, are 
almost the only instances that occur in this membrane. I have never seen adhe- 
sions except with redness of the membrane, or ihe presence of turbid fluid, or after 
the existence of decided symptoms of pericarditis. In the pleura they are con- 
tinually found, without the least previous symptoms of inflammation, and without 
redness or turbid effusion; and though, like chronic dropsy of the membranes, they 
may result from what cannot be proved to be a non-inflammatory state, they cer- 
tainly (like it) are no proofs of any thing deserving the decided name of " inflam- 
mation." 

In the case neither of the pleura nor pericardium, do they in general produce 
the slightest inconvenience. I have seen the whole pericardium so coherent, thai 
its cavity was entirely abolished; and yet the symptoms which had been present 
were exactly commensurate with the organic disease of the heart which existed at 
the same time, and had certainly no relation to the adhesion. I cannot say I ever 
observed a symptom produced, except in one case; and there a single thick adhe- 
sion extended along the front of the heart. In the supine posture this must have 
been dragged down by the subjacent heart; and must have tended to drag the peri- 
cardium of the front of the chest with it, and to suspend the heart; — so that the 
parietal and cardiac pericardium, at their points of union with it, must have been 
put upon the stretch. The patient, accordingly, had been unable to lie on her back; 
—on account of a smarting pain produced, in this posture, at the front of the car- 
diac region. Bertin, in his excellent work upon diseases of the heart,'' states that 
adhesions often produce no symptoms; but gives one case in illustration of the fact, 
that inconvenience sometimes is felt: yet in this case, adduced singularly enough, 
the substance of the heart, in addition to the adhesions, was found very soft; — a 
change quite suflncient to explain every symptom that occurred. 

Organic Affections of the Pericardium. — The cellular side of the pericardium, 
like that of other serous membranes, is sometimes (though very rarely) the seat of 
hydatids and cysts, scrofulous and other tubercles, and of ossification. The diag- 
nosis must be impossible; and, indeed, no symptoms have in some cases been 
observable. 

Hemorrhage into the Pericardium. — The pericardium is the seat of sudden 
and fatal hjEmorrhage without previous indisposition. Sometimes, like the arach- 
noid, it is perfectly dry. Sometimes it contains air, either alone or with a preter- 
natural quantity of fluid; in the latter of which cases, fluctuation or undulation has 
occurred. Sometimes the pericardium is absent: at least five unquestionable cases 
of this singularity are on record. 

* See the previous Paragraph. 

^ " Traite des Maladies du Coeur et des Gros Vaisseaux, par R, J. Bertin. Paris, 1824." 
Pase 254. 



DISEASE OF THE LINING MEMBRANE OF THE HEART. 831 



CHAPTER II. 

DISEASE OF THE LINING MEMBRANE OF THE HEART. 

SECTION L— GENERAL INFLAMMATION OF THE MEMBRANE. 

I SHALL now proceed to describe afTections of what ma}^ be called the membrane 
corresponding to the pericardium. The heart has a membrane within, as well as a 
membrane without; — a membrane which is continuous with the lining membrane of 
the aorta, and of the valves. This is subject to inflammation, — in the same way 
as the pericardium; b)U there are no signs by which we can ascertain its existence 
with certainty. V/e may occasionally suspect it; but, after all, I imagine it will be 
a mere guess. 

Anatomical Characters.— Mter death, this lining mem.brane is occasionally 
found in a state of inflammation; but we are not to presume, in every instance in 
which we find redness of this part, that there is inflammation. If it so happen that 
the parts are all soft, they will become dyed by the blood; imbibing it after death, 
and becoming stained by it. Almost always, when the heart is softened in struc- 
ture, this membrane is of a deep red colour; — simply as the effect of that imbibi- 
tion, which I mentioned, when speaking of inflammation in general; and when I 
pointed out the necessity of being careful, in many instances, not to decide that 
there was inflammation, simply because there was redness.^ Bnt there is no doubt 
that this redness does sometimes result from inflammation. This is proved by 
fibrin being effused upon the coloured portion, and adhering to it closely. Another 
proof is, that we find the part which is so intensely red without a drop of blood in 
contact with it. Sometimes the membrane is red in particular valves, for example; 
and yet the whole cavity will be emptied of blood; so that it cannot be ascribed to 
the imbibition of blood from the part with which it was lying in contact. Occa- 
sionally this redness will arise from great dyspncea. When, before death, there is 
long-continued difficulty of breathing, the mucous membrane of the stomach, intes- 
tines, and bronchia, becomes very red; and the right side of the heart becomes 
gorged with blood. In these cases we shall, in many instances, have redness of 
the inner membrane. But where a patient has died suddenly, and tiiere has not 
been time for the gradual accumulation of the blood from the smaller vessels, — 
where after death no blood is lying in contact with the red part, the lining mem- 
brane is sometimes intensely red. 

Symptoms.— In cases of this description there has sometimes been, before death, 
great rapidity of the pulse, rapid action of the heart, and more or less uneasiness 
and smarting in the region of the latter. If this occur within the aorta, for example, 
there is in general great rapidity of pulse, and a smarting sensation down the 
spine in the course of the aorta. In the case of the heart, the only reason for sup- 
posing its existence is that, in addition to the signs of pericarditis, (for pericarditis 
is generally united with it,) there is a very violent action of the heart; but I confess 
that, more frequently than not, I have found this appearance after death, without 
having had any reason to suspect it during life. 

Usually Chronic in its Nature. — When the lining membrane is affected with 
inflammation, it is generally a mere chronic disease; — ^jnst like inflammation of tiie 
pericardium.^ It undergoes the common changes produced by inflammation; it 
becomes thicker than it should be; and, at the same time, it becomes harder. 

The Valves most frequently Affected. — The parts most frequently affected are 

» See Page 80. •> See Pajre 829. 



832 DISEASE OF THE LINING BIEMBRANE OF THE HEART. 

the valves: which are nothing more than an elongation and doubling of this lininc 
membrane. In the case of the tricuspid and mitral valves, a portion of tendinous 
structure likewise enters into their composition. The " chordae tendineae;" invested 
as they are by the lining membrane of the heart, run along into the valves, and are 
lost there in the lining membrane; so that the mitral and tricuspid valves, are made 
up o{ fibrous membrane and the lining membrane;— tendinous and serous mem- 
brane; whereas the semilunar valves of the aorta and pulmonary artery, are nothing 
more than the lining membrane itself, protruded and extended. 

It is a general rule observed in pathology, that the lining membrane at the open- 
ings of the heart, is more subject to disease than other parts; — whether it be sim- 
ple inflammation, or the effects of chronic inflammation in any other part. We 
know very well, that it is not the stomach at large which is generally diseased; but 
one of the openings; — the cardiac or the pyloric. We also know that, more fre- 
quently than otherwise, disease affects the intestines where the small intestines 
terminate in the large; or, again, where the large terminate in the rectum. The 
rectum is the great seat of scirrhus, stricture, and various other diseases of struc- 
ture. In fever, ulcerations are more frequendy found at the termination of the 
ileum than elsewhere; and there it is we continually see scirrhus and cancer of the 
intestines. Instances of disease of the cardia and pylorus, are infinitely more fre- 
quent than disease of the rest of the stomach. Exacdy the same is observed in 
the case of the heart; so that we have infinitely more cases of disease of the open- 
ings of the heart, than any other part of the lining membrane. This is nothing 
more than an exemplification of a general rule. 

Left Side of the Heart most frequently Affected. — There is another rule, how- 
ever, which is peculiar to the heart; namely, that the left side is more subject to 
diseases of all kinds, and infinitely more to redness, than the right. That is a 
general rule, with respect both to the lining membrane within the heart, and with 
respect to the substance of the heart itself. Various hypotheses have been formed 
to explain this; but the most probable explanation is, that one side of the heart re- 
ceives blood of an arterial character, whereas the other has blood of a venous cha- 
racter. It has been thought that one side of the heart does more work than the 
other; but in proportion it certainly does not. Every time the left ventricle con- 
tracts, the right does the same; and so with respect to the auricles; and if the left 
ventricle have to send its blood farther than the right, yet the structure is much 
thicker than that of the right; and thus it is fully qualified for the exercise of the 
duty v*^hich it has to perform. No difi^erence that I can discover exists between 
them; except that one receives arterial, and the other venous blood. Whether that 
will explain the circumstance, I do not know; but we know, as a general rule, that 
arteries are more subject to active diseases of all kinds, than veins; and it is very 
probable that the greater stimulus of the arterial blood occasions other causes of 
disease, when applied, to act energetically; and also causes disease to take place 
with more readiness. 



SECTION II.—DISEASES OF THE VALVES OF THE HEART. 

Inflammation of the pericardium, when chronic, is very frequendy united with 
chronic inflammation of the membrane within the heart; and most frequently with 
chronic inflammation of those parts that form the valves. This is one way in which 
organic disease of the heart is produced; namely, by pericarditis. Pericarditis sel- 
dom exists long, without being followed by a similar state of the lining membrane 
within. 

Anatomical Characters. — In the natural state, these valves are quite flexible; 
and, though not trans/3«rm^ trans/wcenL But when they have become chronically 
inflamed, instead of being light, they become yellow; and, instead of being trans- 
lucent, they become opaque. They lose their flexibility, perhaps; and become 
more or less rigid. They play less easily; and at last become quite rigid. They 



DISEASE OF THE LINING BIEMBRANE OF THE HEART. 833 

lose their fineness, and become thick; and not only thick, but dense. 1[ these 
changes be not very severe, they give rise to no symptoms at ah. If they do not 
prevent the passage of blood, by narrowing the opening, — if they do not prevent 
tlie valve from doing its duty, no symptoms (that I am aware of) can arise; so that 
the best auscuitator in the world may find, after death, disease of the valves, of 
which he had no idea before the patient ceased to live. It is only when function 
is impeded, that any symptom can arise. 

Converted into Cartilage or Bone. — The cliange which the valves undergo will, 
at last, amount to cartilaginous hardness. They will become perfectly cartilaginous; 
and, in a still further degree, they will become complete bone. When they undergo 
this cliange of consistency, the aperture of the part is diminished. In the case of 
the tricuspid valve, the opening may be reduced to one-ihird or one-fourth. Still, 
however, it generally retains its circular form. In the case of the corresponding 
valve on the opposite side (the mitral), the circular form is still in many instances 
retained; but in other cases the opening grows up in such a way, that it is only a 
chink. Instead of being circular, it is of a crescentic, or semilunar form; and, from 
the valve growing so considerably, a pouch is formed, leading from the auricle to 
the ventricle; so that on opening the left ventricle, a pouch is seen extending into 
it; and, at the end of the pouch, there may be a circular opening. Sometimes, 
instead of a pouch, the valves is ail contracted together; and we have nothing more 
than a chink. 

Sometimes the valves will become bony. When there is bone, it is deposited 
under the membrane, — it is deposited, as in all cases of serous membranes, imme- 
diately under it; and then the membrane, from the presence of the bone, becomes 
exceedingly thin; till at last it will disappear, perhaps, over the bony portion; and 
the bare bone is then in contact with the blood. It is very rare for the valve to be 
universally converted to bone, nor is it common for it to be universally converted 
into cartilage; but the changes exist in different degrees at different spots; so that 
here and there there will be bone, and sometimes the valves will become completely 
cartilaginous. 

Changes in the Auricido- Ventricular Valves. — The valves between the auricles 
and ventricles on either side,— -the tricuspid on the right side, and the bicuspid ov 
mitral on the /e//, — when they are much diseased, instead of falling back, form a 
very considerable curtain, with an opening (generahy of an oval or circular form) 
in the centre of it. The different parts of the valve may become filled, or grown 
up; so that we have a complete membrane between the auricle and ventricle; and 
in the case of the mitral valve, especially, we every day see it extended in the form 
of a pouch. The opening in the mitral, as well as in the tricuspid valve, is gene- 
rally in the centre, and is circular or oval. I before mentioned, that the mitral 
valve is sometimes so grown up, that a mere slit remains; and it is worthy of 
notice, that this slit is not straight, but is generally of a crescent form, — in the 
shape of a bent finger; — the concavity of the opening usually being towards the 
root of the aorta, and the convexity backwards. I believe the latter circumstance 
may be said to be universally the case. On looking from the auricle, the light is 
seen through the chink, in a very remarkable manner. I believe this observation 
was first made by Mr. Adams, a surgeon at Dublin; who wrote a very excellent 
paper on Diseases of the Heart, in the "Dublin Hospital Reports."* 

The Pulmonary and ^8.ortic Valves. — With regard to disease of the other two 
openings of the ventricles, — the opening on the right leading into \\\e pulmonary 
artery, and in the left leading into the aorta, — disease is more frequendy found in 
the valves of the aorta, than in those of the pulmonary artery. This is according 
to the general rule, that all diseases far more frequendy afl^'ect the left side of the 
heart, than the right. It is a rare thing, indeed, for the pulmonary valves to be 
much diseased; but if they are, the appearances are the same as when the aortic 
valves are aflected. When the latter are diseased, they will stand quite firm; and 

* Volume 4. 
VOL. I. — 53 



S34 DISEASE OF THE LINING MEMBRANE OF THE HEART. 

do not give way at all to the common pressure of tlie blood; so that the opening 
becomes diminished. The aperture which is left in the middle of the three valves, 
is sometimes circular; though occasionally it is triangular. It sometimes happens 
that these valves are completely converted into bone. They then form three shells 
of bone; but still they retain the appearance they present when there is only carti- 
lage. It is very common to find bone about the aortic valves, — more common than 
anywhere else; but next in frequency we find it on the rnitral valve. It is some- 
times found at the edge of the valve; sometimes at the bottom of the sac of the 
valves; and sometimes there is bone on the aorta, opposite the valves. The quan- 
tity of bone is sometimes very great; and occasionally it occurs in minute granules, 
and not very firmly adherent; so that by rubbing it with the finger, portions come 
off in the form of grit. 

Warty Excrescences on the Valves. — These changes are not the only ones, how- 
ever, that' we observe in the valves. Occasionally we find excrescences; and these 
are so much like venereal warts on the genitals, that Corvisart, who has written a 
very good work on Diseases of the Heart,^ actually believed they were syphilitic. 
The appearance of warts on the genitals, does not depend upon their being syphi- 
litic, but upon their being morbid growths of a particular structure; and we know 
that, in the greater number of cases, the warts depend upon mere irritation, without 
any other cause. These excrescences are very various in their appearance. Some- 
times they are variously pointed, so as to exacdy resemble venereal warts; and 
sometimes they are of very great length. I once opened a body, in which the ex- 
crescences were so long, that th<?\^ nearly reached to the apex of the heart. It was 
the extremest case I have ever seen. There were a number of projections from 
the outside of the mitral valve; but it was at the roots of the aortic valves that they 
were so very long. 

Shrinking of the Valves. — When the valves become so changed in various 
ways, they frequently shrink, and become shallow; and they also shrink in breadth. 
They also frequently become shorter, so that the aperture is altogether dmrinished; 
and when bone is deposited upon them, they frequently become britde; and from 
their brittleness, they split and crack. The two valves frequently separate at the 
point at which they are usually united. They are no longer bound down, and the 
two are thrown into one; and at that point the valves frequendy split to a greater 
or less extent. This is a very common occurrence. The valve is so corrugated, 
that the division between the two is lost. This is just the same occurrence that 
takes place in the interior of an artery, when bone is deposited there. An aneu- 
rism arises from the deposition of bone, and not from the mere coat of the artery. 
Bone is deposited in the middle of an artery, and the coat splits. In the case of 
the heart, it is not an artery that is affected, and therefore an aneurism is not pro- 
duced; but the part splits in the same way. Dr. Baillie has given an excellent 
representation of some of these affections. 

Corrugation of the Valves.-— When the aortic valves become opaque, thick- 
ened, indurated, and rugged, they sometimes corrugate, so as to curl in towards the 
side of the aorta; and sometimes so as to turn out. Sometimes they are neither 
curled in nor out; but remain rugged. A paper was read at a society by a gentle- 
man, announcing this as a very great discovery; but really it was no discovery at 
all. Corvisarl's work contains a mass of information on Diseases of the Heart 
and Aorta; and is the best next to Laennec's on Diseases of the Chest. I recol- 
lect he states (without announcing it as any thing important) that sometimes the 
valves are folded in, and that sometimes they are folded out. Occasionally the 
induration is merely at the roots of the valve. On rubbing each, we find the root 
semicircular and hard. These are the chief varieties of disease of the valves. 

Comparative Frequency of Disease of the Valves. — With regard to ossification, 
although it is seen so commonly in the aortic valves and the mitral valve, it is a 
very rare thing indeed to find the disease advancing so far upon the right side of 

a " Essai sur les Maladies, et les Lesions Org^niques du Coeur, et desGros Vaisseaux." 



DISEASE OP THE LINING MEMBRANE OF THE HEART. 835 

the heart; but far more rare indeed to see it proceed so far upon the valves of the 
pulmonary artery. Tlie tricuspid valve of the right side, is far more frequently 
diseaseil, than the semilunar valves of the pulmonary artery. Thus tlie aortic and 
mitral valves are not only far more diseased than those on the right side, but (to go 
to the latter situation) the tricuspid valve is more frequently diseased, than tlie 
valves of the pulmonary artery. 

Causes of these Changes, — The changes to bone and cartilage, when they occur 
in young persons, are undoubtedly the result, in by far the largest majority of cases, 
of mere accidental inflammation; so that without having rheumatism, catching 
cold, or being exposed to the causes of inflammation, the individual would never 
have suffered from the disease. But when they occur in old persons, these affec- 
tions can rarely, I believe, be traced to any particular attack of inflammation. They 
appear to be a degeneration of structure dependent upon age. Some parts of the 
body, under the influence of age, suff'er transformations sooner than others; and 
this portion of the heart will become diseased, in old persons, really from a dispo- 
sition to organic disease, and not from the result of accidental inflammation. This 
change of structure is common, in various parts of the body, as individuals grow 
older. 

Other Parts of the Membrane affected. — Although the foregoing are the parts 
of the lining membrane of the heart, which are most frequendy diseased, yet we 
occasionally see other parts of the lining membrane of the ventricles and auricles, 
but panicularly the former, thickened very much, and hardened. Sometimes the 
lining membrane is particularly thickened where it lines the ventricles; while at 
the valves it is in a healthy condition. But this is an exception to the general 
rule. Now and then we see a little ulceration of this membrane; but that is a very 
rare occurrence. 

Deposition of Lymph on the Valves. — There is one circumstance, which I do 
not find to be much dwelt upon in books; and it is, perhaps, the result of inflam- 
mation. Occasionally, after chronic pericarditis, there will be a deposition of 
lymph under the mitral or tricuspid valve; which will bind it completely down, 
so as to prevent it from fulfilling its functions. I have seen several instances of 
this occurrence. My attention was drawn to it by Dr. James Johnson; or pro- 
bably I should not have known any thing about it. After I had published a case 
of this description, I found it had been incidentally mentioned, some years ago, in 
an account of the dissection of a body; but in the regular books on diseases of the 
heart, I do not recollect having been able to meet with any mention of the circum- 
stance. It is well known that the tricuspid and mitral valves have a free floating 
curtain; and that if lymph be deposited between them and the heart, they may be 
bound down. A striking instance of the first of these afffections, occurred to me; 
and I have never met but with three or four cases. I have given a representation 
of the case, in my work on Diseases of the Heart.* This was a case of common 
rheumatic inflammation. The woman had had rheumatism, several times. She 
had had disease of the valves; and also inflammation of the left ventricle. 



SECTION III.— EFFECT OF DISEASED VALVES ON THE FUNC- 
TIONS OF THE HEART. 

Twofold Effect. — We will now proceed to consider what eff'ect these changes 
must have upon the functions of the heart. The eflTect may be twofold; — it may 

* Plate III, The morbid appearances are thus summed up: — " The tricuspid valve thick- 
ened throughout; one half ^rown up, and completely adherent to the inner surface of the 
ventricle, with a hard rounded edge; the other half loose, and put upon the stretch, to show 
its extent, and the dimensions of the opening left during the play of the valve. The figure 
of the heart is altered,— being lengthened by hypertrophy and dilatation of the left ventri- 
cle; while the right ventricle — remaining healthy, and therefore reaching but a short way 
down — looks like an appendage to the lefty 



836 DISEASE OF THE LINING MEMBRANE OF THE HEART. 

be to diminish the aperture through which the blood escapes from tlie auricles or 
from the ventricles; or it may prevent the valves from doing their duty, in offering 
an obstruction to the blood when it attempts to come back. Hence these changes 
may cause an obstruction to the blood going from the auricles to the ventricles, or 
from the ventricles to the pulmonary aorta; or they may prevent the valves from 
offering an obstruction lo the blood, so that it rushes back, in some degree, from 
the ventricles to the auricles, or from the pulmonary artery or aorta into the vent- 
ricles. When the aperture is diminished, and the valves grow up, then there 
will be an obstruction to the transit of the blood; but very frequently the valves 
become so rugt^ed, that they will not distend when the blood attempts to return; 
and therefore they can no longer perform the office of a valve. When the blood 
drives back against them, a portion of it goes through; though, of course, not the 
whole; because, whenever the valves are indurated and rugged, the aperture is 
diminished; and, at the same time that the diminution of the aperture prevents all 
the blood from going out that should do so, it prevents some from coming back 
that wishes to do so; and therefore there is not a complete, but ^.partial retroces- 
sion. Now the same tiling will occur, if the valves happen to be bound down; 
but I have never seen the valve bound down, except in the case of the tricuspid; 
and I cannot conceive it possible that it can happen in the case of the semilunar 
valves of the aorta, or of the pulmonary artery; but if the aortic valves are corru- 
gated, and are only half their size, then they can furnish no proper obstruction; 
and a quantity of blood will return. Thus disease of the valves may prevent the 
blood from going in a natural course; or they may allow it, in some measure, to 
come backwards. 

Natural Sounds of the Heart. — These occurrences could not be known, formerly, 
in the living subject; but now that the ears are employed, they may frequently be 
detected during life. On placing our ear over the heart, or employing the ste- 
thoscope with one extremity placed over that organ, two sounds are heard. The 
first sound which takes place is rather long; and is immediately followed by a 
short sound: so that we have a double sound when the heart acts. The first sound 
which occurs at the moment of the impetus of the heart against the side; and the 
second immediately after it. The stroke of the heart and the first sound take place 
both together; and occur a little before the pulse at the wrist; — at least in most 
cases. Sometimes we cannot distinguish any interval at all, between the stroke of 
the heart and the pulse at the wrist; but very frequently we can; this interval arises 
from the distance of the radial artery from the heart. If we feel the artery nearer 
the heart, v/e find a less interval; if we feel the temporal artery, or the aorta itself, 
there is no interval at all. We may feel the aorta at the arch; and if you place one 
finger on that, and one on the heart, the stroke at each is found to be simultaneous. 
It is quite clear, that the pulse at the wrist is immediately consequent on the im- 
pulse of the heart. The second sound, which takes place after the impulse of the 
heart, always occurs, in health, after the pulse at the wrist; and the pulse of the 
wrist and the stroke of the heart are so close together, that in common language we 
may say they are simultaneous. Laennec supposed that the first sound of the 
heart took [)lace from the contraction of the ventricle, and that the second occurred 
from the auricle;^ and so he was able to predict where an obstruction would be 
found after death. 

Recent Investigations on the Sounds of the Heart. — There is a difference of 
opinion, at this moment, as to whether Laennec was right in ascribing the second 
sound to the contraction of the auricle; and I am inclined to believe that he was 
wrong. My reason is this. On passing the stethoscope over the heart of a jack- 
ass, when the heart was -laid bare, — according to the experiment of Dr. Hope, — I 
heard the second sound when the stethoscope was placed upon the ventricle. The 
sound clearly came from tiie ventricle: and I was told by others who could see what 
happened, that the auricle did not contract at that time. But although I dare say 

^ See Dr. Forbes's Translation of his Treatise on Diseases of the Chest; Part 2; Book 1; 
Chapter 4j Paragraph 1. (Third Edition; Page 558.) 



DISEASE OF THE LINING MEMBRANE OF THE HEART. 837 

the sound did not arise from tiie mere contraction of the auricle, yet I have no doubt 
that it took place at the very moment when the blood passed from the auricle into 
the ventricle; because, as soon as the two ventricles have contracted, they dilate; 
and the instant they dilate, the blood must rush into them. A vacuum is formed 
by the dilatation; and the blood must rush out of the auricles into them; and 1 be- 
lieve this is a passive circumstance. Thejcontraction of the auricle appears to have 
little to do with it. When the ventricle dilates, the auricle empties itself; but, as 
far as I could observe in the experiment made, it does this in an irregular manner. 

[These experiments were afterwards repeated and varied by the Dublin Commit- 
tee of the British Association for the Advancement of Science; and, more recently, 
an extended series of experimental researches, on the same subject, has been con- 
ducted by Drs. Clendenning', Todd, and myself,"" in another committee for the 
same association. It was decided unequivocally, by all the series of experiments 
alluded to, that the first sound accompanies the whole duration of the systole of the 
ventricles, which also causes the impulse felt on the walls of the chest; it was 
equally clear that the second, or flapping sound, occurs at the first moment of the 
diastole, and that the motion of the auricles was not accompanied by any percepti- 
ble sound. 

Production of the First Sound. — -How does the contraction of the ventricles 
produce the first sound? Sound may be defined to be ^^ motion of a certain force, 
resisted with a certain force:" where is the resisted motion in the contraction of 
the ventricles? One of the first ideas that suggest themselves, is that of Magendie: 
does not the heart produce the impulse by striking against the walls of the chest? 
and why should this not cause sound? In forcible pulsations, and when the lung 
does not too much intervene, P have no doubt that the impulse does produce sound; 
and if we listen to the sound of the heart when it is beating strongly, or when, by 
leaning forward or by breathing out, the heart is brought in contact with the walls 
of the chest, we hear the first sound has in it something like a knock, which we 
can scarcely help referring to the impulse. But this is an accessory, and not an 
essential sound; for we may hear the first sound when there is no impulse; — as 
in a person leaning backwards, or taking a full breath; and, in our experiments, we 
heard the first sound at the origin of the arteries, when the body of the heart was 
surrounded with the soft lung or with tow; or was allowed to hang out of the chest, 
and strike against nothing in its motions. It is well known, that liquid in the peri- 
cardium, or liquid or air in the pleura, although it entirely prevent the heart from 
striking the walls of the chest, does not annul the first sound. In moderate pulsa- 
tions, the heart makes a partial rotatory movement: the long fibres of its anterior 
convex surface, drawing the apex upwards and forwards, and causing it to slide 
obliquely on the smooth pericardium, bring it to the walls of the chest too gently 
to produce sound, except in the circumstances before mentioned. 

The first sound, then, is produced by something in the heart itself; — either by 
its contents, or by its own structure. Can it be by its contents; — by the motion of 
the blood resisted by the inequalities of the interior of the ventricles? This was 
supposed by the Dublin Committee to be the chief cause of the sound. But the 
motion of the blood over these inequalities is not rapid, nor is their resistance consi- 
derable at the time of the production of the sound. These inequalities are, as Dr. 
Cowan has pointed out, chiefly confined to the lower or auricular portions of the 
ventricle, into which the blood has already passed before the systole begins; and 
the efiect of the systole is to drive the blood, not over or across the inequalities, but 
from them, to those smooth and funnel-shaped parts of the ventricle which lead to 
the arteries, and which ofier the least possible resistance to its course. The con- 
traction of the ventricles propels the passive mass of blood gradually — that is, during 
the whole period of the first sound — into the arteries; and the motion is therefore 
too slow and easy to be likely to cause sound. Some of our experiments further 
settled this point; by proving that the first sound continued when the ventricles 
contracted without any blood in them. 

" Dr. C. J. B. Williams. 



838 DISEASE OP THE LINING MEMBRANE OF THE HEART. 

By excluding the blood we are thus brought to the condnsion, that the cause of 
the sound must be in the solid structure of the ventricles: it is our next question, 
"whether it be in any part of them in particular. Several writers have ascribed it 
to the auriculo-ventricular valves; which, when they close, are supposed to pro- 
duce a flapping sound. But the act of closing these valves is momentary, and 
takes place only at the commencement of the systole; whereas the first sound of 
the heart is prolonged through its whole duration. Further: in some of our ex- 
periments the first sound continued, although impaired, when the auriculo-ventricu- 
lar valves were prevented from acting, by fingers introduced into their orifices, or 
by some of their cords being hooked back or cut. Still these valves no doubt pro- 
duce a part of the sound; for at each contraction they are suddenly tightened, in a 
manner calculated to generate sound. 

But are the valves the only parts which are tightened at each systole of the 
ventricles? Is not every muscular fibre in the ventricles suddenly tightened by this 
action? Here are the elements of sound, motion vigorous and rapid, suddenly 
resisted by the mass of blood to be urged forwards by the contraction; and the 
contracting motion and the resistance, although greatest at first, continue to act as 
vibrating forces during the whole systole: hence the prolongation of the sound. 
In other instances, abrupt and forcible muscular contraction produces a sound like 
the first sound of the heart; as when we apply the stethoscope to the adductor 
muscle of the thumb of the closed hand, and contract the muscle strongly and 
quickly. Or, to avoid the possibility of the joints being the seat of the sound, if 
"we apply the end of a flexible tube to the abdominal muscles, and start them into 
sudden vigorous action, we may thus get sounds quite as loud as those of the vent- 
ricles, and very like them in character. 

By varying the mode of this muscular action, different kinds of sound may be 
produced. When the contraction is slow or sustained, however strong, we have 
only the dull rumbling noise which Dr. Wollaston first described; and which he 
attributed to the vibration, depending on a regular intermittence in the force of the 
contraction. When the contraction is gentle and slow, it may cause no sound at 
all; as the auricles generally produce no sound, neither do the ventricles, when 
their contraction is very feeble. But whenever there is strong abrupt muscular 
action in any part of the body, like that of the heart, there will be heard a sound 
which will resemble that of the ventricular systole, in proportion as the muscles in 
which it is produced resemble in thickness and density the tissue of the heart. 
The loudness of the sound is by no means in proportion to the thickness or strength 
of the muscle; but rather to its simplicity, and the abruptness as well as the vigour 
of its contractions: tlie transition of a thick muscle from slack to tight, can never 
be so complete and sudden as that of a thin one; where there are many fibres, they 
choke or muffle each other's vibrations; hence the sound is dull and prolonged, 
rather than loud and clear. Many writers who have objected to my explanation of 
the first sound of the heart, have done so in ignorance of the principles on which 
muscular action causes sound. When these are known, the identity of the pheno- 
mena becomes apparent; and, in my experiments,* there was the best proof we 
could have, that the muscular contraction of the heart produced systolic sound; for 
we had the heart out of the body, without its blood, without valvular action, lying 
on the table, or on niy hand; and its contractions were still accompanied with a 
sound, weak indeed, but in character resemblino- its natural first sound. 

The walls of the ventricles appear to be peculiarly calculated to generate sound. 
Their flaccid state when relaxed, the fineness of their fibres, and the harmony with 
which they suddenly contract on their contents, and become almost as hard as a 
stone (as we feel in the living heart of a stunned animal), fulfil the conditions best 
calculated for the production of sound. Tlie commencement of the systole — pro- 
ducing the tighteninij of the auricular valves, and thereby completing the resistance 
of the body of blood on which the contracting fibres have to act — is naturally its 

• Those of Dr. C. X E. Williams. 



DISEASE OF THE LINING MEMBRANE OF THE HEART. 839 

loudest part, and often has a flapping character; that which continues after is more 
dull, and is prolonged according to the quantity of blood to be expelled, and the 
continued strength of the contraction. This prolonged termination of the sound is, 
therefore, best heard when the heart acts slowly and vigorously. 

Production of the Second Sound. — What causes the second sound? That it 
is intrinsic, and not caused (as Magendie supposed) by the heart striking any of 
the surrounding parts, we proved by the same experiments in which the intrinsic- 
character of the first sound was shown; the sound continued when the heart was 
so completely isolated that it could strike against nothing.* What is there, then, 
within the heart, that can produce this short clapping sound at the moment of 
the diastole? Is there any thing that tightens at that moment? Not the walls of 
the ventricles certainly, nor the auricular valves; for they are then all loose and 
flaccid. What can it be but the semilunar valves at the mouths of the arteries; 
which are then suddenly tightened by the reaction of the arterial column of blood? 
And so it was proved to be, in my experiments first, and in many repeated since; 
for by hooking back these valves, or by pressure preventing the reaction of the 
column of blood upon them, the sound was stopped; and by releasing the valves, 
or discontinuing tlie pressure, the sound was as surely restored.'' 

We may consider it, then, as established, that i\\e first sound of the heart is 
produced essentially by the tightening of the valves and walls of the ventricles, 
by muscular contraction; and that the second sound is caused by the sudden tensioa 
of the arierial valves, by the recoil of the arterial column of blood upon them.*'^ 

Abnormal Sounds of the Heart. — The nature of those sounds which occur in 
health, need not be described; because we have only to place a stethoscope, or our 
ear, over a friend's chest, in the region of the heart, and we shall immediately per- 
ceive them. But if there be an obstruction, — so that the blood cannot pass freely 
out of the left ventricle into the aorta, or from the right ventricle into the pulmo- 
nary artery, — -then, in most instances, there is an alteration of the sound. If the 
mouth of the pulmonary artery, or of the aorta be obstructed, a similar effect is 
produced to that resulting from the arch of a bridge being narrowed; so as only to 
permit the stream to pass through it at a certain pace. The stream passing through. 
a narrowed arch, makes a whizzing sound, which was not heard before; and so if 
the blood, while passing from the ventricles into the pulmonary artery or the aorta, 
meets with an obstruction, it produces a sound not heard in health. This sound 
occasionally resembles that produced by a pair of bellows; and is therefore called 
" a bellows-sound;^^ or, in French " bruit de soufilet.^^ Occasionally it is shrill, 
like the action of a file; and then it is called " a rasping sound," or " bruit de 
rdpe.''^ Sometimes it is like the action o{ 2. fine saiv; and then it is called "bruit 
de sde." Perhaps the term ^^preternatural sound" would be a good generic term 
for embracing all these sounds. I have so used it, in my work on " Diseases of 
the Heart." 

Causes of these Murmurs. — [An example or two will set before us something 
of the character and causes of these murmurs. At the moment when the blood is 
issuing from the ventricle, if — instead of a smooth, equally tense channel — it meets 
with a rigid constriction, or an abrupt orifice, its passage through it will be attended 
with a whizzing or blowing noise, which may be heard in the region of the heart. 
Or to take a simple case; if we apply the stethoscope in the course of an artery far 
from the heart, we hear nothing as long as the current of blood flows smoothly and 
unmodified through it; but if by pressure we diminish the calibre of the tube at 
any point, we then complete the elements of sound; we give resistance to the 

« See Page 837. 

'" Dr. Carswell seems to have been the first who conceived, that the second sound is caus- 
ed by the flapping of the semilunar valves. He was led to this opinion by observing the 
signs of a case of aortic aneurism in 18-29; a drawing of which is now in the ?/Tuseuin of 
Uuiversity-Colle2:e, London. The first proposal of this exnlannlion that I know of in print, 
is in a thesis ("De Corde") by Dr. Elliott, Edinburgh, 1831. Dr. Billing, M. Rouanet, and 
Mr. Carlile, were later advocates of this view.— /3r. C. J. B. Williams.^ 

c Dr. C. J. B. Williams, on the Chest; Fourth Edition; Pages 204 to 208. 



840 DISEASE OF THE LINING MEMBRANE OF THE HEART. 

moving blood; and, at each pulse, we hear a blowing or a whizzing sound; which 
v/ill vary in tone and loudness, according to the force of the current, and the degree 
of resistance which it meets with. This is purely a physical phenomenon; it may 
be produced in any tube through which a current of water runs. Thus, if we take 
an india-rubber tube, and adapt it to a reservoir of water, — so that the water shall 
flow freely through the tube, we may by pressure on the tube produce murmurs, 
varying according to the force of the current, and the resistance which the pressure 
opposes to it. They are sometimes like blowing; sometimes like rasping or 
sawing a piece of wood; and now and then they may be heard in quite a musical 
tone, which implies that the vibrations are then regular and sustained. The blow- 
ing and musical murmurs are generally caused by greater regularity, but less force 
of current, than that which produces the sawing or whizzing sounds.*] 

Obstruction of the Miriculo- Ventricular Opening. — If the obstruction be be- 
tween one of the auricles and the corresponding ventricle, then it is the second 
sound which is altered; and it is after the beat of the heart, — after the pulse at the 
wrist, that we hear this preternatural sound; — whether it be a belloios, a sawing, 
or 2. filing sound. 

A vacuum cannot be formed in the ventricle^ without the blood escaping from 
the auricle; and therefore when there is an obstruction between the auricle and 
ventricle, a bellows-sound is heard at the moment we should hear the second 
natural sound of the heart. We may form an accurate diagnosis in this way. I 
have done it over and over again; and have always predicted the exact part where 
the obstruction existed. I have always taken it for my guide, that where a bellows- 
sound was heard at the moment of the stroke of the heart against the side, there 
was an obstruction, either at the mouth of the pulmonary artery^ or at the mouth 
of the aorta; and, on the other hand, where a bellows-sound has been heard after 
the first natural sound, that then there has always been some obstruction to the 
course of the blood from the auricle into the ventricle; or else that the valves at the 
mouth of the aorta, or of the pulmonary artery, have not done their duty; so that 
the blood has partly rushed back into the ventricle. Whatever may be the cause 
of the second sound heard in the heart in health, — whether the dilatation of the 
ventricle or not, it is at that moment that we hear the bellows-sound, when there 
is an obstruction to the course of the blood from the auricle to the ventricle. 

Period at ivhich the Blood leaves the Auricles. — Laennec states, that at the 
moment of the pulse at the wrist, — at the moment of the stroke of the heart against 
the side, the blood leaves the ventricles, and rushes into the pulmonary artery and 
the aorta;* and that it is immediately after this, that the blood leaves the auricle, 
and rushes into the ventricle; — so that the first sound of the heart occurs at the 
moment of the stroke of the heart, and the pulse at the wrist, or just before it, — the 
difference being exceedingly minute; and depends upon the rush of the blood from 
the ventricle; and the second sound depends upon the rush of the blood into the 
ventricle from the auricle. It perhaps may be doubted whether, in the latter case, 
it arises from a contraction of the auricle; but I think there can be no doubt it takes 
place at the period he mentions; though, in all probability, it arises from the flow 
of the blood out of the one cavity into the other. It has been said, that if we in- 
spect the heart of a living animal, we see that the auricle contracts before the 
ventricle; — the reverse of what Laennec has stated. This, certainly, I have seen. 
But it is to be considered, that the muscular part of the auricle is very inconsidera- 
ble; that the greater part is a mere venous sinus; and, I imagine, it must be when 
the ventricle is dilated, that the blood rushes into it. Now the ventricles dilate the 
moment after they have contracted; and therefore I should conceive, that this rush 
of the blood from the auricle, is an effect independent of the contraction of the 
auricle; — that it is merely the effect of a vacuum produced in the ventricle by its 
dilatation; so that the blood rushes on, as it does from the "vense cavae." In the 
experiments I saw, the auricle contracted with great irregularity; — sometimes before 

* Dr. C. J. B. Williams, on the Chest; Fourth Edition; Pages 215 and 216. 
»> See Note to Page 836. 



DISEASE OF THE LINING MEMBRANE OF THE HEART. 841 

the ventricle, sometimes after ii; and I have seen five or six contractions of the 
auricle, taone of the ventricle; so that I do not think the ventricle is filled by the 
action of the auricle. Another great argument is, diat I have been able to make an 
accurate diagnosis, by observing the periods of the morbid sounds, as Tiaennec has 
staled them. Whenever there has been a contraction of the mouth of the aorta, or 
of the pulmonary artery, the preternatural sound — whether it has been a bellows^ a 
sawing, a rasping, or a cooing sound — has been at the moment of the stroke of 
the heart. Whenever the tricuspid, or the mitral valve, has been (Hseased, — when- 
ever I have seen the opening between the auricle and the ventricle (or either side) 
contracted or narrowed, then the morbid sound which I have heard has always 
been after the pulse, — after the stroke of the heart; — showing that it is at that time 
the blood leaves the auricle; that is to say, it is as soon as the ventricles have 
emptied themselves and dilated again. 

Case of Dr. Hopkins. — Details have been published of a post-mortem examina- 
tion, which took place abroad. It was the case of Dr. Hopkins, who was formerly 
a lecturer at Mr. Grainger's Medical School, Webb Street, Southwark., It is stated, 
that the left ventriculo-auricular opening of the heart was ossified, in its whole cir- 
cumference, for three lines in breadth; and that there was a singular contraction of 
the opening. It so happened that this gentleman came to me, about six months 
before his death, with cedema of the lower extremities, and difficulty of breathing. 
I examined his chest; and, in a moment, found signs of a dreadful disease of the 
heart. I made pretty extensive notes of the case, at the time; and, founding the 
diagnosis on what Laennec has said, I stated there was disease of the mitral valve. 
In that case, I heard a very extraordinary sound, immediately after the stroke of the 
heart. It was not a bellows-sound, but a variety of preternatural sounds, and some- 
times there were two or three of them in rapid succession. It occurred immediately 
after the pulse; and was heard on the left side of the heart's region. When I 
listened with the naked ear, instead of this extraordinary sound, it appeared like 
the sound of a saw. I did not doubt that he had disease of the mitral valve; or, if they 
were not an obstruction to the course of the blood from the auricle into the ven- 
tricle, that the aortic valves were so diseased, as to let a litde blood come back. I 
therefore wrote down in my note-book — -"Disease of the mitral valve, or else im- 
perfect action of the aortic valves." If Laennec be wrong, the sound I have de- 
scribed ought to have been heard at the moment of the heart's action. But here is 
a dissection taking place in a foreign country, by a person who knew nothing of 
me or of my diagnosis; and here are the post-mortem examination, and my written 
account of the state of the heart, corroborating each other. This shows us, as 
more than twenty or thirty cases have done before, that Laennec is right. He may 
be wrong in saying that the auricle contracts dien; but I cannot consider him incor- 
rect in saying that the blood rushes, at that moment, from the auricle into the vent- 
ricle. Some ascribe the sound to the circumstance of the ventricle dilating; but I 
am not aware that it gives a sound. I should think it more likely that it is owing 
to the rush of blood into the ventricle. I regretted, when Dr. Hopkins went abroad, 
that I should not have an opportunity of comparing the dissection with the diag- 
nosis; and therefore I was gratified when I saw the case published. 

Cause of the Preternatural Sounds. — Why it is that we have sometimes a bel- 
lows-sound, and sometimes a sound resembling the action of a saw or a file, is not 
well known. Some have supposed, that ossification gives rise to the shrill sound; 
but that is not proved. It depends, I should imagine, on two or three things in 
conjunction. If the opening be very small, and the action of the heart be driving 
on a large quantity of blood, I should think it would be shrill; but if the opening 
be small, and the action of the heart not very strong, then the feeble influence of 
the blood will, I should think, not cause the shrill sound. If the parts were soft, 
then we might have a shrill sound. 

Does the Auricle Contract First? — It has been supposed that the auricle con- 
tracts before the ventricle, — for this reason; — that, in the case of an obstruction, 
the jugular veins swell at the time of the stroke of the heart. Before the pulse is 



842 DISEASE OF THE LINING MEMBRANE OF THE HEART. 

felt, indeed, the jngnlar vein will sometimes sxvell, in disease of the heart; and will 
pulsate strongly. It is supposed, that when the auricle contracts, an obstruction 
must take place in the veins, and the blood accumulate there. For myself, how- 
ever, I do not think that, at the time the auricles contract, there is any obstruction 
in the veins; for when they lose their blood, the ventricles must be open for the 
blood to rush into them; and, consequently, there is a free passage for the blood. 
When the ventricle is contracting, there must certainly be a great obstruction to 
the blood; but the moment the ventricles dilate, that moment the auricles act; and 
the action of the auricle cannot cause an obstruction, because there is a free course 
for the blood to rush into the ventricle. 

Laennec's accuracy has been again called in question by others; and the stroke 
of the heart's apex, and ihejirst sound of the heart, have been declared to happen 
before the pulse; and to be produced by the dilatation and repletion of the ventri- 
cle; and the second sound has been said to occur at the moment of the contraction 
of the ventricles, and to arise from the flapping together of the parietes of the emp- 
tied ventricles. 

I would reply, in the first place, as before,* that when an obstruction exists at 
the mouth of the aorta or pulmonary artery, a morbid sound occurs at the moment 
when Laennec supposes the ventricles to contract; and when an obstruction occurs 
at either auriculo-ventricular openino-, a morbid sound occurs at the moment he 
supposes the auricles to contract. This could not happen had he mistaken the 
periods of the ventricular and auricular contractions. 

Secondly: when the pulse at the wrist follows the stroke of the heart, it does so 
after only a very minute interval; — such as may be explained by the distance of 
the radial artery from the heart; and actually occurs decidedly before the auricular 
sound; — that sound which is now declared to be the ventricular. Moreover, when 
the pulse of the wrist is observed to follow the stroke of the heart, the pulse at the 
innominata (so much nearer the heart) may be found to precede that at the wrist, 
and to occur all but siniultaneously with the stroke of the heart; so that the relative 
distance of the parts explains the whole difference; and the pulsation of the arte- 
ries, in all cases, clearly arises from the stroke of the heart. If an artery still 
nearer the heart than the innominata be observed, no interval between its pulse 
and the stroke of the heart is perceptible. In four cases of aneurism of the ascend- 
ing aorta, producing a strongly pulsating tumour to the right of the sternum, this 
and the heart, when the fore-fingers were placed upon both, were felt, and by all 
seen, to pulsate quite synchronously. When the obstruction is at the mouth of the 
aorta or pulmonary artery, I have always noticed the preternatural sound to be 
synchronous with the pulse; — when at an auriculo-ventricular opening, in the in- 
tervals of the pulse, after or before the pulse. Sometimes in the latter case, it is 
so prolonged, as to last till the pulse is again felt; so that there is no interval; but 
merely an equal alternation of the ventricular, and the preternatural auricular sound: 
or even an interval occurs after the ventricular stroke; — probably from the auricle 
not being disposed for contraction at the usual time; on account of its contraction 
having been so lengthened by the difficult escape of its blood, that a longer repose 
is required, than just during the ventricular contraction. Here the auricular sound 
occurs first; then the ventricular; and then the interval. 

Thirdly: the sounds considered by Laennec to be auricular and ventricular, are 
heard loudest (both in health and when morbid) at the seat of the auricles and vent- 
ricles respectively. 

Cause of Preternatural Sounds after the Pulse. — When these peculiar sounds 
are heard a moment after the pulse, and after the action of the heart, we cannot say 
with certainty, that they arise from a difficulty to the transmission of the blood from 
the auricle; and for this reason. If the valves at the mouth of the pulmonary artery 
and aorta do not do their duty, but allow a portion of the blood to regurgitate, (as 
is very common in the case of the aorta,} I believe the rushing back of a small 

a See Page 839. 



DISEASE or THE LINING 3IEMBRANE OF THE HEART. 843 

quantity of it, will occasion the bellows-sound. We know, that the moment the 
ventricle has acted and dilates again, the blood attempts to rush back into the va- 
cuum; but is prevented by the three aortic valves, wliicli are filled out in a mo- 
ment. But if it so happen that one is torn, or becomes corrugated and small, then 
a certain portion of the blood will regurgitate; and as it is not the ivhole of the 
blood in the aorta that can go back, but a minute portion that passes through the 
small opening which is left, (the valves doing their duty to some extent,) that is 
sufficient to cause the bellows-sound. If the wliole of it regurgitated, doubtless 
there would be no bellows-sound; but if only one valve be torn, or corrugated, or 
if the whole of the valves be partially corrugated, then the small portion which 
returns causes the bellows-sound. This must take place synchronously with the 
emptying of the auricles. The same cause which makes the blood rush from the 
auricles, — namely, the dilatation of the ventricle, — also attempts to make the blood 
rush back from the aorta and pulm.onary artery into the ventricle. The blood 
attempts to go from the auricles, and does so with success; and at the same instant 
it attempts to do so from the aorta and pulmonary artery, but cannot; and it is at 
this moment that we have the morbid sound. Suppose it is one of the auriculo- 
ventricular openings that does not do its duty; — suppose the tricuspid valve on the 
right side, or the mitral valve on the left, is bound down on one side; or suppose 
it is diseased, so that there is a constant aperture there, through which a certain 
portion of blood must rush back from the ventricles into the auricles; — then we 
have a bellows-sound, from this cause, at the time the ventricles contract. I have 
frequently heard a bellows-sound, at the moment of the pulse; — arising, not from 
an obstruction to the course of the blood out of the ventricles, but from a valve 
between the auricles and ventricles not doing its duty; so that a small portion re- 
fluxed. 

Before I was aware of this circumstance, in one or two cases, I gave a false 
diagnosis; and said that there was an obstruction to the course of the blood from 
the ventricle; whereas it turned out that the valve between the auricle and vent- 
ricle was not performing its functions properly. Hence, when there is a bellows- 
sound at the moment of the heart's action, it may arise from disease of the aortic 
valves, or from disease of the mitral valve; and when the bellows-sound takes 
place after the pulse, it may be the result of an obstruction to the course of the 
blood from the auricle, or from a certain portion rushing back into the vent- 
ricle. In every case, it is caused by. one of these two circumstances.^ The 
first case in which I found I had made a false diagnosis, was one which 1 have 
already described.'' The preparation is at St. Thomas's Hospital. There was a 
loud bellows-sound at the moment of the pulse; and I therefore concluded, that 
there was an obstruction at the mouth of the aorta, or of the pulmonary artery. 
But I found that the mitral valve was bound down; so that there was a constant 
opening; and, when the ventricle contracted, the blood refluxed freely into the 
auricle. 

Causes of Diminished Apertures. — These diminished openings may occur' from 
various causes. Sometimes the valves are diseased in the way I have mentioned. 
The valve may be indurated, become cartilaginous, — become bony; and the open- 
ing may be organically diminished. The aperture is sometimes decreased by ex- 
crescences. Twice I have seen the valves perfectly sound, and the pulmonary 
artery contracted immediately beyond the valves; so that only a very minute aper- 
ture existed, for the blood to escape through. In one of these cases the disease 
arose (as it does in so many instances in young persons) from violent pericarditis. 
The pericarditis had gone on to produce cartilage under the pericardium; and the 

» [Recently it has been established by Hope, Pennock and others, that these sounds are 
disiingiiishable by the following circnmsianc'e, viz., that the sounds generated in the mitral 
valve are loudest at the point of the heart, whilst those of the aoria are best heard over the 
region of its valves, i.e. over the sternum opposite the third rib. T. S.l 

^ See Page 835. 



844: DISEASE OF THE LINING MEMBRANE OF THE HEART. 

cartilage liad dipped down so much into llie substance of the heart, that it pressed 
upon the origin of the pulmonary artery, and there produced a great obstruction. 
In that case there was a bellows-sound, heard at the moment of the pulse. I heard 
it on the ri^ht side of the heart's region, in the situation of the right ventricle; and 
it was written down in the hospital-book — "Difficulty to the transmission of the 
blood from the right ventricle to the pulmonary artery." What the cause was, I 
did not know.* I have met with but two cases of obstruction of the pulmonary 
artery. Disease of its valves is exceedingly rare. In fact, all diseases are far less 
common on the right side of the heart than on the left. In the second case the 
diagnosis was equally correct. There was a loud bellows-sound on the right side 
of the heart, at the moment of the pulse; and after death just such a disease was 
found as I have now described; — that is to say, the pulmonary artery was so dimi- 
nished, that the blood could not escape from the ventricle. 

There is an engraving in my work,** of a case which I did not see; and therefore 
I do not know what the particular symptoms were; but there was a loud bellows- 
sound. Part of the interior of the right auricle and ventricle was grown together 
round the mouth of the pulmonary artery; leaving a very small opening, beyond 
which was the real mouth of the artery, of its natural size, with its valves. The 
case occurred at St. Bartholomew's Hospital; and the heart was shown me when 
lecturing at the College of Physicians. The patient was a young woman, and 
died from this affection. I should think it was a case of malformation; because I 
did not perceive any sign of disease of the heart. She was dropsical all her life; 
and, at last, there were signs of great obstruction. The older she grew, the more 
the heart increased in size; but the opening never enlarged. There were more and 
more ill effects the longer she lived. These are very rare cases indeed. If any 
thing press upon the aorta, or upon the pulmonary artery, we have this bellows- 
sound; — although there may be no disease of the vessel itself, — no disease of the 
valves, — no disease of the opening. I recollect seeing a case, where there was a 
piece of bone between the aorta and the pulmonary artery; and it pressed on both. 
There was a bellows-sound at the time of the pulse, on both sides of the chest. 
A case is mentioned by Bertin, where a sort of hymen existed at the mouth of the 
pulmonary artery; but it was probably congenital; and this is the only instance of 
obstruction, that he ever saw at that spot. I have never seen obstruction from dis- 
ease of the pulmonary semilunar valves. Bertin refers to two; — one in Morgagui, 
and one seen by M. Louis at La Charite. 

Preternatural Sounds from Dilatation. — We may have a preternatural sound, 
however, while the opening remains quite natural. The cavity behind the opening 
is very much dilated; and in that way the opening is relatively small, although not 
absolutely. Nature, of course, has established an exact proportion between the 
size of the openings and that of the cavities: and the natural dimensions are those 
which allow the blood to pass through in the most easy manner, and widi the least 
noise. Thus, the natural proportions may be destroyed in two ways. The cavi- 
ties may remain the same, and the openings become too small; or the openings 
may remain the same, and the cavities become too large. In the latter case, the 
openings are no longer large enough for the cavities; and in either case we have the 
bellows-sound. We must not be surprised, therefore, after a bellows- sound, to 
find the openings in a natural state; because the cavity may be too large. Nay, 
when this is the case, the least alteration in the position of the heart, will sometimes 

a Through an oversight, the specimen was allowed to putref}'; and the v/hole was de- 
stroyed, except (fortunately) the portion of the right ventricle at which the artery rises, the 
semilunar valves, the commencement of the artery, and the cartilaginous mass. Besides 
various symptoms from pulmonary and other cardiac disease, there had been a bellows-sound 
at the lower part of the sternum and lo the right of it at the moment of the pulse. The pro- 
duction of cartilage originated in pericarditis. The pericardium was throughout coherent 
and thickened, and was cartilaginous in several other points than where the great mass 
existed. 

^ " Lectures on Diseases of the Heart;" Plate 2; Figure 2. 



DISEASE OF THE LINING MEMBRANE OF THE HEART. 845 

cause a bellows-sound; and, by position, the free course of tije blood from the left 
ventricle may be destroyed. I once had a very curious case of this kind. 

Case. — A woman laboured under ascites; the cause of which I was anxious to 
discover; and also to ascertain, whether there was organic disease. I examined 
the heart, and found a bellows-sound at the moment of the pulse. She was tapped; 
and no sooner was the operation performed, than the bellows-sound went away. 
The water accumulated again, and with it the bellows-sound returned. In this case, 
after death, the opening was found healthy; but the left ventricle was dilated. It 
appeared to me, in that case, that the diaphragm, being pushed up by the water, 
tilted the heart a little, — prevented it from being quite in its natural situation; and 
caused the apex to rise in such a way, that the passage of the blood into the aorta 
would be a little impeded. If the position of the heart be altered, — if the apex be 
lifted up, no doubt the blood will experience a difficulty in going into the aorta. In 
this case, when the heart was pushed up (with the diaphragm) by the water, there 
was a bellows-sound; and when the diaphragm was let down, — the heart going 
with it,— the bellows-sound ceased. 

In any case where a bellows-sound is heard at the moment of the pulse, we may 
find pressure from the abdominal viscera. When a person is upright, and the bel- 
lows-sound takes place at the moment of the stroke of the heart, if we make him 
lie flat, the bellows-sound is increased; — owing to the abdominal viscera pressing 
up, and the apex becoming a litUe tilted. I have frequently not heard the bellows- 
sound at all, when a person labouring under disease of the heart has been standing 
up; but on making him lie down, I have heard it distinctly. It is better, therefore, 
in these cases, to listen to the sound in both ways. When a bellows-sound is heard 
in the case of the aorta, I presume the circumstance arises from the same cause. 
When a person lies down, the abdominal viscera press against the diaphragm, and 
alter the position of the heart; so that the blood cannot so easily escape from the 
aorta. We know that when there is difficulty of breathing, patients wish to sit up; 
and then the heart falls more into a vertical position. In hypertrophy of the heart, 
a bellows-sound is frequently heard where there is no great ddatation. If it so 
happen that the substance of the heart is much thickened, — that the "columnae 
carneag" are much thickened near the mouth of the aorta (towards the semilunar 
valves,) — the increase of the flesh of the heart will cause a little obstruction; so that 
we have a bellows-sound. Frequenfly, therefore, in opening bodies where there 
has been a bellows-sound, we find some other cause than disease of the opening. 
We may find something pressing on the outside of the aorta; — we may find the 
substance of the heart increased; — we may find the heart out of its due position;— 
we may find the cavity behind the opening so much dilated, that the latter, although 
nf its natural dimensions, is not capacious enough for the enlarged cavity which 
forces its blood through it. 

Bellows-sounds sometimes Temporary. — It would appear that sometimes the 
bellows-sound is only a temporary phenomenon, dependent upon spasm or irrita- 
tion. Sometimes there would appear to be a spasm in the neighbourhood of the 
opening; for a person will have a bellows-sound one day, and not another. It is 
said that hysterical women sometimes have this bellows-sound; and they have spas- 
modic affections of various parts. 

Bellows- sound affected by Blood-letting. — Frequendy, by taking blood away, 
we diminish the bellows-sound, and even remove it altogether. If we lessen the 
quantity of blood that has to go through the opening, there will be less obstruction 
felt; and therefore, by bleeding to a certain amount, we diminish (or, it may be, 
entirely remove) the bellows-sound. Sometimes, in inflammation of the heart, this 
bellows-sound is heard; and, on subduing the inflammation, it may never return. 
In this case, the parts may be thrown into a spasmodic state; — ^just as, when the 
urethra is inflamed, a spasmodic stricture may take place; — so that no water can 
pass; and, on bleeding the patient, the affection is removed. So, I conceive, it may 
happen with the opening of the heart. Again: the bellows-sound will be heard if 
we, bleed a patient /oo much. We may bleed a patient till we get a sharp pulse; and 



846 DISEASE OF THE LINING MEMBRANE OF THE HEART. 

then we may be led to suppose that inflammation exists, although the person may 
be blanched hke wax. Now, when a patient has been thus reduced, I have been 
told by many that a bellows-sound has been heard. I presume that, in this case, 
the bellows-sound arises from the violent action of the heart. It attempts to drive 
the blood away faster than it can go with ease. We may, however, have a bellows- 
sound simply from great pleilwra. Tliere is such fulness of the heart, that the blood 
cannot escape through the opening; and, on the other hand, we may have such a 
rapid action of the heart, that more is attempted to be forced through it than the 
opening will allow. 

Mode of Using the Stethoscope. — In observing these morbid sounds, we should 
use the stethoscope without the plug. Laennec does not mention the circumstance; 
but if we examine the sounds of the heart with the plug in the stethoscope, and 
then take it out, we shall generally hear the sounds far louder without the plug. I 
am quite sure of this. I have proved it myself, and mentioned the circumstance to 
others; and they have always said they found it to be the case. It is right to exa- 
mine a patient labouring under disease of the heart, with the plug in as well as out; 
because, when the plug is in the stethoscope, we have a larger surface for the heart 
to strike against. Laennec employed the stethoscope in its entire state, to examine 
the heart; and the presence of the plug is certainly advantageous in ascertaining 
ike impulse. But for observing the sounds of the heart, the instrument is much 
better without the plug. The excavation renders the sounds far more audible. It 
is often very useful to make the patient suspend his breath for a few moments, 
while we are listening to the sounds of the heart. The murmur of respiration is 
often mistaken for a cardiac bellows-sound; and in dyspncEa, the sounds of the lungs 
sometimes completely overpower those of the heart. 



SECTION IV.— GENERAL SYiMPTOMS OF OBSTRUCTED 
CIRCULATION. 

Dilatation of the ^S.uricles. — There are, of course, other symptoms induced, 
besides those which are to be learned by the ear. If there be any difficulty in the 
transmission of blood through the heart, the cavity behind is very much disposed 
to dilate. The blood not going out with ease, accumulates; and gradually causes 
a dilatation. This is a very common circumstance; but it is a curious fact, that 
we do not always have the dilatation in the cavity immediately behind the obstruc- 
tion. The auricles, being much thinner than the ventricles, more easily become 
dilated. The effect of an accumulation of blood, is frequently felt at a great distance 
from the seat of the obstruction. When the mouth of the aorta is obstructed, some- 
times the left veniricle is dilated; but more frequently it is the auricle; and even 
the mouth of the auricle. In disease of the mitral valve, of course we cannot ex- 
pect dilatation of the left ventricle^ because it is beyond the obstruction; but we 
may expect dilatation of the left awric/e,— and dilatation of the right auricle, or 
even of the right ventricle; because all these parts are behind the obstruction, 
wherever that obstruction may be. 

Pulmonary Congestion. — When there is an obstruction at the left side of the 
heart, either at the mouth of the aorta or at the auriculo-ventricular opening, the 
obstruction is shown particularly in the lungs. Dr. Wilson, of St. George's Hos- 
pital, has mentioned that he has frequendy seen what is called " apoplexy of the 
lungs,"* after an obstruction of the mitral valve. We continually meet with an 
obstruction of the mitral valve, without any such circumstance; though certainly it 
will very frequently happen; but in almost every case, there is great congestion of 
blood in the lungs; and this soon shows itself in the whole of the venous system. 
The obstruction is soon felt beyond the lungs, on the right side of the heart. 

Congestion of the Venous System. — Of course any obstruction on the left side, 

« See Page 763. 



DISEASE OF THE LINING MEMBRANE OF THE HEART. S47 

can only act on the system at large. If the hlood do not escape easily from the 
pulmonary veins, it accumulates in the lungs, and therefore vvili not pass freely out 
of the pulmonary artery; then the right ventri-le suffers, and all the venous sys- 
tem. The consequence of all this, is ^reat fulness of the veins of the neck, fre- 
quently of the head, and sometimes of all the veins of the body; — and then general 
dropsy; — not only a swelling of the ankles, and oedema of that part; but general 
csdema, which is called " anasarca," — universal dropsy.* And then, from the 
great accumulation of blood in the head, there is headache and drowsiness, and 
perhaps apoplexy; — effusion into the brain and upon the brain. The patient's 
countenance is blue; his lips are pale; and perhaps the nose and eyes look ex- 
ceedingly livid. In many cases of this description, effusion is first of all seen 
about the eyes, particularly the lower eye-lid. Indeed so striking is it, that many 
persons have considered it an invariable sign of disease of the heart. At any rate, 
when there is an obstruction to the course of the blood in the chest, we find a 
puffiness of the lower eye-lid. 

Palpitation, 4'C. — Besides these, there are symptoms in the heart itself. There 
is palpitation, a great sense of fainting, and great difficulty of breathing, — particu- 
larly on motion. In this and all other diseases of the heart, the lungs are very 
much disposed to fall into a state of chronic bronchitis; so that the patient not only 
coughs but expectorates; and perhaps expectorates blood; and the difficulty of 
breathing becomes extreme. The quantity of urine is diminished; and then, fre- 
quently, a great accumulation of blood takes place in the liver, as well as in other 
parts; and at length there is effusion, not only into the pleura on each side, but 
into the peritonaeum; so that perhaps, at last, we have not only (edema, but general 
dropsy. 

Preternatural Sounds Syncrhonous with the Pulse. — There are two or three 
other points which it is desirable to notice, before leaving diseases of the linino" 
membrane of the heart; and the peculiar and preternatural sounds, to which a nar^ 
rowing of the different orifices gives rise. These preternatural sounds are heard 
far more frequently on the left side, than on the right; because (as I have repeat- 
edly observed) all diseases of the heart are so much more common in that situation. 
In an infinitely greater number of instances, a preternatural sound is heard at the 
moment of the stroke of the heart, than either before or after it. At St. Thomas's 
Hospital, for months together, there has not been a single instance of a preternatu- 
ral sound of the heart, except at the moment of the stroke of that organ; — so much 
less frequent is it to hear a preternatural sound at the time the auricles allow their 
blood to go into the ventricles. All cases of a bellows-sound, in which there was 
no real narrowing of the openings to be found after death, occurred at the time of 
the stroke of the heart; and where it has arisen from a temporary cause, and has 
gone off again, it has been at the same period; so that the impediment appears to 
have been at the mouth of the aorta. In the particular case which I mentioned,^ 
where a woman had a bellows-sound as long as the abdomen was distended with 
liquid, and no longer, — for it ceased when she was tapped, and returned again 
when the water re-accumulated, — it was heard at the moment of the pulse. By 
far the most frequent seat of it, is the aperture leading from the left ventricle to the 
aorta. 

Usual Seat of the Sound. — I need hardly say that, in general, the bellows- 
sound, when it arises from an obstruction of the mouth of the ventricle, is heard in 
the lower part of the cardiac region, in the situation of the ventricle; whereas, when 
it prot-eeds from a diminution of the opening of one of the auricles, it is heard at 
the upper part; — the auricle being situated above, and the ventricle below. We 
may sometimes hear the bellows-sound, not only in the situation where the ob- 
struction exists, but to a great extent around. I have frequently heard it in the 
right axilla, when the heart was not at all enlarged; but frequently it is only per- 
ceptible at the place where the obstruction exists; and when heard in various parts, 

« See Page 147. " See Page 845. 



848 DISEASE OP THE LINING MEMBRANE OF THE HEART. 

it is always loudest in the immediate seat of its cause. Generally, therefore, it is 
loudest in the case of the ventricles^ at the loiver part of the cardiac region; and in 
the case of the auricles, or auriculo- ventricular openings, at the upper part. When 
it is on the left side, we hear it loudest in the left half; and when on the right side 
(where it is rare), v/e hear it loudest at the right part of the cardiac region. 

[Within a few years much light has been thrown upon the subject of valvular 
murmurs, and the mode of their production.* It is now well established that mur- 
murs seated in the semilunar valves are best heard immediately over those valves, 
that is, over the sternum and a little to the right of it, in the neighbourhood of the 
cartilage of the third rib. Murmurs seated in the auricular valves, on the other 
hand, are best heard near the apex of the heart, being most readily conducted to the 
surface, says Dr. Hope, through a solid medium, that of the columnse carneas. 

T. S.] 

Double Belloivs- Sound. — Sometimes we hear a double bellows-sound;- — one 
sound at the stroke of the heart, and then another immediately after it; — like some- 
thing falling against some other object, and then falling back again directly. I 
believe that, in these cases, there is a degree of obstruction to the passage of the 
blood, which produces i\\Q first bellows-sound; and then, as the valves do not per- 
form their duty perfectly, but permit a portion to reflux, we have the second 
bellows-sound. It is by no means a rare thing to hear this double sound; though 
it is not nearly so common as a single sound. When the mitral valve is grown up, 
so that we have merely a circular opening in the middle, of course there is great 
obstruction: and as the valve does not do its duty well, some of the blood always 
comes back, and a double bellows-sound is produced. So, in the case of the aortic 
valves, the opening is sometimes much diminished; and we have a bellows-sound 
when the blood rushes out; and, the semilunar valves being corrugated, a portion 
returns; and thus you have a see-sawing sound, — backwards and forwards. 

Sounds Influenced by the Heart'' s Action.— -1 mentioned'' that, in the case of 
the bellows-sound which occurs at the stroke of the heart, it is heard loudest when 
the patient lies down; and sometimes we can hear it only when the patient is in a 
horizontal position; but when he is standing up, it is always diminished. Varia- 
tions takes place in this respect, however, according to the force of the heart. 
Sometimes the pulse is very irregular; so that first we have a strong thump, then 
a slight one, and then several strong ones. Now in these cases, if there be a 
diminution at the mouth of the aorta, when the heart acts moderately, it gives short 
strokes; so that the blood is not sent violently through the opening, and therefore 
it finds its way pretty well; but when it acts violently, such a torrent of blood is 
driven against the opening, that a great obstruction is felt; and then we have a loud 
bellows-sound. Thus, when there is a bellows-sound, and the heart acts irregu- 
larly, we sometimes hear it loud, and sometimes very inconsiderable; according to 
the quantity of blood driven against the opening, and the degree of obstruction ex- 
perienced. If the parts be not very rigid, when the stroke of the heart impels the 
blood, it may force its way, and the obstruction will not be much felt; but if the 
parts will not give way, the greater the impulse, the more is the obstruction felt. 

Purring Thrill. — Sometimes we perceive another circumstance when these 
bellows-sounds are present; and that is a vibration, like the purring of a cat. It is 
just the same gentle vibration, as that which is felt on placing our hand on a cat's 
back, when she is purring. This has been called " the purring thrill." I do not 
recollect noticing it in the case of the heart, except where there was a bellows- 
sound; and it appears to arise from an obstruction. It is nothing more than a jar 
given to the heart, by the blood attempting to pass through the obstructed opening. 
It is by no means generally observed; but, every now and then, we may feel a 
vibration in the region of the heart, at the moment the bellows-sound is heard. 

Variations in the Pulse. — With regard to the heart's action, it varies both as to 

» See Hope on Diseases of the Heart and Great Vessels, with Notes by C. W. Pennock, 
M. D. Philadelphia, 1842. 
" See Page 845. 



DISEASE or THE LINING MEMBRANE OF THE HEART. 849 

force and frequency. It has been thought that this indicated the want of a free 
opening; but intermissions and irregularity of pulse (both as to force and frequency), 
will take place when there is no obstruction; and I do not know the particular state 
of the heart that gives rise to these variations. We may continually observe this 
occurrence, in old people, who never had disease of the heart. It is more fre- 
quendy observed when there is an obstruction of the mitral valve; but it is by no 
means a necessary consequence of it. 

When the auriculo-ventricular opening is narrowed, the pulse is generally irre- 
gular, both in force and frequency; — a peculiar combination well known to prac- 
titioners, in which several beats succeed each other in rapid succession and wiUi 
tolerable force; while others again occur slowly, and with little force; — perhaps so 
weakly, that they can scarcely or not at all be perceived, although at the heart 
the pulsation is evident enough.* This most irregular pulse is thought by Mr. 
Adams'* to be pathognomonic of narrowing of the left auriculo-ventricular opening. 
Corvisart thought extreme irregularity of pulse in both force and frequency to 
characterize narrowing of the aortic opening. I do not happen to recollect a pulse 
irregular in force and frequency, in a single case of narrowing of the aortic open- 
ing solely, while I know that it is very common in the narrowing of the left auri- 
culo-ventricular opening; though possibly not peculiar to it, nor indeed to narrowing 
of any opening.'' Mr. Hodgson also mentions, that in narrowing of the left auri- 
culo-ventricular opening, there is often a double pulsation of the heart; that is, tiuo 
beats of the heart to one of the wrist; — a pulsation of the heart from the action of 
the ventricle, and another from the action of the auricle. This able surgeon 
attempts to explain the fact; but expresses himself in rather an obscure manner. 
*' The auricle," he says, "first acts, and propels its contents into the ventricle; 
but (from the contraction of the communication) the blood is not, as in the natural 
state, poured at once into that cavity. The ventricle, though imperfectly filled, 
contracts, and forces the blood into the aorta. Thus there is a pulse caused by the 
action of the auricle, and another by that of the ventricle; so that, for every pulsa- 
tion at the wrist, two are perceptible at the heart." But the truth is that, even in 
healthy there is perceptible to the ear a double action of the heart; — one of the 
auricles, and another of the ventricles; though this was not generally noticed at the 
time Mr. Hodgson wrote. When the left am-iculo-veniricular opening is narrowed, 
— so that the blood can be only sqiurted into the ventricle, — this auricular action is 
sometimes very distinct to the hand, in the condition of a thrill or purring; which 
is what Mr. Hodgson had remarked, and called " an irregular thrill, or bruissement^ 
as Corvisart terms it, rather than a distinct pulsation." Sometimes it is a distinct 
shock; and, in another sentence, Mr. Hodgson speaks of it as such: — " Thus there 
is a pulse caused by the action of the auricles, and another by that of the ventri- 
cles;" "nor is the auricular pulse trifling."'^ This happens only, I believe, when 
the walls of an auricle are increased in substance, — hypertrophied; so that they act 
with a force approaching to that of the ventricles, and a double stroke of the heart 
may be felt by the hand. That this, and not the imperfect repletion of the left 
ventricle (by which it acts twice), is the reason of the double stroke, appears to me 
shown by the fact that, when it has been observed, the auricle or auricles have 
always been hypertrophied, and in some cases the auriculo-ventricular opening not 
at all narrowed; and, secondly, that it is not observed, however narrow the auriculo- 

* In cases of any disease, if the pulse is too rapid to be counted at the wrist, it may al- 
most always be counted at the heart. I have easily counted two hundred pulsations a\ the 
heart, when it was impossible to count the pulse at the wrist. Ossification of the radial 
arteries causes the pulse to be feeble, while perhaps the action of the heart is natural, or 
even very strong; and in cases of this condition of the vessels, and in many others, the 
action of the heart should always be examined at the chest. 

•> " Dublin Hospital Reports;" Volume 4; Page 424. 

* Laennec considers irregularity in frequency to arise generally from dilatation: and this 
is a common consequence of narrowing of an opening. — See Dr. F'orbcs's Translation. 
Part 2; Book l; Chapter 1; Paragraphs {Third Edition; Page bid.) 

•1 " A Treatise on the Diseases of Arteries and Veins." Dr. Parry, in his work upon the 
pulse, adopts, without reference, Mr. Hodgson's explanation. 
VOL. I. — 54 



850 DISEASE OY THE LINING MEMBRANE OF THE HEART. 

ventricular opening, if the auricle is not hypertroplued. This hypertrophy is rare; 
as the obstruction usually produces dilatation and tfiinning'.f 

Corvisart remarks that obstruction at eiiher aperture on the left side, causes more 
irregularity than obstruction on the right. Even the thrill is frequently absent 
when the narrowing is considerable, and I am ignorant upon what exact conditions 
it depends; — whether upon the degree of the narrowing, or the shape of the dis- 
eased opening, or some other cause. 

A third peculiarity has been remarked in the narrowing of the left auriculo-ven- 
tricular opening; namely, smallness of the pulse; and a good example of this is 
given by M. Abernethy,'' and another by Mr. Adams.*' The small quantity of 
blood poured into the left ventricle, at each auricular contraction, is insufficient to 
enable this cavity to project a due portion into the arteries; — whence the smallness 
of the pulse. But the same smallness of pulse results from a narrowing of the 
aortic opening; and nothing but the observation whether the preternatural sound 
which may exist occurs at the auricular or ventricular action, can determine whether 
the narrowing is at the auriculo-ventricular, or at the ventriculo-aortic opening. It 
may also result from a general diminution of the cavity of the left ventricle, accom- 
panied by no narrowness of opening; for this, equally with a diminution of aper- 
ture, must obviously occasion a small projection of blood into the arteries. The 
importance of this symptom alone, therefore, is absolutely nothing. It does not 
necessarily indicate narrowing of the openings in the left side of the heart. If, 
indeed, the preternatural sound is heard at the ventricular contraction, this small- 
ness of pulse may assist in leading to the idea, that the narrowing is on the left 
side of the heart; but the greater loudness of the sound on -the left sjde, will suffi- 
ciently declare it. The inferiority of this symptom in the pulse to the observation 
of the preternatural sound, is shown by the preternatural sound occurring long 
before the pulse grows small. I have often noticed no smallness of pulse up to 
the time of death, in cases where an auricular or ventricular preternatural sound, 
loudest on the left half of the cardiac region, showed the left auriculo-ventricular 
or ventriculo-aortic opening to be diminished; and, after death, this state of parts 
was discovered. 

When the narrowness is at the mouth of the aorta, the action of the left ventri- 
cle, — notwithstanding that the pulse is small,- — is sometimes very strong; owing 
to its walls being hypertrophied. 

, Necessity of observing all the Symptoms. — There are no symptoms, except those 
learned by the ear, to indicate particularly what is tlie seat of the obstruction; or, 
indeed, vi^hether there is any obstruction at all; but we shall be much deceived, un- 
less every thing be taken into consideration. If we hear a bellows-sound, it is not 
right to infer that there is structural disease of the heart. In order to justify our 
coming to that conclusion, the sound ought to be heard constantly , — not to-day 
only, but to-morrow and every day; and even then we ought not to be satisfied, 
unless we find other symptoms; — such as enlargement of the heart, dulness of 
sound to a great extent, anasarca, great distension of the veins, and so on. The 
whole circumstances of the case must be taken into consideration. Useful and 
important as it is to attend to the sounds addressed to the ear, it is absurd to depend 

« See the "Dublin Hospital Reports;" Volume 4; Page 416. 

'» " Medico-Chirurgical Transaclions;" Volume 1; Page 27. 

^ Mr. Adams (" Dublin Hospital Reports," Volume 4, Page 435) refers the double pulse 
to hypertrophy and dilatation of the right ventricle, which acts strongly; while the lett has 
too little blood to discharge into the arteries, to give a pulse regularly. But, as the left 
ventricle acts and empties itself every lime the right ventricle does so, there is no reason 
why it should not accumulate blood enough to occasion a perceptible pulse. Dispropor- 
tionate pulsation of the heart and of the arteries is, of course, owing to a strong pulsation 
of the right ventricle, and often also of the left, — both or either of which are often hyper- 
trophied, — and the small quantity of blood discharged from the left. A regularly double 
pulsation at the heart appears very explicable, in the mode mentioned in the text. When 
the pulse varies in force at different moments, I have always observed the strokes of the 
heart to vary proportionally. 



DISEASE or THE SUBSTANCE OF THE HEART. 851 

upon any one of these, to the neglect of all the general symptoms, which medical 
men notice in the ordinary way. 

Effects upon the Lungs. — It has been thought that when there is an obstruction 
on the right side of the heart, the jugular veins are more distended, and the ob- 
struction in the venous system more evidendy shown, than when it comes on the 
left. This is no doubt a fact, up to a certain point; but it is to be remembered, 
that an obstruction on the left side of the heart must produce the same effects, 
after a time. There will at last be great congestion in the lungs; ami, in conse- 
quence of that, there must be an obstruction to the blood passing on the right 
side of the heart; then there must be a distension of all the veins, and dropsy. 
We cannot depend upon these symptoms alone. When the veins of the neck 
are distended, that circumstance, considered in itself, will not justify us in saying 
that the obstruction is seated on the right side of the heart. It may arise from an 
obstruction there; but there may be a real organic obstruction on the left side. 
There is, however, this difference: — when the obstruction occurs on the right sK\e^ 
there is far less difficulty of breathing than when it takes place on the left. The 
blood is not at all impeded in its progress through the lungs; the obstruction exists 
before it goes there; but when the obstruction is on the left side, it causes great 
dyspnoea, on account of its producing congestion of the lungs. But greater reli- 
ance cannot be placed on this point; for this reason:— in structural disease of the 
heart, the lungs are much disposed to become diseased too. From their contiguity 
to the morbidly affected heart, they are much disposed to fall into chronic bron- 
chitis; and when that occurs, we have all the signs of difficulty of breathing, and 
of congestion of the blood. Still it stands to reason, that if there happen to be no 
chronic bronchitis, — no affection of the lungs, there will not be dyspnoea when 
there is an obstruction only on the right side of the heart; whereas, if the obstruc- 
tion be on the left side, we must expect it. 



CHAPTER IIT. 
DISEASE OF THE SUBSTANCE OF THE HEART. 

I WILL now proceed to the consideration of diseases of the substance of the 
heart; and I think this arrangement will make the matter plain. First we consi- 
dered the membrane investing the heart; then the membrane lining the heart; and 
now we will consider diseases of the muscular substance of the heart. 

SECTION I.— CARDITIS. 

The substance of the heart is now and then, but very rarely, the subject of acule 
inflammation. I do not myself recollect having seen an instance of it; but a most 
decided case is recorded by Mr. Stanley, in the seventh volume of the "Medico- 
Chirurgical Transactions."* The symptoms of this disease, would be very similar 
to those of pericarditis. In the case mentioned by Mr. Stanley, tliere was jiericar- 
ditis likewise present.'' I hardly think it can exist without that affection being 
conjoined with it. Extreme faintness has been observed. There is sometimes 
extreme faintness \\\ pericarditis; but it is not common. In the case of inflamma- 
tion of the substance of the heart, however, extreme faintness has been noticed; — 
fits of syncope, indeed. After death, in these cases, the substance of the heart has 

« Page 323. 

'* "Medico-Chirurgical Transactiousj" Volume 7; Page 32G. 



852 DISEASE OF THE SUBSTANCE OF THE HEART. 

been found soft, and black wiih congestion. The aocnmulation is so great, that 
the substance of the heart is black. In Mr. Stanley's case, tlie disease had pro- 
ceeded even to suppuration; so that there were little collections of pus, with which, 
the heart was studded. 



SECTION II.— HYPERTROPHY AND DILATATION. 

With the anatomical marks of previous pericarditis, or inflammatory change of 
the lining membrane of the heart, or after pain in the cardiac region and ))alpitation, 
perhaps occuring during or subsequently to rheumatism, we frequently observe the 
heart thickened or dilated, or both." 

The Result of Inflammation. — I am convinced, — with Bouillaud, Bertin, Andral, 
and others, — that the increase of the heart's substance, no less than the diseases 
of the valves, is generally inflammatory, i have witnessed, after acute rheuma- 
tism, a constant and severe pain in the region of the heart, palpitation, and at length 
death; and found the left ventricle thickened, without any other morbid appearance 
in the organ; and here, no less tlian when the ordinary anatomical results of inflam- 
jnation were visible, it was impossible not to consider the change inflammatory. 
On comparing an hyperlrophied left ventricle with a healthy specimen, M. Cheva- 
lier (a pupil of Yauquelin's) found, under the microscope, that its fibres were red- 
der; and, a portion of each being steeped in a separate quantity of distilled water, 
the hyperlrophied portion reddened the water more than the other, and when taken 
out was still the redder of the two. On being put into boiling ah^ohol, it proved to 
contain less fatty matter.'' Indeed an hypertrophied heart, if undilated, is always 
in the affected portions redder and firmer than usual; and its coronary arteries are 
enlarged, sometimes enormously. Besides, as hypertrophy is a common accom- 
paniment of chronic inflammation of the outer or inner membrane of the heart, no 
doubt can exist upon the subject. Indeed its essence, being excessive nutritive 
action, cannot but be in some measure inflammatory. It is unquestionably pro- 
duced, in some cases, by obstruction in the opening leading from the cavity whose 
walls are thickened; — tlie difficulty giving rise to evident great muscular effects, 
and consequently to augmented circulation, of the organ. But even here it may be 
to some degree inflammatory; because the lining membrane of the cavity has gene- 
rally been in an inflamed state; which, in truth, was the cause of the valvular 
obstruction. 

Varieties of Hypertrophy. — Hypertrophy of the left ventricle is often found with 
disease of the lining membrane of the aorta; sometimes coexistent with true or false 
aneurism of the aorta; but not unfrequenUy the sole diseased appearance. Hyj)er- 
trophy is frequenfly attended with dilatation; and more so, perhaps, when there 
exists an obstruction to the egress of the blood from the diseased compartment. 
Dilatation often occurs alone, especially in the auricles, from this cause. But, like 
liypertrophy, it is sometimes the only morbid circumstance discernible; and there- 
fore not so easily to be explained. The dilated portion, we shall find, is occasion- 
allv thin and soft; and the reason of the dilatation is then evident. 

Hypertrophy is considered by Bertin, according as the compartment of the heart 
is simply thickened, without any change in the dimensions of the cavity: as it 
retains its natural thickness, but is dilated; in which case there must be an liyper- 
trophy or preternatural quantity of substance, or it would have become thinner: and, 
thirdly, as it is not merely thickened, but its cavity diminished. He designates 

' It is in generril said that the heart is naturally about the size of the fist of the individual; 
that the walls of the left ventricle are twice as thick as those of the right, and in infancy and 
old age four times as thick; but that ihe "coluranas carnoe" of the lefi are less voluminous 
than those of the right, though the surface of ihe left presents a more delicate and intricate 
reticulation: that when the two ventricles are cut into, the left should remain open, but the 
right fall together: and that the capacity of the two ventricles is equal. 

'' Bertin. 



DISEASE or THE SUBSTANCE OF THE HEART. 853 

these three forms "sz?n^o/e hypertrophy," "eccm/?'ic hypertrophy," and ''concentric 
hypertrophy." 

The second variety, ''eccentric hypertrophy," — or increase of substance and 
dilatation united, — was described by Senac, Morgagni, and Lancisi; and was deno- 
minated, by Corvisart, "active aneurism of the heart." It is the most common of 
the three; and the excessive deposition must have taken place in the direction of 
the surface. The first variety, "simple hypertrophy," in whicli the dimensions of 
the cavity are unchanged, and the deposition takes place also in the direction of the 
surface; and the third, the "concentric, "in which the cavity is diminished, and the 
deposition must have occurred in a vertical direction,— at a right angle with the 
surface, were first described in 1811, by Bertin.* In the "concentric," the cavity 
is sometimes so small that it will scarcely contain the shell of an almond. 

Every heart with thick parietes and a small cavity, however, is not perhaps an 
example of "concentric hypertrophy." A violent contraction at death might pro- 
bably produce these effects. But, in such a case, the bulk of the organ would be 
proportionately lessened. To be justified, therefore, in declaring the existence of 
"concentric hypertrophy," not only the parietes should be thick and the cavity 
small, but the bulk natural. 

In the "simple" and "concentric" hypertrophy of the left ventricle, the thick- 
ness is sometimes double, or even triple, what is natural; the walls of the left vent- 
ricle, in the healthy state, are about half an inch thick. In the first and second 
varieties ("simple" and "eccentric"), the thickening of the left ventricle is gene- 
rally greatest at the base, and lessens towards the apex. In the "concentric," there 
is usually as much thickening at the apex as at the base. The septum of the vent- 
ricles, and even the "columnae carneae," participate in the increase of substance. 
The thickening is sometimes unequal in different parts; — both in the case of the 
left ventricle, and of any other part that may be hypertrophied. The right vent- 
ricle, when not participating in the disease, is comparatively so small, and reaches 
so short a way down, that it looks like a mere appendage, or as if included in the 
walls of the heart. 

Most Common in the Left Ventricle. — The left ventricle is the most usual seat 
of hypertrophy. When the disease occurs i!i the right, the thickening is seldom 
(if ever) so great, and is generally more uniform; but the "columnae carneae," it is 
said, are generally more enlarged in proportion. Sometimes both ventricles are 
hypertrophied; sometimes one is hypertrophied, in one or other of three varieties 
of the affection (" simple," "eccentric," and "concentric"), while its fellow is only 
dilated. 

Rare in the Aurides. — Hypertrophy rarely affects the auricles; and still more 
rarely unless other disease exists in the heart. It is generally united with dilatation 
of the auricle. Laennec," and many others, never witnessed an instance of pure 
hypertrophy of an auricle." 

If the walls of all the cavities of the heart, or even both ventricles only, are 
affected with hypertrophy and dilatation, the heart may acquire an enormous size. 
In these circumstances, its form usually becomes rounded, — its ap;?x being effaced; 
and it lies almost transversely in the chest. The thickening is in the walls of a 
cavity; sometimes partial only; and even thickening and dilatation may exist sepa- 
rately, in different parts of the walls of the same cavity. The "columnae carneae" 
are in some instances more thickened, in others less, as compared with the walls. 

* See " Traite des Maladies du CcEur, et des Gros Vaisseaux; par R. Berlin. Redigfe par 
J, Bouilland." (" Treatise on the Diseases of the Heart, and Great Vessels: by R. J. Benin. 
Edited by J. Bouillaud.") Book 2; Section 2; Chapter 1; Article 2; Subdivision 1. (Page 432 
of the Paris Edition of 1R24.) 

•» See his Treatise on Diseases of the Chest; translated by Dr. Forbes. Part 2; Book 2; 
Chapter 6; Paragraph 2. (Third Edition; Page GI4,) 

<= We have observed hypertrophy of the auricles under the triple form described as 
affecting the ventricles [" simple," "eccentric," and "concentric']; but hypertrophy witK 
dilatation ["eccentric" hvpertrophy] is incomparably more frequent tlian the other two. — 
Berlin' s'' Treatise on Diseases af the Hearty Bnoli^ Section 2] Chapter \; Article \\ Sub- 
division 3. {Pages 335 anddoG of the Paris Edition of 182-1.) 



854 DISEASE OF THE SUBSTANCE OP THE HEART. 

Varieties of Dilatation. — ^In dilatation of the heart, as we have seen,* the natu- 
ral thickness of the dilated parietes may be retained, or tlieir thickness may be aug- 
mented: but there is a third variety of dilatation — the thickness may be diminished; 
and this was denominated "passive aneurism." The first of these varieties — that 
in which the dilated parietes retain their natural thickness — appears to me, I con- 
fess, as true an hypertrophy as the second, — in which the tliickness is increased; 
because dilatation would inevitably occasion attenuation, were not an addition of 
substance made. Two or even three of these varieties may exist in the parietes of 
the same cavity. 

Causes of Dilatation. — Laennec regards original disproportion of the cavities, 
as the most powerful cause of dilatation.'' But, certainly, a very common cause is 
obstruction to the progress of the blood from the cavity; and the source of this ob- 
struction may be situated in another cavity; — in one farther forwards, relatively to 
the blood's course. It is frequently the auricle, and not the ventricle, that is dilated, 
when there is an impediment at the opening of the aortic or pulmonary artery; 
and wlien the difficulty is at the aortic opening, it is sometimes not the left auricle, 
but the right, which becomes dilated. The obstacle may arise from a diminution 
of an opening, or from diminution of another cavity; as of the left ventricle. A 
permanent patency of the auriculo-ventricular opening, by which too much blood 
attempts to rush into the auricle, will create marked dilatation of it. 

The auricles, from their thinness, are more subject to dilatation than the ventri- 
cles; and the right than the left, — from the frequency of obstruction in the lungs: 
but both ventricles are often dilated simultaneously. Dilatation would appear some- 
times to be of only temporary duration; and tlie right auiicle often becomes dilated 
in the dying state, especially when this state is lingering, from the impediment to 
the blood's passage through the lungs. 

While, in pure hypertrophy, the substance of the affected portion is usually 
very firm and red, it is usually soft and pale in dilatation with thinness: and 
when hypertrophy and dilatation exist together, the substance is generally firm or 
soft, accordingly as the hypertrophy or the dilatation is the greater. In dilatation 
of the ventricles, the septum suffers least; and, contrarily to what happens in hy- 
pertrophy, the expansion takes place chiefly in the direction of the breadth; — so that 
when both ventricles are dilated, the heart becomes usually almost round. 

Dilatation occurs oftener in women than in men; — probably, as is supposed, from 
the female heart being naturally thinner. Hypertrophy and dilatation frequently co- 
exist in thet walls of diffisrent cavities of the same heart. 

Signs of Hypertrophy and Dilatation. — Let us now inquire into the signs of 
hypertrophy and dilatation. When the heart is iiypertrophied, an unusually strong 
impulse is given in the situation of the part affected, and the sound usually heard 
there is diminished, — becomes a sort of murmur; and in severe cases it is not 
heard at all. The contraction takes place more slowly than in the healthy state; 
and, in the hypertrophy of the ventricles, little or no interval of repose occurs after 
the auricular action. When the heart is dilated, the reverse happens; — there is far 
less than the usual impulse in the situation of the part affected; and the sound usu- 
ally heard there is augmented, and is not merely louder, but clearer than natural. 
In dilatation of the ventricles, their action takes place more rapidly than in the 
healthy state; and, as in hypertrophy, little or no interval of repose occurs. 

In hypertrophy of the left ventricle, — its most common seat, a strong impulse is 
felt between the cartilages of the fifth and sixth left ribs; and the action of the auri- 
cles is very short. In hypertrophy of the right ventricle, this strong impulse is felt 
at the lower part of the sternum. 

If the difference is considerable, it is easily discovered by the greater force with 
which the stethoscope is repelled in the affected side, when applied to the carti- 
lages and the sternum in succession. Where the difference is less, it may perhaps 

a See Page 852. 

^ See Dr. Forbes's Translation of Lnennec's Treatise. Part 2; Book 2; Chapter 3; Sec- 
tion 1; Paragraph 3. (Third Edition; Page G04.) 



DISEASE OF THE SUBSTANCE OF THE HEART. 855 

be more easily ascertained, by examining botii sides at once; — placing tlie hand 
longitudinally over the cardiac region; when the stronger impulse against the 
fingers lying over the left or the right half of the region, will presently be noticed. 
In health, the impulse in both halves is equal. Should hypertrophy affect both 
ventricles at once, the excess of impulse in both halves will determine its existence 
in both; and the equality or difference of the morbid impulse, will demonstrate its 
equality or difference in the two ventricles. 

Hypertrophy of the auricles must be very considerable to afTord an impulse; 
which, when present, will be felt in the right or left superior half of the cardiac 
region, — according to the situation of the hypertrophy. The situation of the loud 
and clear sound of dilatation, equally agrees with the seat of the dilatation. 

The accuracy with which the seat and nature of these diseases can be deter- 
mined, is wonderful. If due attention be given, and the symptoms carefully inves- 
tigated, a physician may pronounce with certainty, frequently even at the first visit, 
that a particular ventricle or both are hypertrophied or dilatej, or the two in oppo- 
site states; — no less than that an opening in a particular cavity is deranged; and an 
examination after death will verify his assertions. Laennec considers these results 
of auscultation, when well marked, infallible; and so I believe them to be. A good 
auscultator, after making a full investigation, will never object to write down his 
opinion, and deliver it to another, for the purpose of being read at the autopsy. 

When hypertrophy and dilatation coexist in the walls of a cavity, the two sets 
of auscultatory signs are blended; and those of hypertrophy or of dilatation pre- 
dominate, accordingly as either state predominates. In general, the hypertrophy 
exceeds the dilatation; for, not only do we continually see an increase of thickness 
with dilatation, but, however extensive the dilatation, if the natural thickness be 
undiminished, — nay, even if it be diminished, but not in proportion to the dilata- 
tion, — hypertrophy must still exist. In these compound cases, therefore, the sign 
of hypertrophy,— the preternatural impulse, — is generally the more prominent 
phenomenon; and I own myself to have repeatedly pronounced a case to be one of 
hypertrophy, when the cavity was likewise to a certain degree dilated; — the dilata- 
tion, however, being much inferior to the hypertrophy; and the injury to the system 
arising, not from the dilatation, but from the hypertrophy. This combination is 
every day seen in the left ventricle, the great disease of which is hypertrophy; but, 
with its hypertrophy, there is generally more or less dilatation. 

When the left ventricle is severely affected in this twofold manner, its violent 
pulsations are felt, not merely in the left lower half of the cardiac region, but also 
under the sternum, and even to the right of this bone: for the growth of the dis- 
eased ventricle pushes the right outwards and backwards, and occupies its place as 
well as the left side. But there is violent impulse, equally, in the left half of the 
cardiac region; — proving the hypertrophy of the left ventricle; and there is a dull 
sound on striking the sternum; — from the presence there of the enlarged left vent- 
ricle. 

The cardiac region of the front of the chest corresponds with the lower third or 
the sternum: and thus the cartilages of the fourth, fifth, sixth, and seventh ribs, 
have a right and a left half. The right or sternal half, sounds clear on percussion 
in the healthy state, and often even under dilatation of the right cavities: but en- 
largement of the heart from hypertrophy and dilatation, or the deposition of solid 
or fluid upon or around the organ, makes it sound dull or dead. The left or costal 
half of the cardiac region naturally sounds rather dull in most persons; and even 
dead in fat, anasarcous, and muscular persons; except at the highest (the auricular) 
part, where some hollowness of sound is almost always heard, unless in enormous 
dilatation of the auricles; — such as exists only with constriction, Laennec says, of 
the left auriculo-ventricular opening. 

Dead Sound on Percussion. — A considerable dilatation of the heart necessarily 
causes a dead sound to be heard more extensively than usual, on striking the car- 
diac region with the ends of the fingers; and M. Piorry assures us, that if a hard 
elastic substance is interposed at the time between the chest and the fingers, such a 



856 DISEASE OF THE SUBSTANCE OF THE HEART. 

distinctness of sonnil is producer!, that the size of the portions of the heart imme- 
diately under the sternum and ribs may be ascertained, with the greatest nicety.* 
The auscultatory sitrns are the only means of accurately ascertaining the existence 
and seat of these affections. 

Palpitation. — It is in some of these instances of combination of the two affec- 
tions in the left ventricle, that we frequently see those dreadful cases of violent pal- 
pitation, and of throbbings of the arteries: and for no other reason, I presume, than 
that hypertrophy is here carried to the highest pitch; for when, notwithstanding 
extensive dilatation, the walls are thickened, the quantity of additional substance 
must be enormous. Towards the close of even this variety of hypertrophy, the 
impulse is often much reduced, and the heart sometimes grows soft; — so that the 
pulse is weak, and the morbid action of the heart is recognized only in the cardiac 
region. The occurrence of pneumonia may also obscure the stethoscopic signs 
while it lasts. 

The pulse, the respiration, the state of the veins, the secretion of the cellular 
and serous membranes, the countenance, the state of mind, may all suffer; but the 
changes induced are too varied for any reliance; and may owe their origin to many 
other circumstances. 

State of the Pulse. — In hypertrophy, especially with dilatation, the pulse is 
frequently full; — causing headache, and even apoplexy, if the vessels of the brain 
are weak or diseased: but when the opening of ihe mitral or aortic valves is nar- 
rowed, the pulse may be very small; while the left ventricle is hypertrophied, and 
beats violendy. In mere hypertrophy, the pulse is small, if the variety is the 
" concentric;" — where the addition of thickness is attended by diminution of cavi- 
ty. Irregularity of pulse is natural to some persons; so that regularity occurs 
only in disease. In others irregularity depends upon disease of the head, stomach, 
intestines, or lungs. Frequent faintness may be a purely nervous or sympathetic 
affection. Violence of arterial pulse may be purely functional; and, although the 
action of the heart be also violent, particularly on lying down, we generally deter- 
mine with ease that the violence is independent of hypertrophy: but only by 
noticing that the violence is general, — is of both ventricles and both auricles; 
whereas in hypertrophy, it is nearly always confined to, or is much greater in, one 
cavity of the heart than another; the rhythm is altered; and often some sound pre- 
ternatural in quality or morbidly intense, is constantly heard in some one cavity; — 
indicating organic disease. 

Jinasarea, <^c. — It might be suggested that, in many cases, the presence of ana- 
sarca, lividity, and tumefaction of the countenance, would assist us in discrimi- 
nating organic disease. But palpitation may be violent, and these symptoms 
present, without organic affection of the heart: — a chronic bronchitis, or an original 
dropsy of the pleura may exist, and produce these symptoms; and here nothing 
but auscultation can determine whether the heart is sound, and the anasarca referable 
merely to the lungs or pleura. In all three cases, the anasarca usually commences 
in the feet. 

Remission of the Symptoms. — ^Again: the symptoms produced by a diseased 
heait will sometimes so remit, — either from a decline of the ordinary irritation of 
the heart, or the cessation of some temporary irritation of another organ, — as to 
create a doubt in the mind of any but an auscultator, that organic disease of the 
heart had really existed. Even the dropsy, frequently attendant upon organic dis- 
ease of the heart, subsides and returns, without evident reason; or accordingly as 
the patient is quiet in body and mind, and careful with respect to diet and vicissi- 
tudes of temperature, or the reverse. 

Duration. — Frequently, too, auscultation will disclose cardiac disease, and the 
symptoms may not increase for many years; — so that the auscultator may be ridi- 
culed, and no organic affection be admitted; when, from unfavourable circumstances 

* "C'est h une ligne pr§s que cette mensuration est precise." (" The size may be deter- 
mined almost to a line.")— "Journal Hebdomadaire," No. 30, Page 137. See also his work 
on the same subject, published in 1828. 



DISEASE OF THE SUBSTANCE OF THE HEART. 857 

or the progress of life, the disease may suddenly begin to augment, and dissection 
disclose some organic affection. Many persons die of organic cardiac disease after 
forty; though, for many years of their lives, they had merely a little dyspncea, with 
occasional palpitation, and swelling of the feet; and were told that they were free 
from all disease of the heart. Indeed, Laennec was convinced, that congenital 
disproportion of the cavities of the organ, was one of the great predisposing causes 
of its dilatation.* In slight cases of the " blue disease," where a small direct 
communication existed between the right and left sides of the heart, I have seen 
the symptoms — after being stationary during the whole of infancy, adolescence, 
and the earlier part of manhood — at once augment; — from the sudden enlargement, 
I presume, of the preternatural opening; either through the enlargement of one of 
the cavities between which it formed a communication, or the occurrence of nar- 
rowness of one of the natural openings of the heart farther on. 

The general symptoms, however, may each be highly useful, when viewed by 
the side of the symptoms discovered by auscultation: they may confirm the diag- 
nosis; or, rather, they may unite with the last mentioned symptoms, in forming a 
satisfactory theory of the nature of the case. They should never be neglected; 
for all the phenomena of every disease deserve the attention of a good practitioner. 

Treatment of Hypertrophy. — I have no doubt that hypertrophy of the heart 
may sometimes be cured. The heart (as I mentioned before^) is evidently in an 
inflammatory state. The organ, for the most part, toward the close of the dis- 
ease, is not only firmer and harder than it should be, but likewise redder; and fre- 
quently there is pain in the region of the heart, and even pericarditis also. Now, 
if we make a person live on low diet, cup repeatedly over the heart, keep him 
perfectly still, and relieve the bowels when it appears requisite, — so that there shall 
be no congestion anywhere; and if we exhibit colchicum, perhaps digitalis, and 
sometimes mercury, if he can bear it; — the symptoms of hypertrophy will gradu- 
ally decline. I have certainly known several cases, — where I had every reason to 
believe that the hypertrophy was very great, — in which abstinence from meat, 
spirits, and things of that description, — abstinence from mental excitement, — absti- 
nence from every occupation of mind which could cause anxiety, — abstinence from 
exercise, and every circumstance that could quicken the pulse, — was followed by 
a decline of the symptoms; and the patient became comparatively well. This 
however, requires a long time; and after the patient appears quite well, he must 
persevere in the general plan, though it need not be very assiduously carried on. 

Advantage of Local Bleeding, — Local bleeding, for the most part, answers 
better than general bleeding. It is not very safe, in chronic diseases of the heart, 
to bleed at the arm; for, now and then, patients will fall into a state of syncope; 
and it is a dangerous thing, in diseases of the heart, to bleed to syncope. We have 
all heard of cases, where a patient with diseased heart has lost more blood than 
was intended; so that faintness was produced by the abstraction even of a couple 
of ounces, and the individual has died. A remarkable instance of this kind hap- 
pened within the last few years. A distinguished personage,' labouring under 
disease of the heart, was bled at the arm. The bandage slipped; and although (it 
is said) only a few ounces escaped, yet he fainted and died. It is more safe, there- 
fore, to take blood from the region of the heart itself, by means of cupping or 
repeated leeches, than to bleed at tlie arm; for it is dangerous to induce syncope. 
If we do bleed generally, — as we often may, with perfect safety, when the patient 
is strong and hearty, — it should not be to the extent of syncope; because patients 
with diseased heart will sometimes die suddenly. Indeed, it is not an uncommon 
occurrence; and they die, more frequently than not, through syncope. 

Treatment of Dilatation. — Active measures are not required in such a case as 
this. AVe have merely to bleed locally (in order to take off the congestion), to 
keep an open state of the bowels, and to enjoin rest. Very frequently, however^ 

a See Laennec's <' Treatise on Diseases of the Chest;" translated by Dr. Forbes. Part ^ 
Book 2; Chapter 3; Section 1; Paragraph 2. (Third Edition; Page (304.) 
'' See Pages 851 and 852. 
' Sir Thomas Lawrence. 



858 DISEASE OF THE SUBSTANCE OF THE HEART. 

tonics are required. If the pulse is soft and feeble it would be dangerous to take 
away blood; — the only object of venesection being to remove congestion. Leeches, 
applied to the anus, frequently answer a good purpose in such cases; but, for the 
most part, a strong evacuation is not at all required. When, however, there is 
dilatation, there is (much more frequently than not) hypertrophy, and a disposition 
to dropsy. From tlie dilatation, the blood is not sent out so freelyas it ought to 
be; and, consequently, there is an accumulation, and a tendency to morbid secre- 
tion in the cellular membrane; and in the serous cavities. Great congestion takes 
place in the liver, and likewise in the head; and there is also a tendency to general 
effusion. Such being the case, it is very desirable to give diuretics; and a combi- 
nation of three or four, as I formerly mentioned,'' is best. Squills, digitalis, and 
acetate of potash, answer very well. In fact, I do not know any thing so good. 
They answer far better than hydragogue purgatives. Patients are very much 
relieved by measures of that description; but if they be weak, we shall find it ser- 
viceable to give iron; and I believe the best preparation is the Ferri Potassio-Tar- 
tras; because, in conjunction with other means, it has a tendency to increase the 
flow of urine, and the discharge from the bowels. I have seen patients with every 
symptom of dilatation of the heart, lose the greater part of these symptoms, and 
be able to go about, after taking the potassio-tartrale of iron. As I formerly men- 
tioned, it may be given in lartre doses. In fact, instead of a few grains, we may 
give a drachm, or even two drachms, twice or thrice a day; but still we cannot 
give it in such large quantities as the sesquioxide;** because it is apt to purge and 
to pinch. Many persons cannot take more than a drachm. When it is mixed with 
treacle, it opens the bowels, causes an increased flow of urine, and strengthens the 
patient. If it should purge too much, it is a good plan to mix with it an equal 
part of the sesquioxide. 

Superiority of Iron.— -In such cases, I should give this tonic in preference to all 
others; because I know, from experience, that it answers so much better than they 
do. Many cases of hypertrophy with dilatation occur, where the patients are in a 
state of anaemia, — in a leucophlegmalic condition; and if we take blood away, it is 
watery, and we make the patient worse. When patients are in a state of anaemia 
induced by blood-letting, or in that peculiar state in which the blood is not properly 
manufactured, the pulse will become sharp; and so, in disease of the heart, we 
sometimes have a sharp pulse, with great debility of the patient. Whenever I 
have seen this condition united with disease of the heart, I have abstained from 
evacuations, and given preparations of iron; and have found the patients improve. 
But if there is a tendency to effusion, — as shown in the ankles, or if we hear 
mucous or other rattles in the bronchia, diuretics are of essential service. If there 
be general paleness and debility, then iron is one of the best things that can be 
given; and if the debility be very great, while we give diuretics, we should exhibit 
the potassio-tartrate of iron; which is both a diuretic and a tonic. With such 
treatment as this, it is wonderful how much good may be done. We may certainly 
cure some cases; and even where the affection is very severe, — so that a cure is 
out of the question, — we may still do a certain portion of good; — we may make 
the patient feel better than before, and may prolong life. It is our business to pro- 
tract life, whether it be desirable for the patient or not. It is our business to act 
upon a general rule, and endeavour to prolong life; without considering, for a 
moment, whether the individual woulil be better out of the world than in it. If 
we treat all these cases antiphlogistically, we may do harm. When there is a state 
of anaemia, the adoption of such measures would be madness. The administration 
of iron, and even good nourishment, is then the proper treatment. 



SECTION III.— ANEURISM OF THE HEART. 

Partial Dilatation. — Dilatation of the heart is sometimes partial. Dr. Berlin 
» See Pages 17S and 745. '^ See Page 656. 



DISEASE OF THE SUBSTANCE OF THE HEART. 859 

says, that he has frequently found a cavity dilated in one point: while in every 
other it preserved its natural state, or was even narrowed or hypertrophied.'' " The 
right ventricle, for example," he adds, " is often considerably dilated near the pul- 
monary artery; while the rest of the chamber preserves its ordinary dimensions." 
I have not yet met with this; but now have before me an example of partial aneu- 
rism of the heart;— of aneurism such as occurs in arteries, and therefore necessarily 
partial. 

Cases on Record. — Upon the superior and lateral part of the heart of a young 
negro who had died in a state of asphyxia, Corvisart found a tumour nearly as 
large as the heart itself. Its interior contained several dense layers of coagula, 
perfectly similar to those which fill the cavities of arterial aneurism; and commu- 
nicated with the cavity of the ventricle by a narrow opening, the mar<7in of which 
was smooth and polished. The German anatomist, Walter the elder, had pre- 
viously described a case of this kind. Drs. Baillie,*' Zannini, James Johnson, 
Cruveilhier, Rostan, Breschet, each mention one; Dr. Berard mentioned two; and 
Talma's heart proved to be in this state. "^ Two aneurisms are mentioned by Dr. 
Reynand, as occurring in the same heart. "^ There are two specimens in the museum 
of St. Thomas's Hospital: in one the aneurism is nearly as large as ihe heart; and 
in the other the aneurism is pyramidal, and projects into the left auricle. One lately 
occurred at St. George's Hospital; and, like one of those at St. Thomas's, pro- 
jected into the left auricle. "^ Two are mentioned by Mr. Adams; one of which 
was, like the other at St. Thomas's, nearly as large as the heart.^ 

Situation at luhich it occurs. — In all these cases, the aneurism existed in the 
left ventricle: in some, at the apex; in others, almost equally numerous, at the 
base; — as in the case before me, in which there are two aneurisms; in others, 
between the base and apex; — in Corvisart's at the side, in others at the front. 
Aneurism is a disease of arteries, never of veins; and it is remarkable, that the 
disease was never detected but in the left (the arterial) side of the heart; and, in- 
deed, never but in the ventricle, with which the general arterial system is directly 
continuous. This circumstance accords both with the general observation of the 
greater frequency of all diseases on the left than the right side of the organ, and 
in the ventricle than the auricle; and with the other fact, that this individual disease 
(aneurism) is arterial; or rather, I would say, is a disease of parts containing decar- 
bonized blood; for the pulmonary artery, containing black blood, has not (I believe) 
yet been seen the seat of aneurism. 

Most frequent in Men. — As far as appears known, all the instances, but one, 
have occurred in adult males; and arterial aneurism occurs eight times more fre- 
quently in males than in females. 

Symptoms not known. — This cardiac affection is the first of those in which 
auscultation renders no assistance. All the cardiac diseases in which it is useful, 
have been considered. The general symptoms which occur may well, therefore, 
be supposed, by those who know the value of auscultation, to leave the nature of 
the disease in doubt. Dr. Baillie says the symptoms " are similar to those which 
belong to aneurism of the arch of the aorta." And what does Dr. Baillie enume- 
rate as the symptoms of aneurism of the arch of the aorta? First, difficulty of 
breathing. But that may arise from many other causes in the heart, lungs, or other 
parts; and has been absent in this disease. Secondly, more or less of pain in the 
aneurisraal tumour, or some other part of the chest. But here is no tumour; and 
pain in some other part of the chest would certainly never lead us to a knowledge 
of the disease, but rather to a misconception of its seat and nature. The pulse, 
he says, is sometimes irregular; but immediately subjoins, that " ofien no irregu- 

* See his Treatise on Diseases of the Heart; Book 2; Section 2) Chapter 2; Article 2j 
Note to Subdivision 5. (Page 387 of the Paris Edition of 1824.) 
b "Morbid Anatomy;" Chapter 2; Section 4. 

«= " Roperioire Generale d'Anaiomie et de Physiologic;" Tome 2; Parties 1 et 2. 
^"Journal Hebdooiadaire;" Fevrier 28, 1829. 
e Dr. James Johnson's " Medico-Chirurgical Review;" July, 1829. 
^ " Dublin Ho.spiial Reports;" Volume 4. 



S60 DISEASE OF THE SUBSTANCE OP THE HEART. 

larity can be felt in it." The chief symptoms he pronounces to be •* a strong 
pulsation in the oliest, commonly visible to the eye, when the chest is exposed to 
view." But ajrain immediately subjoins, tliat he has felt tlie same kind of pulsation 
in other cases: for example, in adhesion of the pericardium, slight pericarditis with 
slight hydro-pericardium, and in ordinary morbid enlargement of the heart. Indeed, 
no strong pulsation, except palpitation of the heart, and in most cases not even that, 
lias occurred in this affection. The most decided cliaracteristic of the disease, 
however, — belonging only to aneurism, — he regards as a strong pulsating external 
tumour, when the aneurism has attained a large size. But aneurism of the heart 
rarely attains a large size; and I do not know that it ever produced an external 
tumour. And after all, a diagnosis would be required between aneurism of the 
heart and of the arch of the aorta. It therefore appears to me, — and I say it with 
all the respect due to an amiable and industrious man, — that Dr. Baillie would have 
done better in saying, that there were no particular symptoms of the disease; espe- 
cially as he never met with more than one example of it.^ 

In Talma, who died of strangely neglected stricture of the rectum, no symptoms 
had led to a suspicion of cardiac disease.* In a patient of Dr. Johnson's — General 
Kidd, death took place suddenly from rupture of the aneurism, without any pre- 
vious symptom of its existence. The same happened in Dr. Reynaud's case. In 
a patient of Cruveilhier's, severe asthmatic paroxyms took place; with a sense of 
constriction, particularly about the heart, and a peculiar sensation in the arm-pits. 
These symptoms, together with hardness, fulness, and occasional intermittence of 
the pulse, and suffusion of the face, led to the suspicion of organic disease in the 
heart. But, at that time, auscultation was not cultivated. The hardness and ful- 
ness of the pulse arose from hypertrophy of the left ventricle. 

Case. — A man, aged thirty-two, was admitted into St. Thomas's Hospital on 
the second of March, 1826; — on account of palpitation of the heart, especially on 
moving or lying down; inability to lie in any other position than on his back; sud- 
den starting up during sleep; constant dyspnoea, and cough, with a litde mucous 
expectoration. The pulse was regular, — not much quicker than natural; but ex- 
ceedingly weak. He had discharged large quantities of tape-worm, by means of 
oil of turpentine; and had suffered severely, during the preceding winter, from 
rheumatism; of which he still complained. These symptoms gave no information 
as to the nature of his disease; they led to a suspicion only of some affection of 
the heart. I was not at that time well practised in auscultation; but found the vent- 
ricular impulse of the heart very strong all over the right half of the cardiac region; 
and therefore concluded, that the disease existed in the right ventricle. In two 
months, under rest and moderate antiphlogistic treatment, he became much better, 
experienced less palpitation and dyspnoea; could lie on both sides; and was 
stronger. The ventricular action was no longer strong on the right side; but was 
now both loud and strong in the lower part of the left. I could thus form no opinion 
as to the seat or nature of the disease. The dyspncea, after this time, gradually 
increased for a fortnight; and he then died. 

On opening the body, two aneurisms were found at the upper part of the left 
ventricle; but on the right ventricle was a tumour or large tubercle, the size of a 
pigeon's egg^ with several smaller ones. The force originally observed in the right 
half of the cardiac region was now explicable, although the aneurisms sprang from 
the left ventricle. The aneurisms, when I first saw him, were probably not large 
enough to occasion symptoms so considerable as the tumour on the right ventricle; 
but, as they increased, decided symptoms necessarily arose in the left half of the 
cardiac region; — -much exceeding those produced in the right by the tumour. 

Aneurism of the Auricle. — I have met with a case of aneurism of an auricle; — 
a part which has never, I believe, been recorded to have laboured under this dis- 
ease. There was hypertrophy and dilatation of the left ventricle, with extreme 
ossification and cohesion of the mitral valve; — the auriculo-ventricular opening 

■ " Morbid Anatomy;" Chapter 2; Section 4. ^ See Page 859. 



DISEASE OF THE SUBSTANCE OF THE HEART. 861 

being proportionally redured. The sinus of the left auricle formed an aneurism of 
large size, with very dense and thick layers of fibrin for its walls; and these had 
reduced its cavity to a very small capacity. The action of the ventricles had been 
strong, loud, and extended; and a dull sound, more extensive than natural, had 
been given on percussion of the cardiac region. The hypertrophy and dilatation 
of these parts, were pronounced during life. The pulse had been feeble, and the 
breathing very difficult; and the legs had swelled. The feebleness of the pulse, 
notwithstanding the strong action of the left ventricle, arose from the small quantity 
of blood discharged into the left ventricle to be propelled into the aorta; but had not 
been ascribed to this cause, as there was no belloius-soiind or thrill; — neither the 
aneurism, nor the constriction of the left auriculo-ventricular opening, had been sus- 
pected. The absence of bellows-sound arose from the opening, though constricted, 
being still perfecUy commensurate with the reduced capacity of the auricle; to which 
it retained its natural proportion; and thus aff'orded a sufficient outlet to the small 
quantity of blood to he discharged. The fact is as interesting, as the situation of the 
aneurism is extraordinary. 

The case proves, for the first time, that cardiac aneurism is not peculiar to the left 
ventricle, nor even to the ventricles: and I may remark, that my case of ventricular 
aneurism is an additional argument to those already on record and adduced by Dr. 
Reynaud, of the error of Breschet in supposing aneurisms to be generally situated 
towards the apex or the ventricle. In this case, the two aneurisms were lined by 
a smooth membrane, continuous with that of the ventricles; and tlius aff'orded also 
an additional proof that, in these cases, the internal membrane is not necessarily 
injured; — as Breschet must also imagine, when he calls these '•'•false consecutive 
aneurisms;" though it must be allowed that he did not consider the ten cases with 
which he was acquainted, sufficient to afford a perfect history of the disease. 



SECTION IV.— CORONIC CHANGES THE RESULT OF 
INFLAMMATION. 

Induration. — Hypertrophy of the heart, I have stated,^ appears to be of an in- 
flammatory nature. With it is generally united some degree of induration. Some- 
times induration exists, alone, or in great proportion to the hypertrophy. I believe 
it is attended by palpitation, a full and rather hard pulse, and frequently by pain in 
the heart. We must suppose it inflammatory. 

Softening. — On the other hand, the substance of the heart is sometimes soften- 
ed; and the pulse and action of the heart are then feeble and frequent, dropsy takes 
place, and a disposition to fainting; and the heart is generally found also dilated, 
and of a deeper or paler colour than usual. This state also may be the result of 
inflammali(Mi; as softening of other organs, beyond all question, frequently is. Yet 
softening of the heart and all other parts, and even gangrene, probably may occur 
without inflammation; and sometimes when it occurs with inflammation, the in- 
flammation may not be its cause, but only one of the circumstances of a peculiar 
condition. 

Very acute inflammation of every part generally, I believe, induces a softened 
state: and, although a softened state may also result from a chronic inflammation, 
the latter generally causes induration. This is seen with regard to the various 
muscles of the body, as well as to the various internal organs. 

GreaUy as modern pathology has been improved by the knowledge that many 
diseases, formerly not regarded as inflammatory, are so essentially, or to a certain 
extent; and greaUy as medical practice has been improved, by the administration 
of antiphlogistic measures in such cases, I am satisfied that we are now ratlier too 
prone to believe afTections nothing more than inflammations, and to treat them only 
as such; — that many so regarded are not at all inflammatory; or have inflammation, 

a See Pages 851, 852, 856, and 857. 



862 DISEASE or the substance op the heart. 

not as a fundvimental state, but merely as one circumstance among the morbid 
actions; or really have inflammation as a consequence; and that the hope of curing 
them by antiplilogistio measures alone is vain; — whatever relief may be effected by 
lessenino; the inflammation which accompanies them.'' 

The deep-coloured and the pale softening of the heart, distinguished by Laennec,** 
occur, according to Berlin, the former as an acute, the latter as a chronic, affection. 
The chronic is often an attendant upon general cachexy; tlie acute, on pericarditis. 

Abscess and Ulceration. — Abscess and circumscribed ulceration are sometimes 
found. The latter may commence in the lining membrane, or in the pericardium. 
Whether it be the result of an abscess of the heart, or originate in one of these 
membranes, it may proceed to perforation; or to such attenuation that rupture 
ensues,- — perhaps on some efl"ort. 

Grangrene. — I have not read of gangrene of the heart: but it has been seen soft 
and black, without any gangrenous smell, from excessive inflammatory congestion 
of blood; and Cruveilhier gives a view of a heart beset with black patches of con- 
gested blood, similar to those observed in what is absurdly called " apoplexy of 
the lungs. '"= 



SECTION v.— RUPTURE OF THE HEART. 

Harvey is said, by Morgagni, to have first noticed rupture of the heart. Abundant 
cases of rupture of the heart, independently of ulceration, are on record; and are 
compared to rupture of the arteries, arising from violent muscular effort; though 
generally there is also a want of firmness in the organ. 

Usually in the Left Ventricle. — They may occur in every part, but usually 
happen in the left ventricle; where the most forcible muscular contraction takes 
place; and a spot too thin, or soft, or ulcerated, is most likely to occur, and is most 
exposed to violence; if the heart is made to act forcibly, by mental or muscular 
causes. It is the apex or its vicinity, — naturally the thinnest part of the ventri- 
cle, that usually gives way in general softness or thinness of the organ. Death is 
usually instantaneous; but sometimes does not happen for several hours; — differ- 
ences also observed when the heart is wounded. 

Case. — An instance of rupture of the heart was witnessed by me, in company 
with my friends Dr. Roe and Mr. Alcock. The rupture was a zigzag fissure in 
the fronltof the left ventricle; not at once discerned on bringing the heart into view, 
but which had filled the pericardium with blood. The patient, — Mr. Hayes, a 
highly respectable general practitioner, in Charlotte Street, Fitzroy Square, — cor- 
pulent and about sixty years of age, had suflfered three attacks of pain. about the 
praecordia with dyspepsia and vomiting, during six days; but had gone out as usual 
in the intervals. On the morning of his decease, a fourth attack of pain, referred 
by him to the heart, took place before he rose in the morning; and he gave his 
assistant directions for preparing him a fomentation. Presently his bell rang vio- 
lently, and was instantly answered; but he was found dead. The heart was very 
soft; the fat external to the abdomen excessive; and considerable adhesions existed 
among the abdominal viscera. 

Eupture of the Right Ventricle. — While numerous instances of rupture of the 
left ventricle are on record, we have very few of the rupture of the right. Yet 
George the Second perished suddenly of this accident, in 1760: and so, in 1730, 
did the Princess of Brunswick; whose case, no less than the celebrated one of 
George the Second, is referred to by Morgagni.^ 

* This I stated in my work on Hydrocyanic Acid; Page 105. Andral has many excel- 
lent remarks to the same purpose, in his work on Morbid Anatomy. [Translated by Drs. 
Townsend and West.] 

b See his Treatise on Diseases of the Heart, translated by Dr. Forbes. Part ?; Book 2j 
Chapter 9; Paragraph 1. (Third Edition; Page 620.) 

«= See Page 764. 

d "De Sedibns et Causis Morborum;" Liber II. Epistola Anatomico-Medica, xxvii. 7. 



DISEASE OF THE SUBSTANCE OF THE HEART. S63 

Ixiipture of the Valves. — The valves alone someiimps suddenly give way; and 
I believe that imniediale extreme dyspnoea and rapidity of pnlse, are the usual 
effects of an extensive injury of tliis kind. They split either from intensity of 
disease, from mere fragility, or from some violent effort; — exactly the circum- 
stances in which frequently the inner, or inner and middle coats of asi artery crack, 
and give rise to aneurism. An engraving of a split aortic valve, is given in Dr. 
Baillie's work. I saw an instance in which the same valves were beset with 
grains of earth, and obstructed the course of the blond; when suddenly, without 
obvious cause, all the symptoms were aggravated, and the patient died in a few 
days; two of the aortic valves were found rent. I have already referred to these 
two cases.* In the "Medical Gazette" for June 20, 1829,'' an instance of rupture 
of the tricuspid valve is described. The heart was variously diseased, but not par- 
ticularly the tricuspid valve: and, under an exertion, a snap had been felt in the 

" Histoire de rAcademie des Sciences;" 1732. In the same volume, is recorded an instance 
of rupture of the left ventricle. 

Smollett, in his " History of England" (Volume 5, Page 418), makes two egregious 
blunders, in his account of the king's death. He says: — " Un the twenty-iifth day of Octo- 
ber, 1760, George, King of Great Britain, vnthout any 'previous disorder^ was early in the 
morning seized with the agony of death, at the palace of Kensington. 

" He had risen at his usual hour, drank his chocolate, and inquired about the wind — as 
anxious for the arrival of the foreign mails: then he opened a window of his apartment; 
and, perceiving the weather was serene, declared he would walk in the garden. In a few 
minutes after this declaration, while he remained alone in his chamber, he fell down upon 
the floor: the noise of his fall brought into the room his attendants, who lifted him on the 
bed; when he desired, m a faint voice, that the Princess Amelia might be called; but before 
she could reach the apartment, he had expired. An attempt was made to bleed him, but 
without effect; and, indeed, his malady was far beyond the reach of art; for when the cavity 
of the thorax was opened, and inspected by the serjeant-surgeons, they found the right vent- 
ricle of the heart actually ruptured, and a great quantity of blood discharged into the peri- 
cardium; so that he must have died instantaneously, in consequence of this effusion. The 
case, hovvever, was so extraordinary, that we question whether there is such another instance 
upon record. A rupture of this nature appears the more remarkable, as it happened to a 
prince of healthy constitution, unaddicted to excess, and far advanced beyond the period of 
life when the blood might be supposed to flow with a dangerous impetuosity." 

Now we have seen, that a member of the very same family, — the Princess of Brunswick, 
died not only of a rupture of the heart, but of a rupture of the very same ventricle of the 
heart, in 1730; and Dr. Smollett's reflecdons upon the improbability of rupture from the 
moderate impulse of the blood in the king are groundless; since ruptures of the heart and 
aorta rarely occur under the most violent impulse, unless there be disease of substance; and 
when the latter exists, they may occur under the most feeble impulse of the blood. Rup- 
ture of the blood-vessels of the head is most common in the aged; as their coats are most 
frequently diseased in the decline of life. 

So far IS it from being correct that his Majesty had experienced no particular disorder, 
that Dr. Nicholls, the king's physician, — in his account of the dissection, in the " Philoso- 
phical Transactions" for 17G2,— informs us, that "His Majesty had for many years com- 
plained of frequent distresses and sinkings about the region of the heart; and his pulse was 
of late years observed to fall very much upon bleeding." 

As if errors were destined on this point. Dr. Forbes (in his translation of Laennec, Part 
2; Book 2; Chapter 14) states, that "George the Second of England is often s?Pid to have 
fallen a victim to the same accident as Philip the Fifth of Spain (rupture of the heart); but 
his death was occasioned by rupture of the aorta." — The words of Dr. Nicholls, however, 
are the following: — "The pericardium was found distended with a quantity of coagulated 
blood, nearly sufficient to fill a pint-cup; and, upon removing this blood, a round oritice ap- 
peared in the middle of the upper side of the right ventricle of the heart, large enough to 
admit the extremity of the little finger. The ventricles were found absolutely devoid of 
blood, either in a fluid or coagulated state." 

Aneurism of the aorta existed, but was not ruptured. The middle and interior coats were 
split, but the external was entire, — as in the first stage of false aneurism; and merely an 
elevation was produced. 

It is at this time amusing to read Junius's letter, calculating on hereditary tendency, and 
hinting, in 1770, to George the Third (who died in 1820), the possibility of a long minority; 
as "every true friend of the House of Brunswick see«;, with affliction, how rapidly some of 
the principal branches of the family had dropped off." (Letter 37.— "To the Printer of the 
Public Advertiser.') 
« See Page 834. ^ No. 81; Volume 4; Page 78. 



S64 DISEASE OF THE SUBSTANCE OF THE HEART. 

heart; immediate rapidity and irregularity of pulse had occurred, with syncope, 
and (I presume) dyspnoea; and ihe patient had died in six days. 

Effects of Ruptured Valves. — If the rupture is not extensive, tlie irritation of 
the laceration, and the imperfect function of the valve, give rise to chronic disease; 
— such as hypertrophy of the substance of the heart, dilatation, and structural 
change of the valves themselves; and death does not occur for some time. Dr. 
Abercrombie* mentions an instance, in vi^hich, after a severe fall on the left side of 
the chest, death took place in five months; and an aortic valve was found torn at 
its base, — so as to give the appearance of a ring; and the left ventricle was hyper- 
trophied and dilated. Morgagni found an aortic valve ruptured.'' 

Sometimes the "chordae tendineae" of the valves are ruptured. A case is re- 
corded by Mr. Adams, in the "Dublin Hospital Reports," Volume 4; Page 404. 
The patient lived about a month. Corvisart mentions three instances of their lacer- 
ation during violent efforts. Laennec found a tendon of the mitral valve ruptured, 
in eccentric hypertrophy of both ventricles." M. Bouillaud found a "columna car- 
nea" of the tricuspid valve torn through. 

Generally complicated ivith Disease of the Heart. — In all these instances of 
rupture of the valves and their attachments, there has generally existed some disease 
of the heart; and most frequently even of the valve itself. But occasionally — ^just 
as in rupture of the substance of the heart, and of the inner and middle coats of the 
aorta — no diseased appearance is discernible; although one must suppose a morbid 
friability, at least, in those cases where no external force, no effort of voluntary 
muscles, and no mental excitement, — some one of which is commonly the cause of 
rupture, — took place. 

I met with an instance of a circular hole in two aortic valves, on either side of 
their septum, from original defective formation. Morgagni once found a hole in 
one of the leaves of the mitral valve.'^ 



SECTION VI.— STRUCTURAL DISEASES OF THE HEART. 

Ossification. — The induration of the heart occasionally amounts to a cartilaginous 
or osseous state. But these changes are almost always originally seated in the lin- 
ing membrane, or in the pericardium, or in the subjacent cellular membrane. A spot 
of the heart or its membranes is sometimes so changed; sometimes nearly a whole 
cavity becomes a bony case. Mr. Burns declares, that he once saw not only com- 
plete ossification of the pericardium, but also the ventricles ossified as firmly as the 
skull, except for about an inch at their apex. The "chordae tendineae" are occa- 
sionally ossified. 

Ossification of the Coronary Arteries. — The coronary arteries are sometimes 
ossified; and, not unfrequently, thekmd of suffering denominated "angina pectoris" 
is the result. But they may be ossified without such a result; and "angina pectoris" 
may exi§t with various structural diseases of the heart, or without any. 

Fatty Degeneration of the Heart. — I once saw the muscular substance of the 
heart completely changed, except at the surface, to fat. A mere layer of red mus- 
cular structure covered the internal and external parts of the heart, and the "columnas 
carneae:" within, every spot was fatty matter. The patient had been subject to fre- 
quent attacks of syncope; palpitation, irregular and small pulse, with dyspnoea, and 
anasarca.^ There were five pulmonary veins. 

* In a paper on the Pathology of the Fleart; published in the "Transactions of the Medico- 
Chirurgical Society of Edinburgh;" Volume 1; Page 49. 

•• Epistle 24; 10. 

c See his Treatise on Diseases of the Heart, translated by Dr. Forbes. Part 2; Book 2; 
Chapter 21; Case 47. (Third Edition; Page 6G8.) 

1 Epistle 23; 6. 

« A case will be found in the " Dublin Hospital Reports;" Volume 2. The symptoms 
were the same as in my patient. A case was previously given by Dr. Duncan, Jun., in the 
" Edinburgh Medical and Surgical Journal," for January, 1816; Volume 12; Page 43. 



DISEASE OF THE SUBSTANCE OF THE HEART. 865 

Atrophy of the Heart. — Sometimes tlie heart wastes, — is atropliied; — becoming 
small and wiinklecl. This is often, tfioiigh not always, observed after chronic dis- 
eases; and especially after phthisis. Pressure, from pericardial effusiuii or any- 
other cause, has the sam« eff'ect. The walls of an atrophied heart, it is said by 
Dr. Bertin,*may be thinner or thicker than usual, or of their usual dimensions; — 
their thinness being occasioned by dilatation, their thickness by narrowing-, of the 
cavities. But it appears to me, that if the walls are thickened, we are not justified 
in pronouncing the smallness of the heart an atrophy; as the externa] smallness of 
dimension may arise from violent contraction at deatli; and, if the walls are dilated, 
that we are not justified in calling the thinness "atrophy;" because the original 
quantity of substance may be in them, and only spread out. If the whole heart 
weighs less than is natural, then only (I think), we ought to say that the organ is 
atrophied; and, even then, the smallness of tlie organ may be an original defect; 
unless indeed it appears wrinkled, like a shrivelled apple, — to use Laennec's com- 
parison. 

Scirrhous and other Deposits. — The heart has been seen cancerous; it has con- 
tained, in its substance and in its cavities, cysts, and true hydatids;'' and, in its sub- 
stance, scrofulous tubercles, scirihus,'' bone, encephaloid deposit, &c. 

I once opened a person who died of repeated haemoptysis. In the substance of 
the lungs were hard patches of the deepest red; and, in the ventricles of the heart, 
innumerable thin globular cysts — containing bloody fluid, and atiached by a 
peduncle — could be squeezed out from among the " columnae carnece."'* 

Cyanosis. — Upon the state of the heart which gives rise to a mixture of venous 
and arterial blood, — the state termed " cyanosis,"® I have little to say. It is usually 
a congenital malformation; upon which the works of Dr. Farre and Mr. Burns 
leave nothing to be desired.^ I have already remarked, that I have seen the ad- 
mixture rather suddenly begin to increase, in adult age. Berlin believes, that the 
admixture has occasionally commenced after birth, from an ulcer in the auricular or 
ventricular septum; — throwing the two corresponding cavities into one.^ In most 
cases, the right auriculo-venlricular or ventriculo-arlerial opening becomes narrowed; 
and the right auricle or ventricle or both are dilated and hypertrophied; and the 
usual ill consequences of that affection are, sooner or later, experienced.'* 

* In his "Treatise on Diseases of the Heart;" Book 2; Section 2; Chapter 3; Paragraphs 1 
to 3. (Pages 389 and 390 of the Paris Edition of 1824.) 

'' In the " Medico-Chirnrgical Transactions," Volume 11, is a case of cysts or hydatids 
in the substance of the heart. Three apparently true animal hydatids, were found in a heart 
by Dr. Andral (" Precis d' Anatomic Pathalogique," Tome 2, Page 332), Dr. Abercrombie, 
in the "Edinburgh Medico-Chirurgical Transactions" (Volume 1, Page 53), mentions 
having found a cyst in the left auricle, apparently containing others collapsed in a darlc 
thick fluid. I may mention that, at Page 58, he gives a curious case of partial cohesion of 
ihe sides of the right ventricle, an inch and a half from ihe bottom;— producing a small 
cavity. 

«= There has been just placed in the museum of St. Thomas's Hospital, by one of the Phy- 
sicians, an adult heart, in which the walls of the left ventricle contain Vjiany deposits of 
scrofulous matter, — surrounded by white and almost cartilaginous induration. 

<* I gave the dissection in the " Annals of Medicine and Surgery," 1816. Laennec there- 
fore erroneously considered himself the first who described what he terms "the globular 
excrescence." See Dr. Forbes's Translation of his " Treatise;" Part 2; Book 2; Chapter 
21. (Third Edition; Page 665.) And, indeed, he refers to numerous authors for what ap- 
pear to have been analogous formations. For the details of this case, see Page 7G5. 

® From nvcLVQt;, blue. 

^ The malformations referred to in Dr. Farre's work, together with my own moibid spe- 
cimens of diseased heart, are all deposited in the museum of St. Thomas's Hospital; and, 
with numerous others, constitute (perhaps) an unrivalled collection of cardiac lesions. 

5 See his " Treatise on Diseases of the Heart;" Book 2; Section 6; Article 1. (Page 433 
of the Paris Edition of 1824.) 

^ See Berlin's "Treatise on Disease of the Heart;" Book 2; Section G; Article 1. (Page 
436 of the Paris Edition of 1824.) He ascribes the circumstance to the excitement of the 
right half of the heart by the admission of a portion of arterial blood into it. 

A high degree of obstruction in the right auricular or ventricular opening, or in the 
lungs, will, without any malformation, produce a blueness, approaching to blackness, in the 
countenance, long before death. 
VOL. I. — 55 



866 DISEASE OF THE SUBSTANCE OF THE HEART. 

Preternatural Situation of the Heart. — Preternatural situation of the heart oc- 
casionally occurs; sometimes congenitally; but oftener in consequence of the morbid 
presence of solid, fluid, or aeriform substances in tfie left cavity of the thorax, — 
pushing the heart to the right; — a circumstance which is by no means uncommon. 
Dr. Abercrombie mentions a case in which the right lung had become solid; and 
the left, dilated extensively to perform the function of both, had pushed the heart 
to the right.'' Increased bulk of the heart itself, or pressure from other parts, — 
either above (as from aortic aneurism), or from abdominal enlargement below, — 
will likewise occasion other changes in the situation or the direction of the heart. 
These may be recognised by the touch. 

Fibrinous Coagula. — Although the greater part of the fibrinous coagula observed 
in the heart and large vessels are produced after death, some are unquestionably 
produced during life; for they are occasionally organic, and adhere by vessels to 
the substance of the heart; and symptoms evidently arising from obstruction to the 
course of the blood, appear during life; — exactly as we find to be the case from the 
existence of organized coagula in arteries and veins at a distance from the heart. 
Sudden paralysis of an extremity, attended by loss of pulse in it, and sometimes at 
length even mortification, has frequendy occurred from the production of coagula 
in arteries.'' 



SECTION VII.— NEURALGIA OF THE HEART. 

Like various parts of the body, the heart is subject to neuralgia. I had a case 
of this kind, wliere the pain was intense; not only affecting the region of the heart, 
but liarlingat the shoulders and back; sometimes dull and aching, at others stabbing; 
not increased by motion or posture; and unaccompanied by any stethoscopic signs. 
It occurred in a middle-aged woman, at St. Thomas's Hospital; and the symptoms 
were removed by iron, but afterwards (I believe) returned. 

A second case has occurred to me in the person of a lady, who appears to have 
laboured under the disease very many years. Besides a constant aching in the 
lower part of the cardiac region near th.e sternum, there are frequent stabbing pains, 
— plunging (to use the expression of most persons afflicted with neuralgia); so that 
she is compelled to rise and walk the room almost every night. These occur 
during motion and rest; but most severely during motion. They shoot in all 
directions, and occur occasionally in distant nerves. As soon as they are over, she 
is apparenUy well; and, when they are not very troublesome, sings, dances, or 
takes horse-exercise. In the first case, the ear discovered nothing morbid in the 
heart: in this, a slight ventricular bellows-sound is heard. Andral mentions a 
dreadful case of this kind, which proved fatal; without leaving any trace of disease 
in the heart, or its dependencies.'' 



SECTION Vni.— ANGINA PECTORIS. 

Symptoms. — I5y " angina'^ pectoris" is meant a sudden violent pain, in some 
part' of the chest near the heart, and especially at the sternum; — a pain which 
causes the patient to stand still if he be walking, and induces a sensation as if he 
were about to expire. The pain, at first, is fell only at one spot, — in the situation 
I have mentioned; but at length it extends to the shoulder, darts through to the 
spine, goes down the arm, and occurs at the end of the fingers. In general the 

« "Edinburj^h Medico-Chirurgical Transactions;" Volume 1; Page 65. 

b See Berlin's Treatise on the Heart, Page 417; Mr. Adams, in ihe "Dublin Hospital 
Reporis," Volu-me 4, Page 432; "Edinburgh Medico-Chirurgical Transaciions," Volume 
•Z^ Page 1; anrl compare with the.se the "Transactions of a Society for the Improvement of 
Medical and Surgical Knowledge," Volume 3, Page 448. 

c "Precis d'Analomie Pathologique;" Tome 2; Page 344. 

•1 From ayyw, to strangle. 



DISEASE OF THE SUBSTANCE OF THE HEART. 867 

pain is confined to llie left eide; though there are a few cases where it has extended 
to the right shouUler, and down the right arm, and even down the front of the 
loins; but that is usually after it has existed for some tifne (longer or shorter) at 
the sternum, and down the left arm. There is not necessarily palpitation; for we 
may have this affection without any palpitation at all. 

Pathology. — Dr. Haygarth, of Bath, has collected a vast number of cases of 
this description; and has inferred that these symptoms are characteristic of disease 
of the coronary arteries. He does not say "characteristic d{ ossification^^'' as 
some make him; but "characteristic o( disease of those arteries;" — whether it be 
induration, or the formation of cartilage, or of bone. But it is now ascertained, 
that " angina pectoris" does not characterize any particular affection of the heart. 
We may have it without ossification, or any perceptible disease of the coronary 
arteries; and, on the other hand, we frequently find ossification of the coronary 
arteries, without the symptoms called " angina pectoris." Angina pectoris is very 
well described by Dr. Heberden, in the second volume of the "Transactions of 
the College of Physicians."^ It is not one of the common symptoms of disease 
of the heart. In the greater number of instances in which tlie heart is affected 
with disease of any kind, we have not the symptoms of " angina pectoris;" and 
although it is a fact, that we fi-equenlly have these symptoms when there is ossifi- 
cation of the coronary arteries, or great ossification of the mouth of the aorta; yet 
it is also a fact that we may have them in almost any disease of the heart what- 
ever; and also that we may have them without an}'- ossification at all. 

Distinguished fro?n Gastrodynia. — Such symptoms, it is now well known, will 
take place without any disease of the heart. A few years ago, there were pub- 
lished some cases, accurately described as " angina pectoris," but in which no 
disease of the heart was found after death. The truth is, I believe, that gastrody- 
nia (spasmodic pain of the stomach) frequently resembles this affection. The left 
side of the stomach is situated close to the heart; and a violent pain of the stomach 
frequenUy shoots upward; sometimes as far as the shoulder, and even down the 
arm. Cases of pure spasmodic or neuralgic pain of the stomach, will give way to 
stramonium, prussic acid, and remedies of that description; and are shown to be 
diseases of the stomach, not only by their ceasing entirely, on the exhibition of 
remedies calculated to relieve functional disorders of the stomach, but by acidity, 
perhaps vomiting; and by various other symptoms, indicating disease of the sto- 
mach, and not of the heart. In such cases, I have known persons seized with a 
violent pain, when they have moved quickly; — ^just the same as when there has 
been disease of the heart itself. 

Distinguished from Neurcdgia. — The heart is certainly subject to pain of a 
neuralgic character. I have seen several cases of persons who have had violent 
pain, at different times, in the region of the heart; and the difference between it 
and what is called "angina pectoris," I have found to be this; — that the latter is 
only felt when the patient moves about; whereas a neuralgic pain is felt quite as 
severely when the patient is sitting still. FrequenUy, too, there is pain darting in 
other distinct nerves of the body. The pain is of a stabbing character; and 
although it may be made worse by the patient jolting himself about, yet, when he is 
perfectly still, it will frequently come on in the most violent way. Another diag- 
nostic mark is, that neuralgia is not particularly disposed to dart through the left 
arm; nor is it attended with a "dying" sensation; — as though the individual were 
about to expire. 

Treatment. — I have relieved "angina pectoris," more by prussic acid than by 
any other remedy. If there be organic disease of the heart, we cannot relieve it 
to the same extent as we can a neuralgic affection of the organ; and I do not 
know that I ever did much good in such cases. 

» Paore 59. 



868 DISEASES OF THE AORTA, 

CHAPTER IV, 

DISEASES OF THE AORTA. 



SECTION L— AORTITIS. 

Symptoms. — I formerly mentioned,^ that the lining membrane of the heart and 
aoria was subject to inflammation, and sometimes simultaneously with the pericar- 
dium. In the case of the heart, I believe that the symptoms are, increased general 
sound, force and frequency of action, with more or less pain or uneasiness: and 
when the former continue for a length of time, without the peculiar auscultatory 
signs of organic disease, or proportionate pain on pressure (as observed in pericar- 
ditis), we certainly may infer the existence of this inflammation. 

The lining membrane of the aorta is generally inflamed at the same time; and 
when the affection extends along the descending portion, there is frequently a sense 
of smarting in the direction of the spine, and in the abdomen a violent pulsation, 
not only of the aorta, but even of the iliacs; without any perceptible enlargement 
of the vessels, the existence of any tumour in its neighbourhood, or such a small- 
ness of any of the arteries as might render it probable that the aorta was narrowed 
in any part, and thus forced into violent pulsation. 

Causes. — Aortitis seems caused by all the circumstances which produce inflam- 
matory affections of the heart, and perhaps by disease of the heart itself. Either 
hypertrophy of the left ventricle gives rise to inflammation of the aorta, or the con- 
verse happens, or they spring up together; for they are frequently conjoined. 

Morbid Signs. — Of the intensely bright redness of the inner surface of the 
inflamed aorta, and the impossibility of ascribing it to any thing but inflammation, 
I formerly spoke;* as well as of the occasional effusion of fibrin. It appears as a 
red stain; and sometimes the middle coat appears more loaded with blood than 
usual. 

Chronic Changes. — But we far more frequently discover the chronic change of 
structure in this vessel. Yellow spots are seen every day: often a yellow curdy 
substance can be squeezed through the inner membrane, nnder which it is depo- 
sited; — the membrane having become friable, and under distension giving it issue. 
Sometimes the deposition projects into the canal of the artery, like a tubercle. 
Frequently spots and patches of bone are seen bare, and in contact with the blood: 
originally deposited below the inner membrane, I believe, and exposed by its crack- 
ing and becoming destroyed. Sometimes all the coats are thickened and indurated. 
Ulceration is occasionally seen, and fatal hcemorrhage has been thus produced; — 
the extenuated outer coat (perhaps the only one remaining) giving way under soine 
exertion or strong action of the heart. More commonly the aorta, like other arte- 
ries, dilates. 

SECTION XL— ANEURISM OF THE AORTA. 

Varieties. — Either all the coats dilate together throughout the circumference of 
the vessel, or in one spot, so that a pouch is formed: or, the inner or middle coat 
cracking, or (which is less frequent) ulcerating, the blood distends the external into a 
pouch; and this gradually gives way also, and hasmorrhage occurs: or the surround- 
ing parts adhere to the vessel; and thus haemorrhage is prevented, till these likewise 
ulcerate or burst. Occasionally the three coats first dilate generally or partially; 

» See Page 831 



DISEASES OF THE AORTA. 869 

and then the internal and middle give way, and the external continues to dilate 
alone. The middle coat often cracks at the same lime as the internal. 

Conditio?! of the Vessel. — Both the simultaneous dilatalion of the three coats, 
and the rupture of the internal, nearly always arise from far more than mere debi- 
lity of structure, — generally from some disorganization: at least some change of 
colour, some deposition, or unusual appearance, is nearly always observed at the 
same lime. 

True and False Aneurism. — The partial dilatation of the three coats of the 
aorta and other arteries, is by some termed '^ true aneurism;" while others restrict 
the term to the dilatation of the middle and external or of the external; — the inter- 
nal or the internal and middle being ulcerated or ruptured. Those who apply 
the term to the partial dilatation, call the instances in which one or more coats are 
ruptured, — ^'false aneurisms." Yet all allow that, whether the three coats dilate 
together, or only the middle and external, — the internal being cracked or destroyed, 
the morbid condition of the vessel giving rise to the change is much the same. If 
partial dilatation of all the coats occurs first, and then rupture of the inner coat in 
one spot of the dilatalion, both kinds of aneurism exist. 

Most frequent in the Ascending Portion. — This disease most commonly takes 
place in the ascending portion or the arch of the aorta;— the extension usually 
occurring at the anterior or lateral portions of the vessels, and inclining to the right 
side: and dilatalion, general or partial, usually precedes the ulceration or rupture 
of the inner and middle coals. 

Rupture usually Transverse. — Aneurism frequently exists without giving rise 
to any symptoms: and as the aorta within the pericardium is detached, — is without 
the possibility of surrounding parts becoming adherent to it, and preventing the 
escape of blood when its coats entirely give way, sudden death from this cause 
frequendy surprises persons apparently in good health. The rupture is usually 
transverse, and has been seen throughout the circumference of the vessel; though 
limited rupture is much more common; and, when confined to the internal and 
middle coats, it is almost universally transverse. 

If the inner and middle coats only are ruptured, blood escapes under the exter- 
nal; and sometimes separates it, to a greater or less distance. Laennec saw it 
separated from the commencement of the aorta to the iliacs; — giving the appear- 
ance, at first sight, of a septum in the middle of the vessel. When, after an inter- 
val, varying in length, the external coat ruptures, the opening may be in a different 
direction from the fissure in the internal and middle coats. 

Case. — A woman was admitted by me into St. Thomas's Hospital, on account 
of severe pain of the left half of the head, face, and neck, and of the left shoulder. 
I ordered thirty leeches to be applied; and, during their application, she suddenly 
screamed with pain in the region of the heart, fell back, and expired. On exami- 
nation, the pericardium was found distended with clear serum, and a very large 
coagulum of blood; which had escaped through a small longitudinal rent in the 
outer coat and pericardial covering of the aorta. The outer coat was separated 
from the internal and middle into a pouch; which contained a portion of adherent 
fibrin, precisely similar to the fibrin found in aneurisms, and a quantity of ordinary 
coagulum; without any morbid appearance of structure. In the internal and middle 
was a transverse slit. The latter had, no doubt, taken place some time before death; 
the longitudinal fissure at the moment of decease. 

Case of George the Second. — In George the Second, the aorta had undergone 
the first half of this process: the internal and middle coats of the aorta presented 
a transverse fissure, around which was a coagulum under the external coat; which 
would soon likewise have burst, perhaps longitudinally, — exacUy as in this case of 
mine; and, had no rupture of the right ventricle occurred, as I formerly described,* 
sudden death would ultimately have taken place, from the rupture of the aorta.** 

aSeePage8G-2. 

b In ilie irack of the aorta, we found a transverse (issure on its inner side, about an inch 
and a half long; through which some blood had recently passed under its exiernal coal, and 



S70 DISEASES OF THE AORTA. 

Mode of Rupture. — In two instances, an aneurism of the pericardial aorta burst 
into the pulmonary artery. When the disease is situated in the arch of the aorta, 
the rupture may take place into the trachea, the cesophagus, the pericardium, or 
the pleura. The descending tlioracic aorta usually bursts into the pleura, cesopha- 
gus, or posterior mediastinum, or even into the lungs. Aneurisms of the pectoral 
aorta most frequently burst into the left pleura. But aneurisms of the arch and 
descending aorta sometimes destroy life by compressing the organs of respiration 
or the oesophagus. 

Symptoms. — When a certain size is attained by an aneurism of the ascending 
aorta, a tumour is usually formed at the fifth and sixth ribs of the right side: when 
at the anterior part of the arch, the tumour is at the third and fourth of the right 
side: when at the superior part of the arch, it is above the sternum and clavicles. 
The strongly pulsating character of the tumour shows its nature, even should the 
tumefaction subside considerably for a time; as happened, from repeated venesec- 
tion, in three cases of this disease that I treated; and in one of which the tumour, 
at one time, actually pointed. 

There is frequently cough, with mucous and bloody expectoration; dysphagia; 
dyspncBa, even orthopnoea; attacks of spasmodic sufibcation; pain in the right shoul- 
der, axilla, inner side of the arm in the course of the nerves (which may be tender), 
and up the right side of the neck and head. Pricking pains may be felt in the 
tumour. 

Previously to the appearance of any tumour, there may be no sign of disease; 
or the signs which present themselves may be very uncertain: and persons con- 
tinually perish of aneurisraal rupture of the aorta, apparently in perfect health. 
Laennec declares the diagnosis to be difficult;^ and confesses that he had frequently 
not suspected the disease when it existed, and suspected it when it did not exist.* 

Violent pulsation of the carotids has created a suspicion of the disease; but may 
arise from mere excitement of the heart, hypertrophy of the left ventricle, dilatation 
of them, or from any obstruction to the course of the blood in other directions;— 
as in the descending aorta or the subclavians. Dulness of sound on percussion of 
the superior sternal portion of the chest, and to the right of that spot, as well as 
smallness and irregularity of pulse, arise from many causes. A bellows-sound or 
a thrilling sensation, given to the hand only or chiefly when applied above or to the 
right of the cardiac region, may justly give a strong suspicion of the disease. But 
neither the bellows-sound nor the thrill always occurs. In four cases out of seven 
that I have seen of the disease, as well as in cases of aneurism of the arteries, 
neither occurred.'' Laennec never observed the thrill before the tumour had be- 
come visible externally. 

Diagnosis. — Laennec, however, considers that the chief diagnostic sign of an 
aortic aneurism, is a strong and single pulsation; discernible by the ear in the 
region of the aneurism, synchronous with the pulse at the wrist, stronger and 
louder than the action of the ventricles, and unaccompanied by the sound of the 
auricles." In three instances of aneurism of the aorta under the sternum, he was 

formed an elevated ecchymosis. This appearance showed the true slate of an incipient 
aneurism of the aorta; and confirmed a doctrine which I had the honour to illustrate by an 
experiment, to the satisfaction of the society, in the year 1728; namely, that the external coat 
of the aorta may (and does) often control an impetuosity of the blood, capable of breaking 
the internal or lig'amentous coat. — Extract from a Paper read to the Royal Society; No- 
vember 26, 1761. By Frank Nicholls, M. D., F. R. S., Physician to his Majesty. 

* See his Treatise on Diseases of the Chest, translated by Dr. Forbes. Part 2; Book 2; 
Chapter 25; Section 3; Subdivision 3; Head " Signs." (Third Edition; Pages 689 to 692.) 

^ Laennec states, that a bellows-sound occurs frequently in aneurisms of the aorta and 
other arteries; bnt that, as it is not constant, and may be heard sometimes when no aneurism 
exists, it cannot be considered among the signs of aneurism.— (" Treatise on Diseases of 
the Chest," translated by Dr. Forbes. Part 2; Book 2; Chapter 25: Section 3; Subdivision 
3; Head "Signs;" Pages 690 and 691 of the Third Edition.) 

" See Dr. Forbes's Translation of Laennec's Treatise. Part 2; Book 2; Chapter 25j 
Section 3j Subdivision 3; Head "Signs." (Third Edition; Pages 690 and 691.) 



DISEASES OF THE AORTA. 871 

(according to Berlin") mistaken: but would not have been, Berlin contends,'' had 
he applied the stethoscope over ihe sternum. Berlin asserts, that whenever an 
aneurism of the aorta exists, as well as of any other artery, a stront^ single sound 
may be perceived in it, distinguishable also from the beating of the heart by its 
greater intensity:'' and he maintains, that if the stethoscope is applied upon the 
sternum, in aneurism of the substernal aorta, the disease may be recognized with 
facility before it is visible;'' and that liaennec does not appear to have applied the 
instrument in this situation. ** Bertin discovered the disease in two cases in which 
there was no tumour.*^ Aneurism of the descending aorta, he considers, may be 
recognized by the same phenomenon at the pectoral spine.® 

The aneurismatic pulsations (Bertin adds) are so peculiar, intense and sharp, 
that they cannot be described; and a person who has once heard them can never 
mistake them. 

I once discovered aneurism of the ascending aorta and of its arch, before any 
pulsating tumour appeared, by this strong pulsation to the right of the sternum and 
at its upper part, synchronous with the pulse, stronger and louder than the ventri- 
cular action of the heart. But then the aneurism was very large, though it formed 
no external tumour; — having extended chiefly backwards and to the right. ^ Yet 
neither in that case, nor in those in which a pulsating tumour existed, can I say 
the pulsations appeared peculiar. The pulsations, as heard, were double; — the 
sound of the aneurism was (of course) heard with the action of the ventricles, but 
the sound of the auricles was also distinctly heard in the region of the aneurism; 
and the frequent occurrence of this circumstance is mentioned by Laennec. The 
same was the fact in the cases with tumour, when the stethoscope was applied to 
the latter; although the impulse was of course single. In that case a bellows- 
sound was heard; and in it, and also in all the cases with tumour where the bel- 
lows-sound was heard, the sound was double; — occurring both at the moment of 
the pulse and afterwards; and that sound which was heard after the pulse, was 
much louder in the aneurism than in the heart. 

I presume that a bellows-sound is heard with the pulse, if the mechanical state 
of parts produces any difficulty to the course of the blood, or if there is general 
dilatation of the vessel as well as aneurism; so that the blood is checked when 
flowing on into the narrower healthy portions. The second bellows-sound possibly 
arises from the elasticity of the parts impelling some of the blood from the dilated 
portion, after the action of the left ventricle. 

Treatment. — In a case of this description, nothing can be done but to enjoin 
perfect rest, and deprive the patient of all stimuli; — giving him that nourishment 
which is least likely to quicken the pulse. Bleeding, from time to time, is ex- 
ceedingly useful; as it relieves the sufferings of the patient very much. We know 
that, in aneurism, nature fortifies the part, by producing adhesions around it; but 
there is frequently more inflammation than is useful; and there are frequendy 

* See his Treatise on Diseases of the Heart, Book 1; Chapter 2; Article 2; Section 3. 
(Page 144 of the Paris Edition of 1824.) 

* See his Treatise on Diseases of the Heart. Book 1; Chapter 2; Article 2; Section 3. 
(Pages 143, 144, and 146 of the Paris Edition of 1824) 

•= See his Treatise on Diseases of the Heart, Book 1; Chapter 2; Article 2; Section 3. 
(Page U:^ of the Paris Edition of 1824.) 

•I See his Treatise on Diseases of the Heart, Book 1; Chapter 2; Article 2; Section 3. 
(Pages 143 and 144 of the Paris Edition of 1824.) 

e See his Treatise on Diseases of the Heart. Book 1; Chapter 2; Article 2; Section 3. 
(Pages 145 and 146 of the Paris Edition of 1824.) 

f I lately h;id a patient with enormous aneurism of the ascending aorta. It extended to 
the left, upwards, and backwards; so that its summit adhered to the highest ribs under the 
left scapula; and a pulsation, with a double sound, existed many months before death at the 
lower right anterior part of the chest; corresponding with the situation of the apex of the 
heart on the left. No aneurism, nor any thing but the healthy lungs, existed at the seat of 
pulsation: and this must have been produced by the reaction of the aneurism from the upper 
posterior left ribs, upon the lower anterior right part of the chest. No one suspected aneu- 
rism. 



872 DISEASES OF THE AORTA. 

pricking-, stabbing pains, together with violence of the heart's action; and all these 
are diminished by bleeding. The blood is buffy and cupped, in such cases; be- 
cause there is inflammation going on. It is of the jgreatesl use to bleed from time 
to time; and to keep the patient low and quiet. These are not cases to be ne- 
glected. We may not be able to save life; but we may diminish the pain very 
much. 



BOOK V. 

DISEASES OE THE CHYLOPOIETIC VISCERA. 



CHAPTER I. 
DISEASES OF THE PERITONEUM. 

SECTION I.— PERITONITIS. 

Symptoms. — The first disease of which I shall speak, after passing the dia- 
phragm, is inflammation of the peritonaeum; — " peritonitis." It is, of course, 
attended by pyrexia, — general feverishness.'* Although the whole body is hot, yet 
generally the abdomen is hotter than other parts. The pulse, for the most part, is 
rather small. It is quick, sometimes wiry, sometimes hard, and sometimes soft. 
There is no invariable pulse in peritonitis; except that it is always quick. More 
frequendy it is small than full; and perhaps more frequently rather hard than soft. 
There is great variety as to the appearance of the tongue. Sometimes it is tolerably 
clean, — at the utmost only whitish; sometimes it is covered with a thick, creamy 
mucus; and sometimes it is rather dry. There is no very great index to the dis- 
ease, either in the appearance of the tongue, or in the character of the pulse; but 
the abdomen is always very tender on pressure; and the tenderness is too general 
for one to suppose that any particular organ is inflamed. One of the modes of 
distinguishing peritonitis from inflammation of a particular organ, is by observing 
that the tenderness of the abdomen is not in the seat of any particular organ what- 
ever; but is more or less general. As the peritoneeum stretches all over the abdo- 
men, and usually a great proportion of it is inflamed, the patient is most frequently 
easier on his back, than in any other position; and sometimes, to obtain all the 
ease possible, the patient lies with his knees spontaneously raised. In general, 
patients cannot sit up, — on account of the abdominal viscera gravitating so much as 
to produce painful distension; and therefore they are easiest in a lying posture. 
Besides the tenderness, there are very frequendy pricking pains of the abdomen, 
—as if needles were running into difTerent parts; and occasionally there is a sharp, 
cutting pain. The abdomen is usually very tense. As it is a mere membrane 
that is inflamed, the bowels are not in general ])articularly disturbed. They are 
regular, or at the utmost only slightly confined; and are easily opened. There is 
no obstinate constipation. 

Although the inflamm.ation is usually very general, yet it may be more severe at 
one spot than at another. Consequently there is more pain at one part than at 
another; and if that part be situated over any particular organ, then the function of 
that organ is more or less disturbed. If, for example, at any particular period of the 

« See Pages 88 and 234. 



874 DISEASES OF THE PERITONEUM. 

disease, the membrane covering the stomacli be inflamed, vomiting is induced; — if 
it be the portion vvhicli partially covers the bladder, then there may be very great 
irritation of the urinary organs. In the former case we have vomiting; in the latter, 
strangury. 

Diagnosis and Prognosis. — As the inflammation spreads, it attacks one part after 
another. It is the peritonaeum at large that is inflamed; and therefore the tenderness 
is general, and the pain difl^used; and any disturbance of function that exists in the 
abdominal viscera, is trifling in proportion to the general pain and uneasiness. It is 
in this way we distinguish it from inflammation of any particular organ. This dis- 
ease, when acute, may last about a week before it proves fatal; but if it remit, it may 
of course last much longer. 

Morbid Appearances. ~^kkev death, the appearances found are nothing but those 
which are usual in inflammation of a serous membrane;— -for example, a quantity of 
serum of a whey-colour, more or less turbid, with flakes of fibrin. It is rare to find 
the serum bloody. The fibrin is frequently efl*used in a gelatinous form, both in the 
parietal and visceral portions; and perhaps adhesions are thrown out, so that there 
are bands. Now and then the secretion resembles pus; and now and then it is really 
pus. As to the redness of the peritonaeum, that may be either in litUe stars, — a col- 
lection of red points, or diflfused in patches. The peritonaeum, like most other serous 
membranes, becomes rather thicker than usual. It is not so translucent as in health; 
and, now and then, it is quite pulpy. When the peritonceum covering the aliment- 
ary canal is inflamed, the redness will sometimes spread inwards, even to the vil- 
lous coat; but it is very rare to find inflammation of the parietal portion spread 
outwards, towards the abdominal muscles. When the portion covering any par- 
ticular organ is inflamed, we may find the organ itself affected; as, for example, the 
omentum or the mesentery; so that we may have "omentiVis," or "mesenteri^zs," 
or any other itis we may choose to manufacture out of the name of the organ, and 
the termination ^'itis^^ added to it. 

Puerperal Peritonitis. -^This disease very often occurs in a puerperal state; and 
by some it is thought occasionally to be contagious. It is called, when occurring 
in that state, "puerperal fever^ Sometimes it will take place immediately after 
delivery; and sometimes many days afterwards,— whether the patient is sickly or 
not; and, on the other hand, it will sometimes take place during the latter period of 
pregnancy. Whether it be a contagious fever or not, it certainly is very often epi- 
demic; and one might say "endemic;" for this disease (puerperal peritonitis) fre- 
quently prevails to a great extent at a particular period; and sometimes it prevails 
only in particular districts. 

Causes. — Peritonitis is very frequently a cause of death in cancer of tlte womb, 
or various other diseases of the uterus, or of the ovaries. Whenever cancerous or 
other ulceration occurs in these parts, and exists for some time, the peritonaeutn 
around the ulceration comes to be inflamed; so that peritonitis is a common termi- 
nation of organic diseases of these parts. Peritonitis sometimes occurs, also, after 
a rupture of the stomach or intestines, from ulceration. It sometimes takes place 
from a hernia; — either from the operation for it, or the hernia itself; from litho- 
tomy; from "paracentesis abdominis;" — from wound, or mechanical injury of any 
sort, inflicted on the abdomen. It is frequently consequent upon the application of 
cold; and especially cold and moisture applied when the body is over-heated; — -just 
the same as any other inflammation.* 

Treatment. — The treatment of the disease is easy enough. It consists of gene- 
ral bleeding, followed by an abundance of /oc«/ bleeding (by means of leeches), a 
rapid affection of the mouth by mercury, and keeping the bowels well purged the 
whole time. Cupping would produce great pain. Some prefer fomentations, and 
others blisters. Perhaps, it is not a matter of importance which we apply; but if 
we have bled as much as we dare, and still want to do more, then blisters will be 



DISEASES OF THE PERlTON.IilUM. 8 i i* 

the great point of treatment. Some have recommended tlie external application of 
cold to the abdomen, in such a case; but I never employed it. 

Treatment of the Puerperal Forin. — In that form of the disease which occurs in 
connection with pregnancy, or the puerperal state,^ it is found that a great variety 
of treatment is necessary. We may have cases wliere there is active inflammation, 
demanding a vigorous antiphlogistic treatment (such as I have novv mentioned); 
whereas, in others, the very utmost that can be borne is the application of leeches. 
Patients are seized with more or less pain in the abdomen; but the pulse is feeble; 
and if we bleed tliem, they will certainly sink so much the sooner. All that can 
be done, therefore, is to apply a few leeches, give a moderate quantity of mercury, 
and exhibit opium freely. So slight is the inflammation, in some of these cases, 
and so great the loss of power, that after death the peritouEeum is not found red, 
but rather pale; and it will have very soft lymph lying upon it; — showing that 
there was an inflammatory state, but that it was attended with extreme weakness. 
Where the pulse is feeble, and the patient's countenance expressive of great de- 
bility, opium is far more suitable than bleeding: but if the tenderness seems to in- 
dicate bleeding, a few leeches will be all that is proper. In such a case as this, 
even purging has been found to be too severe a measure; but there can be no ob- 
jection to a moderate quantity of mercury; — using such a preparation as will not 
produce an affection of the bowels (Hydrargyrum cum Creta, for instance). The 
application of warmth and moisture, will be found very serviceable. Dr. Gooch, 
who (as far as lean observe) has treated the subject well, strongly recommends the 
application of bran, moistened with hot water, and placed between two pieces of 
linen. A bran-poultice appears to afford very great relief. 

The peritonseum, therefore, may occasionally be in an inflammatory state; at- 
tended with such extreme weakness, that the common remedies for inflammation 
can hardly be put in practice, 'i'his is somewhat analogous to what I mentioned 
respecting hydrocephalus; — that occasionally children have all the marks of that 
complaint, and yet no signs of inflammation are observed after death.^ In the case 
before us, however, the membrane is inflamed; but the debility is out of all pro- 
portion to the inflammation. The treatment of peritonitis connected with the puer- 
peral state, especially after delivery, requires to be much varied. 

Chronic Peritonitis. — Inflammation of the peritonosum is very frequently a 
chronic affection; and in that case there is pain on pressure; — that is to say, there 
is tenderness, and likewise pricking pain. There is almost always a feeling of 
tension; and sometimes that is more complained of than the pain itself; but there 
is not necessarily any tension to be discovered; for sometimes the integuments 
are quite flexible. Of course there is pyrexia- The pulse is constanfly quick; 
there is more or less thirst; the skin is generally more or less dry; the tongue is 
foul, and either white or yellow towards the back. The breath, in this disease, is 
very frequently fetid; the face sometimes assumes a doughy aspect; the bowels 
generally are torpid; and fiequendy there is ascites, from the chronic inflammation 
of the membrane causing an excessive secretion. As the inflammation is of a 
chronic character, of course the body wastes. The internal functions are very 
much deranged. The stools are very copious, and generally of a white-brownish 
colour; — not being so fully impregnated with bile as they should be; and the me- 
senteric glands are frequently diseased. In fact, when chronic peritonitis occurs in 
young persons, it is for the most part a scrofulous disease; and is connected with 
more or less afl^'ection of the mesenteric glands. After death, we find excessive 
redness and thickness of the membrane; and an effusion of serum and fibrin. 

Treatment. — The treatment of the disease consists in the frequent application 
of leeches; the frequent use of the warm-bath, general or partial; warm applica- 
tions, — such as the bran-poultice I mentioned, applied constantly day and night; 
or (as some have recommended) cold applications, frequent blisters, and a regular 

« See Page 874. ~ »•. See Page 501. 



876 DISEASES OP THE PERITONAEUM. 

purging with calomel. The contents of the intestines are very abundant. The 
diet should be mild. After the disease has lasted some time, if there be no very 
great excitement, we may try mild tonics; — the mildest form of iron, for instance; 
but during the greater period of the disease, antiphlogistic measures, mildly carried 
on, constitute a preferable mode of treatment. 



SECTION II.— ENLARGEMENT OF THE MESENTERIC GLANDS. 

If, along with chronic peritonitis, the mesenteric glands are enlarged,— or if, in- 
deed, they are enlarged without that affection, — we may, or may not, have a 
tumour. The mesenteric glands are frequently much diseased, without producing 
a tumour; yet they are sometimes so diseased, that there is a general hardening of 
the abdomen. When peritonitis exists, in the greater numberof cases we can only 
infer disease of the mesenteric glands from the scrofulous look of the patient, from 
his wasting away, and from there being something more than what chronic inflam- 
mation of the peritonaeum can produce. When there is tumefaction from disease 
of the mesenteric glands, frequendy a great deal of it is from flatulence; so that if 
we strike with the fingers, we have a very considerable sound. Sometimes tuber- 
cular matter is deposited in the peritonaeum itself; so that, besides chronic perito- 
nitis, we have scrofula of the peritonaeum. It is by no means easy to make out the 
exact nature of such a case as this. It is pretty clear that there is peritonitis, and 
that there is likewise scrofula; but whether there are tumours or not, or whether 
the disease affects the mesenteric glands, or the peritonaeum itself, is not always aa 
easy matter to decide; nor is it of any consequence. 

Symptoms. — Occasionally the mesenteric glands acquire a very large size; and, 
before that, there is a great sense of dragging in some particular direction. In those 
cases which are very bad, and where there is scrofula in the abdomen at the same 
time, there is great emaciation, together with sallowness of the complexion, — some- 
times a sort of marble-white; and a hectic flush on the cheek, — at any rate, at 
certain parts of the day. The eyes look clear and glazed. Occasionally, in the 
course of the day, there is deep lancinating pain in some parts of the abdomen. 
The stools are generally abundant; — foul, frothy, and imperfectly tinged with bile. 
Occasionally there is great disturbance of the stomach; so that patients complain of 
a burning sensation in that organ. The lips frequently swell; are of a deep red 
colour; and crack, from ulceration in the corners. There is also feverishness. 
Although the pulse is constantly quick, yet there are exacerbations. When the 
patient does not sweat on falling asleep, the skin is frequently quite dry. The 
emaciation, in these cases, is often extreme; and the ends of the fingers become 
enlarged; — exacdy as in phthisis. 

These are the general symptoms of scrofula of the mesenteric glands, and of 
peritonitis. The symptoms are always much more severe, and the emaciation is 
greater, than in simple inflammation of the peritonaeum; but still it is often difficult 
to say whether the latter affection exists alone, or whether the two complaints are 
united. It is only by finding that the disease will not give way to common anti- 
phlogistic measures, that we begin to suspect, at last, that there must be something 
more than inflammation of the peritonaeum. Occasionally it is not so much the 
mesenteric, as the lymphatic glands that are diseased; — particularly the glands of 
the loins. 

Most Frequent in Children. — All these affections occur more frequendy in 
children, than in adults; but occasionnlly they occur in the latter. 

Effects of Mesenteric Disease. — If the mass of tubercular substance be very 
gri^at, it may produce peculiar effects, by its pressure on various parts. From 
pr;ssure on the ureters, we may have more or less suppression of urine; by pres- 
sure on the gall-ducts, we may have jaundice; and by pressure on the pylorus, we 
may have vomiting. Some have supposed, that when the mesenteric glands are 
enlarged, the emaciation is the consequence of the chyle being interrupted in its 



DISEASES OF THE PERITONEUM. 877 

course; but even if the chyle be not obstructed, the scrofulous disease is sufficient 
to account for the wasting of the body. In fact, some experimenters say, ihal they 
have always found an injection pass freely through the absorbent glands; alihougli 
they were enlarged in various degrees. Many have asserted this. 

AJorhid ^Appearances. — The havoc which is found in these cases, is sometimes 
dreadful. The whole of the intestines may be glued together. Sometimes there 
is ulceration of the peritonaeum itself; — the intestines within being sound. O^-t-a- 
sionally the ulceration makes the peritoneum quite thin. It even ulcerates through; 
and then we find ulceration of the intestines, and chronic inflammation of the mu- 
cous membrane of the intestines, and of the lacteal glands. Frequently the lumbar 
and dorsal glands, are all in a state of enlargement and suppuration; so that there 
is extreme suifering, and the most decided hectic before death; and, after it, we 
certainly have the most frightful spectacle that can be seen in morbid anatomy. 
This is entirely a S(;rofulous afTection. 

Treatment. — When the disease does not give way to ordinary treatment, — to 
the application of moisture, warmth, and steady purging; or moderate purging, 
local bleeding, and similar remedies, we may suspect there is something more than 
chronic inflammation of the peritonaeum; and, on meeting with such a case as this, 
it may be right to exhibit iodine in its various forms; and if we can discover a 
tumour in any part, or any general hardness of the abdomen, — so as to make it 
probable that the mesenteric glands are enlarged, — it may be given from the first. 
We should also rub in iodine, in the form of hydriodate of potass, if the patient 
can bear it; but there is frequently too much pain for it to be borne at all. The 
hydriodate of potass will often be borne, when the iodine itself cannot. But these 
are very unsatisfactory cases to treat; and frequently all that we can do, is to send 
people from the unhealthy situation in which they may reside, to the fresh air. 



SECTION III.— ASCITES. 

Sometimes, although the chronic inflammation of the peritonaeum is very incon- 
siderable, yet the effusion is exceedingly great. Sometimes, indeed, there is 
scarcely any mark of inflammation to be found; but we have a structural change 
of the peritonaeum, and a great deposition of water. The peritonaeum becomes 
thick, and assumes a satin-whiteness. In fact, it looks like a piece of satin-ribbon; 
so that it may be doubted whether this state is inflammation; but it is of an in- 
flammatory nature. When this effusion is very considerable, we call the disease 
*' ascites" (from aa^o^, ci large abdomen). 

Causes. — When ascites is not the result of acute or decided inflammation, we 
find (in most cases) that there are marks of structural change; and some ascribe it 
to disease of the liver; so frequently is that organ affected at the same time. Where, 
however, the peritonaeum is diseased, the portion covering the liver is very thick, 
quite white, and opaque: and I believe thai ascites does not arise from disease of 
the liver, but from a structural change in the peritonaeum itself. Some ascribe it to 
an obstruction in the liver or spleen. An obstruction may exist in those organs; 
but if the ascites arise from that stjurce, it is very odd that we do not find a varicose 
slate of all ihe veins, effusion into the intestines, and changes of that description. 
I liave seldom opened a case of ascites, in which the liver was not diseased, in some 
pari or other. 

Si/iuptoms. — Dropsy of the perilonaeuni is characterized by a fluctuating and 
elastic equable tumefaction of the abdomen. At first it only inconveniences the 
paiiei\t when he is silling upright, and fluctuation is discovered only at a certain 
point; but, as the disease extends, die tumefaction becomes universal. The best 
mode of discovering the fluctuation, is to place the hand against one part of the 
abdomen, and then to give a gentle tap wilh the fingers on another. Occasionally 
the integuments, or the peritonaeum, are very much thickened; and it is then neces- 
sary to give a good sharp tap; but, for the most part, a very gentle lap will lead 



878 DISEASE OF THE PERlTONiEUM. 

US to feel the fluctuation. Sometimes the fluctuation does not exist throughout: 
and occasionally the peritonceum differs in thickness at various parts; so that it is 
necessary to tap from above downwards, and in various ways. There is in general, 
as in most other dropsies, very little urine; but however much the abdomen may 
be distended, there is generally lilde dyspnoea, so long as the chest remains free. 
So long as there is not disease of the heart, or pleuritis, or bronchitis, it is surpris- 
ing hov/ well patients will breathe with a very large abdomen. The tumefaction 
begins, of course, in the lower part; and gradually ascends, till the whole abdomen 
is distended. 

Progress of the Disease. — This affection, after a time, is followed by CBdema 
of the legs; but sometimes the latter takes place first; and the ascites is nothing 
more than the result of a general tendency of the cellular membrane of the body, 
and serous membranes, to secrete fluid. But where there is not this general dis- 
position to dropsy, and its occurrence in the abdomen is a local disease, swelling of 
the legs frequently does not take place for a considerable time. Shakspeare de- 
scribes Falstaff as having a decrease of the legs, and an increase of the belly.^ 

Prognosis. — If the disease be the mere effect of acute inflammation, subdue 
that, and the dropsy will cease; but when it does not arise from that source, or is 
not the result of any discoverable inflammation, the prognosis is generally bad; and 
more especially if we can discover disease of any of the abdominal viscera. 

Characters of the Fluid.— The fluid that is found after death, or which we let 
out, is generally yellow and glutinous; and the longer the disease lasts, and the 
more frequently the patient is attacked, the darker it generally becomes, and the 
worse becomes the case itself; because the peritonaeum falls more or less into dis- 
ease, and perhaps becomes quite soft. 

Treatment. — The treatment of the disease must depend, in the first place, on 
the fact of there being any inflammation or not. If we discover inflammation, 
generally speaking, we have merely to treat that; but if there is no inflammation, 
but simply a swelling of the abdomen, we may frequently get rid of it by purging 
the patient briskly with elaterium, or any other hydragogue purgative;' — such as 
jalap or cream of tartar. 

Elaterium. — Elaterium is better than any other purgative;* and patients will 
take it for a considerable time, every day, or every other day. It is necessary, 
however, to begin the dose very carefully; for one person will not bear above a 
quarter of a grain, whereas I have given others five or six grains. Much depends 
upon the preparation; for nothing is more adulterated than elaterium. Some houses 
prepare it very carefully, and some very badly; but when we have a tolerably good 
preparation, we should give a quarter of a grain, and ascertain how far the person 
to whom it is given can bear it. If we give a grain at first, it may produce such 
violent vomiting and purging, as to cause great distress. Some patients will bear 
the dose increased to five grains; but generally the average quantity is from half a 
grain to a grain and a half. "While exhibiting this every day, or every other day, 
it will be good practice to support the patient with wine; so that while we drain 
him well, we make him some sort of amends for it. It is astonishing, how much 
fluid may be got away; and while there is no rule for the dose, yet the object is to 
discharge as much liquid from the alimentary canal as possible,^ — according to the 
patient's strength. 

Iodine and Mercury. — Purgatives are certainly among the best means we can 
employ. Neither leeches nor blisters do much good. If there is organic disease 
of any sort, we may give mercury, iodine, and remedies of that description; but 
frequenfly, with all these, we do not succeed; and are obliged to tap the patient. 

* Sir John Falstaff. You that are old, consider not the capacities of us that are young. 

Lord Chief Jitstice. Do you set down your name in the scroll of youth, that are written 
down " old," with all the characters of agel Have you not a moist eye, a dry hand, a 
yellow cheek, a white beard, a decreasing leg, an increasing belly? ^'King Henry the 
Fourth;'' Act 1; Scene 2. 

" See Paj?e 173. 



DISEASES OF THE PERITONEUM. S79 

I do not know tliat there is any harm in tapping early. On the contrary, it may- 
be of great use in preventing the parts from becoming so stretched, tliat they will 
not contract again. Others liave thought the same; but I have not a series of cases 
treated on each plan. It is a fact with respect to dropsy of the ovaries, that the 
more we tap, the more harm we do. The sooner we tap the patient, the sooner 
must she be tapped again. In ovarian dropsy, the greater the lengtli of time we 
can postpone the operation, the longer we may still put it off; but this is not the 
case in dropsy of the peritonseum. 

Jjiuretics. — If we choose to treat the disease with diuretics, — which is fre- 
quently a good practice, — squills, digitalis, and mercury, answer exceedingly well. 
This is not so certain a practice as treating the case by hydragogues, which are 
also diuretics; for if we adopt it, we frequently find that the kidneys will not act; 
and yet, on tapping the patient, they will act directly. It is common, when the 
abdomen is in a state of great distension, for the kidneys to refuse to secrete; but if 
we take off the tension, the patient will make a great quantity of water. We may 
observe this, whether patients are taking diuretics or not. It is always a useful 
plan, when the water is diminishing, to have the abdomen well bandaged; or to 
have a thin belt, producing equal pressure throughout; which is apparently of very 
great use. 

Precautions in Tapping. — As to the mode of operating, and the part to be 
selected for the purpose, 1 need not say any thing on that subject. It would be 
well, however, before proposing the operation to a surgeon, carefully to ascertain 
whether the disease exists;— to ascertain, not merely that there is fluctuation, but 
fluctuation from a collection of water in the peritonaeum; because tiie urinary blad- 
der will occasionally become enormously distended. I have seen it so distended, 
that the person has been supposed to have ascites; but on drawing off the urine, 
the ascites entirely disappeared. This disease sometimes coexists with pregnancy; 
and pregnant women have been tapped for ascites with success. Sometimes it 
will coexist with a diseased ovary. I have known instances where the ovary was 
as large as a child's head; and where, in addition to that, there was ascites all 
around it. 

Tympanites. — Occasionally air is collected in the peritongeum; and this is one 
of the diseases called "tympanites." Sometimes the intestines are exceedingly 
distended with air; so that the person becomes very large, and the tumour gives 
rise to a sound like a drum; whence its name (from tv^iTtavov, a drum). But, 
properly speaking, tympanites is a great collection of air in the peritona3um; and 
I believe this usually takes place from an aperture existing in the intestines;— so 
that air escapes. 



SECTION IV.— OROANIC DISEASES OF THE PERITONEUM. 

The peritouEeum is subject to some other diseases; — such as to become cartila- 
ginous, or even bony; and to have hydatids, or scirrhus, or fatty tumours deposited 
in it. The same remark applies to the omentum. 

Diseases of the Jib dominal Glands.— The lymphatic glands within the abdo- 
men, besides being subject to the disease I iiave mentioned (scrofula)'', are some- 
limes found after death to have become indurated, — almost changed to cartilage; 
and to have suppurated, independently of all scrofula; — to have pus collected in 
them, in small quantities, or in drops. These glands are also subject to melanosis, 
to scirrhus, and to the formation of earthy concretions; and so likewise are the 
mesenteric glands; but we cannot make out the real nature of the affection, till 
after death. When the inner surface of the intestines is much diseased, we are 
almost sure to find the mesenteric glands also affected. When there is scirrhus, 
or cancer of the intestines, all the neighbouring glands, lacleals, and absorbents, 

a See Paofe 87u. 



880 . DISEASES OE THE PERITONEUM. 

are commonly enlarged, and labouring under the same disease. But we cannot 
discover this during life; unless, by chance, some particular tumour is produced. 

Cysts in the Abdomen, — The peritonseum (or, at least, the sub-peritonseai cel- 
lular membrane) is likewise subject to the formation of cysts. Occasionally cysts 
are found in other organs, — projecting into the peritonteum. Sometimes the ova- 
ries will become dropsical; — cysts being formed in them. Occasionally large cysts 
are attached to the concave surface of the liver, — sometimes to the centre, ancl in 
other instances to the side. Besides general dropsy of the peritonaeum, therefore, 
we frequently have large serous cysts. In these cases the tumour is not general, 
but local; — does not occur at the lower part particularly, but may take place any- 
where in the abdominal region. It usually occurs at one side, in the first instance, 
and arises from one of the ovaria. The fluctuation is local. Though the tumour 
most frequently arises from the ovaria, yet I have seen a large cyst at the epigas- 
trium, attached to the liver. Now and then there are small cysts attached to the 
spleen; and, at last, the tumour will become so excessively large, that it is impos- 
sible to say whether there is ascites or not. The whole peritonaeum will become 
filled. So again, with respect to the ovaries, we may not be able to say whether 
there is ovarian dropsy or not. 

Quantity of Fluid in Ovarian Dropsy. — It is surprising to see how much 
water is sometimes collected, in cases of ovarian dropsy. I once saw an old 
woman, who had had the disease many years, and never would be tapped. At 
last, a certain quantity of water was let out; and we found that it amounted to 
eio-hty-four pints. The diaphragm had been pushed up to the fourth rib; the 
chest was exceedingly small; but the size of the abdomen was immense. That, 
however, was nothing to what other people have seen. M. Chevalier says, that 
he once saw one hundred and thirty-six pints removed;— all of which must have 
existed at once. The case is mentioned in the third volume of the " Medico-Chi- 
rurgical Transactions."^ It was drawn off at three or four times. The health, in 
these instances, is not affected, as it is in dropsy of the peritonaeum; so that a 
woman at Paris lived to be tapped three hundred times. Another woman was 
tapped one hundred and fifty-four times. In the course of that period she had 
three children; and was tapped two or three times during each pregnancy; so that 
she lost no time, but went on bearing children and water too. At least twenty 
pints were removed at each time; and she was tapped, at various periods, during 
twenty years. There is another case recorded, where six thousand six hundred 
and thirty-one pints were taken away. It was not all removed at once; but was 
drawn off at eighty operations, performed in the course of twenty-five years; — so 
long do women sometimes live in this affection. I suppose they kept a very accu- 
rate account. In one year this woman had four hundred and ninety-five pints taken 
away. The case is mentioned by Dr. Mortimer, in the " Philosophical Transac- 
tions." There is an account, by a celebrated French surgeon, of a case where four 
hundred and twenty-seven pints were taken away in ten months. A case is men- 
tioned by Mr. Carruthers, in his work on inflammation, where a woman was 
tapped nineteen times in three years. A German author mentions an instance, 
where a person was tapped one hundred and forty-three times. A few years ago, 
an advertisement appeared of a woman who wished people to go and see her (and 
pay for it, I presume); and who stated that she had been tapped one hundred 
and twelve times, and had had two thousand eight hundred and eighty-eight pints 
taken away from her. She came from Chepstow. I had not time to see her; but 
she had the certificate of a medical man; — stating that he had j)erformed one hun- 
dred and twelve operations, and had removed two thousand eight hundred and 
eighty-eight pints. Whether the case is true or not, is of little consequence; be- 
cause, without doubt, great quantities have been taken away. It is no matter 
whether exacUy six thousand six hundred and thirty-one pints were drawn off, — 
as mentioned in one of the foregoing cases. Five thousand will do very well to 

» Page 40. 



DISEASES or THE PERITONAEUM. 881 

illustrate the fact, that people in this disease will live very long, suffer an immense 
secretion of water, and bear the operation of tapping an exlraordinary number of 
times. 

Characters of the Fluid. — The fluid, in ovarian dropsy, is often exceedingly 
greasy; so that a quantity of iridescent, or at least whitish shining matter is seen 
on the surface; and, if rubbed in the fingers, will form an unctuous mass. I have 
collected it; and found that it would melt and burn, like any waxy matter. It 
emits a bright flame, and is insoluble in water. Dr. Bostock mentions, in the 
fifteenth volume of the " Medico-Chirurgical Transactions,"" that in a case of very 
old hydrocele, he found the serum mixed with a portion of this unctuous substance. 
He conceives it to result from a change which the fluid has undergone, subsequently 
to its original deposition. In order, however, for that to have taken place, it must 
have been of very long standing. He found it to be analogous to that greasy matter 
which is called "adipocire." He terms it "albumino-serous matter;" and says it 
is distinct from cholesterine. It is not the same as that which is found in the liver, 
the urine, and certain biliary calculi; though it is of an analogous nature. Some- 
thing like this has sometimes been found in the thyroid gland, and in the fluid of 
various tumours. 

Tapping in Ovarian Dropsy. — In dropsy of the ovarium, I should certainly 
make it a rule to defer the operation of tapping as long as possible: first, for the 
reason I mentioned before;'' — that it is a fact, (and also a common opinion among 
the vulgar,) that when we have once tapped a patient, she soon requires to be 
tapped again; and, secondly, because, although in an early period of the disease 
■ there may be many cysts, yet in general they ultimately open into each other; so 
that we have only one great cavity. Hence, in tapping early, we most probably 
draw ofl' only a portion of the fluid by the operation; — the cysts being distinct, and 
not freely in communication with each other. 

Iodine and Mercury. — In these cases, the only remedies that (so far as I am 
aware) are of any use, are iodine, and sometimes mercury. Indeed, the best prac- 
tice, in cases of encysted dropsy of the ovaria, is to support the patient's strength; 
to put off tapping as long as possible; and to give no medicine whatever, except it 
be iodine. It is in vain to attempt to excite absorption by diuretics; and by purging 
we only nauseate the stomach, and take away the appetite. I have seen cases of 
encysted dropsy of other parts of the abdomen yield, apparently, to the free exhi- 
bition of iodine internally, and its application externally; and I have seen it suc- 
ceed partially in dropsy of the ovarium. I have fancied that the power of this 
remedy has been increased, in a trifling degree, by combining it \vith mercury. 

Very often, when an ovarium is enlarged, there is no fluctuation to be found for 
a long time. The walls are solid; — solid substance is deposited; and it is not till 
the fluid has accumulated to a considerable extent, that we can discover fluctuation. 
Encysted tumours of the abdomen, especially in young women, are partly solid 
and pardy fluid; and occasionally, on squeezing the part, we find small movable 
tumours, having portions of cartilage sometimes deposited in them. In some cases, 
they contain hydatids. I had a case, in 1828, in which there was a tumour of this 
description; and which I concluded was a tumour of the ovarium. Fluctuation 
was not very apparent; but still there was fluctuation. I was giving this patient 
considerable doses of calomel, — on account of there being a large quantity of solid 
substance, apparenUy of very great hardness, — when she was seized with violent 
vomiting and purging, accompanied by intense pain. Whether the vomiting and 
purging arose from the calomel, I will not say; but she had been taking it for some 
litde time; for I fancied there might be solid matter, as well as a collection of fluid. 
In the course of one night, the tumour entirely disappeared; after having resisted 
every other means for some months. It might be that the tumour, in this case, had 
burst into the peritonaeum; and that the fluid had been quickly sucked up by the 
absorbents of the peritonaeum, and as quickly secreted by the vessels of the kidney. 

* See Page 154. " See Page 879. 

VOL. I. — 56 



SS2 DISEASES OF THE PANCREAS. 

Or it might be, that violent purging being set up, a great discharge took place from 
the intestines; and the absorbents went to work, and reduced the tumour. How- 
ever thai may have been, the fluid re accumuhited; and the tumour became as large 
as ever; — and that after no very great lapse of time. One would hardly suppose, 
that the absorbents within the tumour were sufficient to produce such rapid absorp- 
tion. It is more likely that the tumour had burst at some part. We are told, tliat 
occasionally the fluid has been discharged by tlie vagina; — that tumours of this 
kind have ruptured into the peritonaeum; — that the fimbriated extremities of the fal- 
lopian tubes have set to work, and have poured the fluid into the uterus; and that 
thus it has been discharged througli the vagina. There are several cases on 
record, of women falling down with ovarian dropsy; and beginning, very soon, to 
discharge a quantity of water from the vagina; which discharge has continued till 
the swelling has disappeared. It is sometimes difi^icult, in tliese cases, to know 
whether the water comes from the vagina or the urethra. If it come from the 
former, we must suppose that the tumour has ruptured, and that the fallopian tubes 
have pumped up the fluid; whereas, if it come from lire latter, we must suppose 
that the vessels of the peritonaeum have sucked it up, and that it has then been re- 
secreted by the kidneys. 

Dropsy of the Fallopian Tubes. — Occasionally we may have what perhaps may- 
be, and sometimes is, called "encysted di'opsy of the abdomen;" — arising fi'om a 
fallopian tube being closed at each end, and a great quantity of fluid being accumu- 
lated within. 



CHAPTER II. 

DISEASES OF THE PANCREAS. 

Affections to which it is liable. — The diseases of the pancreas with which we 
have to do, are all structural. We do not know whether there is any functional 
disease to which it is liable; unless it be the formation of stone. We do not know 
what office the pancreas performs, either when it is out of order, or when it is in 
order. We know nothing about it. No one would refer a symptom that he has, 
to mere functional disease of the pancreas. It is very seldom that it is the subject 
of acute inflammation. I never met with such a case. But now and then it is 
diseased in a chronic manner; especially when there is disease of a neighbouring 
organ. 

The most common affection of this organ, is either common induration, or that 
particular disease called "scirrhus." Dr. Baillie says that he once saw an abscess 
in it;* and, now and then, common ulceration is seen. It is said to be sometimes 
ossified; and sometimes to have hydatids. Sometimes it is wasted, and sometimes 
it is very large; but, for the most part, this organ is not found diseased in dead 
bodies; and whenever it is, I believe the disease has evidenfly been of a chronic 
form. 

Diagnosis. — The diagnosis of structural disease of the pancreas, must be exceed- 
ingly difficult. Dr. Pemberton, in his woi'k on Diseases of the Abdominal Viscera,'' 
says there is deep-seated pain in the epigastric region; especially if one hand be 
placed at the back, and the other on the stomach. However, the pain may not 
be fell; or we may have pain there from an affection of the stomach; so that very 
little, I conceive, is to be learned from that. He says there is more or less sick- 

• "Morbid Anatomy," Chapter 12; Section 1. 

^ "Practical Treatise on Various Diseases of the Abdominal Viscera. By Christopher 
Robert Pemberton, M. D." Chapter 4. (Third Edition; Page 63.) 



DISEASES OF THE SPLEEN. 8S3 

ness, gastrodynia, and emaciation; but I should think that, in general, it must be a 
mere guess, — even if the person is right, — when lie pronounces that the patient is 
labouring under disease of the pancreas. 

Pancreatic Calculi. — Now and then a calculus exists in the pancreatic ducts. I 
opened a patient, not long ago; and was surprised to find calculi in the pancreatic 
duct. I forget what was the matter with him. The appearance was exactly the 
same as that given in one of Dr. Baillie's engravings. We know that the duct of 
the pancreas runs the whole length of the organ; that it is fine at one end, and 
large at the other; and that the ramifications of it, altogether, look like a feather. 
I believe these calculi are always homogeneous; and there must have been at least 
a hundred in the case that I opened. The duct represented in Dr. Baillie's engrav- 
ing, had attained an enormous size. Pancreatic calculi were analyzed by Dr. Wol- 
laston; and were found to consist of carbonate of lime in the human subject, and 
phosphate of lime in the ox. But these topics are more the subject of Morbid 
Anatomy, than of the Practice of Medicine. 



CHAPTER III. 

DISEASE AS OF THE SPLEEN. 

The next disease of which I will speak, is an affection of the spleen. We 
know nothing of disordered/imc/ion of the spleen, any more than of disordered 
function of the pancreas; but structural diseases of the organ, and inflammation of 
it, are sometimes exceedingly evident. Like the pancreas, it is very rarely affected 
with acute inflammation, or with suppuration. Now and then, in peritonitis, that 
portion of the membrane covering the spleen is inflamed; but the substance of the 
spleen is seldom affected in that way. 

Chronic Splenitis. — When it is the subject of chronic inflammation, there is 
pain in the region of the spleen; — pain far back on the left side, higher than the 
kidney; but there are no symptoms of chronic inflammation of the kidney; — such 
as a retraction of the testicle, pain down the thigh, pain in the testicle, and an 
unnatural desire to make water. There is an absence of the symptoms of inflam- 
mation of the kidney. 

Hypertrophy of the Spleen. — It is not uncommon to see the spleen enlarged 
after ague. I formerly stated'' that this disease is called *' ague-cake" by the com- 
mon people; but technically it is termed "hypertrophy of the spleen." When it 
is in this state it is generally harder than natural. The size that the spleen will 
attain is very considerable. I have seen it reaching the pelvis; and extending from 
the navel towards the other side. We may easily distinguish between an enlarge- 
ment of this organ, and an enlargement of the liver, by this circumstance; — that, 
on applying the fingers, we find the edge is vertical; whereas, in enlargement of 
the liver, the edge of the tumour is horizontal. The hypertrophied spleen has 
sometimes weighed twelve pounds. Hoffmann mentions finding one that weighed 
fifteen pounds; and Morgagni, on second-hand information, mentions a case where 
the tumour weighed thirty-five pounds. 

Causes. — This disease will occur in children, and I have frequently seen it in 
infants. It generally arises after ague, or after the patient has been exposed to 
malaria. I met with a singular instance of this enlargement, some years ago. A 
woman had two children; and she herelf had had ague, but they never had. 1 rather 
think she had lived in an aguish part of the country, before the children were born. 
One of them had enlargement and induration of the spleen, and died. After a time, 

See Page 241. 



884 DISEASES OF THE SPLEEN. 

t?ie same disease began in another child; and I believe it is going on now. I have 
no doubt but that it will kill it. On opening the body of the first, we found the 
spleen enlarged, and very hard; but, in other respects, the structure appeared 
healthy. Theie was no unnatural appearance in it. 

Constitutional Effects. — Patients, in this disease, are generally very pale. The 
blood is not proper in quality, if it is in quantity; — it is deficient in fibrin, and 
likewise in red particles. The wasting of the body is not in proportion to the pale- 
ness. The patient's bulk remains pretty good, for a long time; although he will 
become blanched,- — in a state of ansemia. Now and then there is a little ascites. 
The peritonaeum covering the spleen becomes aff'ected, like the rest of the mem- 
brane; and produces a larger secretion than before. The diagnosis is very easy, 
long before the spleen has attained to a large size. 

Treatment of Hypertrophy. — With regard to the treatment, it would be merely 
that for any chronic inflammation, or induration. I believe that, if the tumour 
attains any very great size, nothing can be done; but I have diminished it by the 
administration of iodine, externally and internally. I have successfully treated 
many cases in this way; but I have seen others in which treatment of this descrip- 
tion failed. If there be pain on pressure, local bleeding, mercury, and the common 
remedies for inflammation, will be proper. Where the disease has arisen from 
malaria, it would certainly be well to give the sulphate of quinine; for I have seen 
improvement take place where the constitution has suff'ered from malaria; and I 
have also seen enlargement of the liver much diminished, and give way, with very 
little other trouble. If, therefore, there had been any exposure to malaria, I should 
give the remedies for ague; but iodine has frequently, I know, a considerable 
eff'ect in diminishing diseases of this description. Sometimes there is no pain 
whatever; and there, of course, we should not think of applying leeches, or bleed- 
ing the patient. But if there be pain on pressure, local bleeding ought to be re- 
sorted to, in proportion to the general afl^ection. 

Induration and Softening of the Spleen. — Sometimes, without any enlarge- 
ment, we find the spleen exceedingly hard, — cutting exactly like liver; and some- 
times, on the other hand, it will become exceedingly soft. Very often where, 
during life, we could discover no particular ailment referable to the abdomen, the 
spleen is soft. If it be not preternaturally hardened, we may, by working it up in 
our hand, bring it to the consistence of currant-jam; but in various diseases we find 
that the spleen, on being cut, is soft. 

Congestion of the Spleen. — The spleen sufl!ers a great accumulation of blood, 
■when there is any obstruction in the organs of respiration. It is supposed by 
some, that the size of the spleen may depend very much upon the mode in which 
patients die. If they die after long-continued dyspncea, we may find the spleen 
large; although, during life, it was not so enlarged. 

Tubercles of the Spleen. — Tubercles, of various kinds, are found in the spleen; 
and I met with a singular instance of a large number of vessels in the spleen in a 
state of ossification. 

Pancreatic Calculi, SfC. — Calculi have been found in the spleen; but diseases 
of this organ are not very apparent, unless the organ itself becomes enlarged. It is 
said that people can do as well ivithout this organ, as with it; and, since the time 
of Galen, persons have amused themselves with cutting out the spleens of the 
lower animals; and have said that they perceived no difference afterwards. It is 
said tliat the spleen, as well as the pancreas, has been absent congenitally; but 
such things must be exceedingly rare. 



DISEASES OF THE LIVER. 885 



CHAPTER IV. 

DISEASES OF THE LIVER. 

SECTION I.— HEPATITIS. 

We will now proceed to consider the diseases of an organ far more important 
than the pancreas or spleen; — namely, the liver. It is very subject both to acute 
and to chronic inflammation. 

Symptoms of Jicuie Hepatitis. — AYhen the liver labours under acute inflamma- 
tion to any considerable amount, the symptoms are pyrexia and constant pain, 
chiefly in the right hypochondriam. The greater part of the liver is on the right 
side; and therefore we have the pain chiefly there. There is likewise a sense of 
tension, or weight. It is said, that if the surface of the liver sufl*er, there is mere 
tension; whereas, if the substance be affected, then a weight is experienced; or if it 
be the peritonasal coat which is inflamed, then we have a greater degree of pain on 
pressure, and pain of a sharp character. The pulse is said to vary accordingly as 
we have inflammation of the peritonteal coat, or inflammation of the substance; but 
we cannot depend much upon that. We have diflferent kinds of pulses, in various 
circumstances. The pain extends up to the scapula, goes through to the back, 
and very frequently to the right shoulder. The patient lies best on the right side; 
because, if he lie on the left^ the whole m^iss of the liver (situated as it is chiefly 
on the right side) drags towards the left, and all the parts are put on the stretch. 
We find, in disease of the heart, that he lies best on the right side; and this is also 
the case in disease of the liver; but the situation of the uneasiness makes the 
difference between the two diseases very remarkable. There is difficulty of 
breathing, and an aff"eclion of the chest, in disease of the liver; but not so great as 
in disease of the heart. The difficulty of breathing arises from the motion of the 
liver, in respiration, in accordance with the ascent and descent of the diaphragm. 
There is likewise, from the proximity of the liver to the diaphragm, a dry cough; 
and if we have any doubt about the situation of the pain, — whether it is just on 
one side the diaphragm, or on the other, — we have only to apply the stethoscope. 
If it be disease of the liver^ there is no alteration of the sounds; whereas, in an 
affection of the chest, we find the various signs which I mentioned before.* From 
the proximity of the liver to the stomach, there is very frequently nausea and 
vomiting. Very often there is a little jaundice; and sometimes com/7/e^e jaundice. 

Termination in Suppuration. — This acute inflammation frequently terminates 
in resolution; and sometimes in suppuration. Tlie latter circumstance is rare in 
this country; but in hot climates it is very common. Occasionally, — as I men- 
tioned when speaking of suppuration of the brain,'' — the pus is secreted in small 
drops throughout the organ; but in other cases it forms one immense abscess; and 
sometimes both circumstances occur. The quantity of matter which will be col- 
lected in this way, is sometimes enormous. There are various ways by which 
nature gets rid of this pus. Occasionally an adhesion forms between the two parts 
of the peritoneum, — the loose and the visceral: and the matter points externally. 
Sometimes an adhesion takes place to the slomacli; sometimes to the intestines; 
and I think the matter more frequently finds an outlet in that way, than in any 
other. Sometimes nature does not succeed in forming adhesions, and then the 
matter is poured into the peritoucieum. Now and then an occturrence takes place 
less favourable than the discharge of the pus, into the stomach and intestines; — 

a See Pa.qres 707 to 715. " See Page 488. 



886 DISEASES OF THE LIVER. 

adhesions take place to tlie diapliragm; and the matter is discharged tlirongh the 
air-passages. We have cases on record, in which the pns has discharged itself into 
the gall-bladder; and cases still more rare, in whicli it has presented itself, not at 
the fr072l, or at the side, but at the back. Cases of this description have been mis- 
taken for lumbar abscess. Occasionally the matter lias been discharged with the 
urine; and there is one case upon record, in which an abscess emptied itself into 
the " vena cava;" and death was the consequence. Sometimes the abscess does 
not discharge itself at all, but there it remains; and patients have died with a large 
abscess in the liver; — the existence of which was not known before. If the matter 
be disposed to discharge itself externally, it is evident enough; if it discharge itself 
into the stomach, we have vomiting of matter; if into the intestines, we have a 
quantity of matter in the stools; and if it discharge itself by the air-passages, you 
have cough, and many of th.e other signs of phthisis. 

Terminates in Chronic Hepatitis. — But more frequently than otherwise, per- 
liaps, the acute disease subsides into the chronic form. If the inflammation be 
situated on the surface, we shall have great chronic inflammation; — there will be 
great pain, especially on pressure, and (in all probability) ascites, — from the peri- 
tonaeum being affected. If the substance only is diseased and llie peritonaeum 
escapes, we have merely a dull heavy pain there; and very frequently no ascites at 
all. Of course chronic inflammation of tlie substance, and of the surface of the 
liver may be conjoined; — the same as in the acute form; and the former, as well as 
the latter, will produce an abscess, and be followed by all the structural diseases to 
which the part is subject. 

Common in Fevers of Hot Climates. — The acute form of the disease is very 
common in all the fevers of hot climates; and hepatitis is continually united with 
all other inflammations of the abdomen; — with enteritis, peritonitis, gastritis, and 
all the other inflammations of that region* The chronic form is very often united 
with dysentery. It is very common for a person to have chronic dysentery, and 
chronic hepatitis at the same time. 

Causes. — The causes of hepatitis, whether acute or chronic, are the common 
causes of inflammation; — getting wet, exposure to cold, and other similar occur- 
rences. It appears to be much predisposed to by continued heat; the disease, at 
least, is very common in hot climates. It is said that long-continued heat alone in- 
duces pure hepatitis; whereas, if the long-continued heat be united with the cause 
of fever, — such as malaria and other things, — then we have a combination of hepa- 
titis with various fevers. 

Diagnosis. — As to the diagnosis, the disease is easily distinguished from in- 
flammation of the chest, in the way I have mentioned; — by the absence of all 
auscultatory signs; by the situation of the pain; and by there being nausea and 
vomiting. It is distinguished from gastritis by the situation of the pain, which is 
much to the right side; while, in gastritis, it is in the epigastrium, and more to the 
left side, — from the stomach being to the left of the epigastrium. We may have 
symptoms at the epigastrium in hepatitis; but we have also considerable pain on 
the right side. It is distinguished from peritonitis by the local nature of the pain; 
for, in peritonitis, there is inflammation at other parts of the abdomen. 

Morbid ^Appearances. — On examining tlie liver after it has been in a state of 
common inflammation, we find that it is the convex portion of the liver that is 
generally inflamed. There may be red points, lymph, and turbid serum upon it; 
and the peritonasum may perhaps be thicker than it should be. In chronic inflam- 
mation, we find adhesions; and t!ie bands are very strong. Sometimes there are 
white patches on tlie surface of the liver; and the peritonaeum becomes white, 
opaque, and soft. If the substance have been inflamed, there is usually a general 
redness; and the size of tiic liver is increased, — from the quantity of blood it con- 
tains. Sometimes the redness is only partial; and then the red plates, mingled 
with the parts naturally pale, give it a mottled appearance. In cutting the liver, 
generally a large quantity of blood flows out; and we must lemeniber that, without 
inflammation, the liver frequently suflTers a great congestion of blood. In the dis- 



DISEASES OF THE LIVER. 8S7 

ease called " purpura," there is great cono-esiion of blood in the liver. After 
asphyxia, chronic bronchitis, all diseases of the heart, and all obstructions to the 
course of the blood througli the heart or kings, we ^md the liver in a great state of 
turgescence; so that, on cutting it, the blood pours forth, and the ves>:els look like 
sinuses. In infants who have been aspliyxiated at birth, the congestion of blood 
in t!ie liver is occasionally so great at the part under the peritonaeal coat, that some- 
times it will burst through it into the abdomen. Sometimes, in inflammation of the 
liver, there is haemorrhage into the substance of the organ; and sometimes the 
blood will rupture the substance of the organ. I presume there must have been 
some degree of softness of it previously. We may fim] a great mass of blood, or 
several litUe collections of it; sometimes it is coagulated, and sometimes not; oc- 
casionally we may iind it in the vessels, and sometinies not; — accordingly as it has 
oozed from one, or from several. 

Treatment. — We have now to consider the freafment of acute and chronic he- 
patitis; and this may be dismissed in a very few words. It is the simple commdn 
treatment of inflammation; and, for the most part, it is very successful. W"e have 
only to make our diagnosis; — to ascertain that it is disease of the liver, acute or 
chronic; and to treat it accordingly. It was once supposed (as we find mentioned 
in works published twenty or thirty years ago), that mercury ought not to be given 
in acute inflammation of the liv^er, because it stimulated the organ; but that it was 
proper in the chronic form. The truth is, however, that both forms req'.iire the 
same treatment. The terms "«cZc'/e" and ''chronic''' refer merely io [he duration 
of the disease; and there is no difference between them, except that the symptoms 
are less urgent at one time than at the other; and whatever is good in the one, is 
beneficial in the other in a less degree. But, independently of that consideration, 
I do not know that mercury has any extraordinary power in stimulating the liver, 
in ilie way that has been supposed. It was thought it would give a bilious tend- 
ency, when there was not one; and it is possible that mercury may produce 
bilious evacuations, when it is long continued; but lam sure that mercury, pushed 
on to ptyalism, is just as useful in active hepatitis, as in any other active inflam- 
mation. I do not know that it will do any good by its specific action on the liver; 
but it will by its general tendency to subdue active inflammation. Purgatives are 
particularly useful in inflammation of the liver; — much more so than in inflamma- 
tion of the chest; because they act as local means, and prevent a great quantity of 
blood from going into the " vena p(3rtce;" and therefore less gets into the liver. 

Treatment of the Chronic Form. — The chronic inflammation requires the same 
treatment as the acute, only carried on less violently, — carried on chronically; — 
not doing all we have to do in a day or two; but carrying on our measures for some 
weeks, or even months. The moderate exhibition of mercury — not to produce a 
rapid ptyalism, but so as to keep up a gentle affection of the mouth — is useful. 
Long-continued purging is very beneficial in chronic disease of the liver; and hence 
the Cheltenham waters do great good in this affection, by draining the abdomen, 
generally. Some have conceived that acids are useful as tonics; and the nitric and 
muriatic acids were very famous some time ago; but I do not know that there is 
any particular use in them. I have always succeeded in treating chronic inflam- 
mation of the liver, by tiie same means that I employ in any other inflammation; — 
more or less loss of blood, general or local, and the moderate exhibition of mercury, 
I have never found it necessary to make any difference between treating inflamma- 
tion of the liver, and inflammation in any other part. Some have thought that 
dandelion does good; but I have never seen its virtues in afl'ections of this kind. 

Treatment of the Suppurative Stage. — As to the suppuration which sometimes 
occurs, that reqiiires to be treaterl on com.mon principles. If the abscess point to 
the skin, of course a knife may be applied, and the matter let out; — just as in any 
(^ther abscess: only that it might be dangerous to let out a great quantity at once. 
It should be done gradually, in order that the part may slowly contract. If the 
discharge take place inwardly through the lungs, or the intestiiies, we have only to 



888 ' DISEASES OF THE LIVER. 

lessen the irritation by narcotics, — as in other cases; and this will also be required 
on opening the abscess. 



SECTION II.—STRUCTURAL DISEASE OF THE LIVER. 

Symptoms. — Many diseases of the liver are called "chronic hepatitis." The 
liver is subject to a vast number of structural diseases; and these pass as chronic 
hepatitis. Indeed, it is very often impossible to make the distinction. At the outset, 
there is pain on the right side, pain at the shoulder, perhaps a little jaundice, ten- 
derness in the region of the liver, feverishness, and wasting; and we may say that 
the patient is labouring under chronic hepatitis. We treat him accordingly; but 
without success. On the contrary, the disease obstinately remains; and at last, 
perhaps, the liver becomes much thickened, and very much enlarged. Sometimes 
it is enlarged and hardened, from the very first; — simply as the result of inflamma- 
tion; and sometimes it may be subdued by the common remedies of inflammation. 
I am quite sure that the liver will inflame from mere turgescence of blood; and 
perhaps without inflammation, — from mere congestion, — it will become very large. 
I am sure that the bulk of the organ ^v\\\ niter, according to the quantity of blood 
in it; for I have seen it large, and very soon (in a week or two) it has been small 
again. I have no doubt that internal organs will vary much. They will suffer (if 
I may so speak) a sort of erection, from the congestion of blood. Certain it is, 
that tiie liver will sometimes be large from blood; and by active measures will be 
brought down, in a very short space of time, to the natural state. 

But supposing we have used the remedies for inflammation, and that the disease 
does not cease, and that the size of the liver does not diminish, then we have reason 
to suppose that there is something more than chronic inflammation; — that there is 
a change of structure; and it is of no use to push on, with activity, the means for 
remedying inflammation. Indeed, we should only break up the constitution by 
them. It may be necessary, if there be pain and tenderness, to bleed occasionally 
(either by cupping or leeches), to exhibit mercury, and to order low living; but if 
we push these things far, we frequently break up the patient's constitution, without 
aff'ording him any relief. It is often necessary to support the strength well, and 
even to give the patient stimuli, in order to enable him to bear up against this 
organic disease. 

Diagnosis. — With regard to the signs of organic disease of the liver, we may 
sometimes make it out very well, by the edge of the liver being well defined; — 
running across, and being hard, and even sharp. Sometimes the most easy way 
of discovering an indurated liver, is not by pressing hard down around the region 
of the organ; but by putting our hand over it, and suddenly bringing down the 
fingers. Frequently the liver is an inch or two from the surface; and if we press 
it regularly, we may not feel it; but if we press the integuments down upon it, we 
feel it in a moment. Occasionally we may discover tubercles in the liver. 

Varieties of Organic Diseases in the Liver. — With regard to chronic disease 
of the liver, we must recollect that the liver, like the kidney, consists of two parts; 
the one sanguineous and red; and the other white or yellow, — containing bile. 
They are not divided; but throughout the liver there are two constituent parts, 
lying in juxla-position. Now sometimes it is only the red portion of the liver 
that is hypertrophied; so that the organ is enlarged and red. Sometimes it is the 
hiiiary portion; — the bile-tubes are all in a state of hypertrophy; and then v/e have 
apa/e liver, — a liver enlarged and pale. Sometimes, without being enlarged at all, 
it will be pale, 'i'he red part is atrophied, — the vessels shrink; and the biliary 
part is hypertrophied; or, if not hypertroj)hied, it is indurated; or, if not indu- 
rated, it remains as it was; but as it has a preponderance over the red portion, the 
liver looks pale. These changes sometimes occur throughout the liver, and some- 
times only in spots; so that here and there one portion of the liver is firmer and 



DISEASES or THE LIVER. 889 

retlder than it should be; while, perliap?;, in other instanc?s, the biliary portion is 
hyperlrophied here and tliere, — giving- it a mottled appearance. 

Gin-Liver. — Sometimes tlie hypertrophiod portion of the liver lias the appear- 
ance ol' white lines running along- it; and sometim.es of granules, — varying in size 
from that of pins' heads, to that of hazel-nuts. There is a difr-rence of opinion, 
among morbid anatomists, with regard to this aflection; wh.icdi has been railed 
"o-in-livcr," and which is the most common of all organic diseases of the liver. 
Dr. Baillie and others supposed that it was caused by minute yellow tubercles 
throughout the liver; an*d Andral imagines that it is a mere hypertrophy of the 
biliary portion. Cruveilhier has given a good delineation of this dise;ise; and has 
called it " small brown tubercle." I suppose, as it is a " _^z?2-liver" in this country, 
it is a " brandi/Aiver'^ in others. Perhaps " alcohol-ViveY^^ would be the best name. 
It occurs in spirit-drinkers in one country, just the same as in another. There is 
the same punishment for them all. I presume that the constant use of alcohol, 
induces a chronic change of the biliary portion of the liver; — causes it to become 
hypertrophied, and indurated; — ^just as any serous membrane will become (from 
other circumstances) indurated, opaque, and hard. This is the history of this par- 
ticular matter. 

Sometimes this morbid change occurs more in one lobe than in another. Some- 
times the liver is increased altogether; and sometimes, instead of being increased, 
it is shrunk. The liver generally feels very hard on the external surface. Fre- 
quently it is indurated in particular portions; but wasted on the whole. I think 
that, in by far the greater number of cases, a "gin-liver" is of a bright yellow 
colour; and generally there is more or less ascites. The peritonaeum over the liver 
is generally more or less diseased. It is particularly opaque and hard. 

Fatty Degeneration of the Liver. — Perhaps the disease to which the liver is 
most liable, is that of becoming fatty. The liver is sometimes exceedingly fat. 
We know that the liver naturally contains fat and cholesterine; and these matters 
will sometimes exist in a great degree. When the liver has degenerated into this 
fatty state, instead of being indurated, it is usually soft and flabby. Sometimes it 
is grayish or whitish; and such is the quantity of fat deposited, that on cutting or 
handling it, our fingers become greasy; and in those parts which are the most 
fatty, it appears as if there were no blood at all. This disease, like every other, 
will affect either the whole liver, or only portions of it. This state is frequently 
united with })hthisis. It is a disease seen continually; — without the person having 
been addicted to drinking, or having imbibed any bad habits. It frequently occurs 
in young persons. 

Encephaloid Disease of the Liver. — The liver is also subject to encephaloid dis- 
ease; — to what is called "fungus haematodes." This is much more rare than either 
of the other forms of disease to which I have adverted;^ but when fungus haema- 
todes has existed in the extremities, then it is very common for a collection of this 
nature to take place in the liver. Occasionally, I believe, encephaloid tumours are 
said to be found in the liver, without the disease occurring in other parts; but more 
frequently they are found in combination with disease of the extremities. These 
tumours are, of course, white; and sometimes there are tuberae, producing an ele- 
vation on the external surface; — bumps. They are of various sizes; — some existing 
near to the surface, and some towards the centre of the organ; and, when cut, are 
found to contain a brain-like substance. 

Scrofula, Scirrhus, and Melanosis of the Liver. — The liver is also subject to 
another disease, — to a new formation; namely, scrofula. Scrofulous tumours take 
place, from time to time, in the liver; and they are, of course, white. The ence- 
phaloid tumours look exactly like them. Cruveilhier has given some good repre- 
sentations of them. The scrofulous disease is sometimes mixed with encephaloid 
matter, — with "brain-like" substance; and sometimes there will be a mixture of 
scirrhits v/ilh it. I have frequently seen scirrhus in other parts, with scrofula de- 

^ » See Pages 885 to 889. 



890 DISEASES OP THE LIVER. 

posited in its neigliboiirhoocl; and so it is in the liver. Occasionally melanosis 
exists in the liver; — the black deposit of which 1 formerly spoke. 

The foregoing are the chief organic diseases of tlie liver. Besides inflammation, 
we may have enlargement from congestion of blood, or from abscess; — we may 
liave the red part hypertrophied here and there, -r—so as to give the organ a mottled 
appearance; and indurated at the same time, — so as to give ns red tubers; — 
"tubercles," as they have been called in this country; but I would rather say 
"tuberae." Then we may have the biliary portion hypertrophied; and that is 
called "gin-liver." In addition to that we may have encephaloid tumours; — re- 
sembling the brain in structure, consistence, and colour; and perhaps with blood 
effused in them here and there. Lastly, we may have scrofulous and scirrhous 
tumours, and melanoid deposit. 

Size tchich the Liver may attain. — Mr. Gooch, a surgeon, mentions that he 
saw a liver which weighed twenty-eight pounds. I have frequently seen it reach- 
ing into the pelvis. It is a curious circumstance, that we sometimes meet with a 
liver thus enlarged, which has caused no suffering at all. The patient has never 
complained of pain; but has felt weak, and tias wasted a great deal. This is par- 
ticularly the case in women. I have frequently examined women in this state; 
though, during life, they were not known to have disease of the liver. They 
never drew attention to the abdomen; but merely said they w^ere weak. It shows 
the necessity, when we cannot understand patients, of having them placed in bed; 
and of examining them from the throat downwards, — over the heart, lungs, and ab- 
domen. In that way we continually meet with something, which was not in the 
least apprehended. 

Hydatids of the Liver. — The liver is very subject to the formation of hydatids. 
The kidneys and the liver are the two organs of the body, w?hich are most subject 
to the formation of hydatids. The true animal nature of these hydatids, has not (I 
believe) been pointed out in the human subject; though it has in sheep. In the 
latter they have been observed to have a contractile power; but this has not been 
noticed in human beings. The appearance, however, is so much the same, that 
one must suppose them to be real hydatids. They are sometimes inclosed within 
others; — like pill-boxes. Sometimes they are attached by peduncles, hanging one 
within the other; and sometimes they grow to the outside of eacli other. A repre- 
sentation of them is given in Dr. Baillie's work. Sometimes they are attached to 
the liver externally; — hanging to-it: but, generally speaking, they are enclosed in a 
cyst. Sometimes they are found in the middle of the substance of the liver. The 
cyst which contains them is usually hard, even cartilaginous. I believe they have 
two coats; and, when dead, they have no longer a globular appearance; but are like 
skins, or half dried mucus. In sheep, I believe, they are seen to have a neck and 
a mouth. 

I had a very remarkable instance of this description, in a lady who had laboured 
under chronic hepatitis for fifteen yeai-s. At last she began to cough, and to spit 
hydatids; and died. On opening her, I found a large cyst of these hydatids, at- 
tached to the concave portion of the liver, on the riaht side. In the middle of the 
liver, there was another sac filled with them. Ulceration took place, and they 
made their way through the diaphragm; — the cyst emptying itself pardy into the 
air-passages. Under all this the irritation was so great, that she died. 

Worms in the Liver. — Worms have sometimes been found in the human liver; 
and a lumbricus has been found in the ducts; but I should rather think it was not 
a native; but a wanderer that, being on its travels fi'om the intestines, lost its way. 
Treatment. — In all these cases, it would be quite fair to have recourse to iodine, 
in the form of iodide of potassium, — both inlernally, and rubbed over the indurated 
part. I have seen hirge livers, — reaching to the umbilicus, and below it, — reduced 
bv the steady use of iodine, and sometimes iodine combined with mercury. But 
it'is frequenUy necessary, while doing this, to support the patient well; — especiallv 
if we exhibit mer'cury. Not only should mercury be given with caution, but we 
should support the patient well; because the dose thul is necessary to do good, tends 



DISEASES OF THE LIVER. 891 

to impair the constitution^ Iodine, however, may be made to do good without in- 
juring the patient. Setons may, perhaps, be serviceable. 

The greater number of these cases cannot be distinguislied during life. We can 
tell that there is organic disease, by feeling that the liver is very large and very 
hard, by the patient wasting a\)g^, and becoming sallow and jaundiced; and some- 
times we find there are tuberse (bumps) in the region of the liver; but very often it 
is impossible to say what exact structural disease there is. If we have seen " fun- 
gus haematodes," or scirrhus, in other parts of the body, we may suppose the dis- 
ease in the liver to 'be of that nature. 



SECTION III.— JAUNDICE. 

The next disease of the liver which I shall describe, is one in which the secre- 
tion (instead of passing out properly into the intestines) is absorbed, enters into 
the blood, and tinges the skin and the urine yellow. I need not say that this dis- 
ease, in common language, is called "jaundice;" — a term which is derived from 
the French word "■jaune^^ (yellow.) 

Synonymcs. — In brutes it is called ^^\\\e yellow s^ In medical language it is 
called " icterus;" which is said to be the name of the golden thrush; and by look- 
ing at that bird, like tlie Israelites looking to the brazen serpent in the wilderness, 
it was thought those that had the disease would be cured.** The thrush, it was said, 
would die. In ancient nations, the cure of disease was often attempted by looking 
on certain things; and I suppose it had its origin from what occurred to the Israel- 
ites. In Latin, jaundice is termed " morbus regiws," — " the royal disease;" and 
the reason given by several writers is, that in this affection persons require many 
kinds of amusements, that none but kings or royal persons can command. It is 
also called, in Latin authors, " morbus arquaius^''^ from the patient having the 
various hues of the rainbow (" arcus.") It is also mentioned under another name, 
— "«//r/o-o." I presume this has its origin from "aurum" ("gold"). The word 
^^jaundice^^ is simple, and a very fine name for "yellow." In the case of poor 
people it is called, in plain terms, "the yellows;" but if a lady have the disease, it 
is termed ^^ jaundiced 

Symptoms.— Th'i^ disease is marked by yellowness of the skin, eyes (conjunc- 
tivae), roots of the nails, and urine. This disease may occur without the faeces 
being pale: but generally they are so. The parts which are first seen to be yellow, 
are the nails and eyes; and they are the parts that remain yellow longest. It is 
simply for this reason; — the "half-moon" of tlie nails (as it is called), and the con- 
junctivae of the eyes being naturally so very white, we discover in them the slightest 
tinge of yellow. 

Venule ties in Colour. — The yellow is not always of the same cast. There is a 
bright, a dark, and a green yellow; and some persons labouring under jaundice, 
are of a dark olive-colour, so that it borders upon green; and therefore we some- 
times hear of "^reen jaundice." If a person be naturally swarthy, when labouring 
under green jaundice he looks very dark; and then he is said to have " the black 
jaundice;" — so that we Irave a green-yeWow and a black-yeWow. It is a contradic- 
tion of terms; but it shows the variety of hues under which the disease appears. 

Ye.Uoumess of Vision. — Occasionally it has happened that patients have "seen 
yellow." It was maintained, by some, that that was always the case. Dr. Pem- 
berton says he saw this occurrence twice; and that, in both eases, the jaundice was 
not very intense. On the other hand, we every day see cases of intense jaundice, 
without any yellowness of tlie vision. HoOmann says, tliat twice he saw patients, 
who declared that every thincr appeared yellow. It has happened to me to have 
two patients labouring under jaundice, who made the same statement. In July, 

» Moses made a serpent of brass, and set it npon a pole; and it came to pns<: that, if a ser- 
pent had bitten any man, when he beheld the serpent of brass, he lived.— "iV(t7?i^'tf?-5,-" Chapter 
21j Verse 9. 



892 DISEASES OF THE LIVER. 

1823, I had (in St. Thomas's Hospital) a case of icterus, where there was albugo 
of each eye, — particularly of the left. IiUo this eye ran two large red vessels, and 
with it the patient "saw yellow;" but tiie right eye, which had no inflammation 
before liie cornea, — into which no large vessels were running, saw things in their 
natural colour. In 1827, I had another hospital-patient, who "saw yellow" with 
both eyes; and in bim the conjunctiva immediately around the cornea, — quite at 
the ei^ge of the orbit, was greatly inflamed. In 1831, I saw a patient labouring 
under jaundice; and be said that, at tbe beginning of the disease, he "saw yellow." 
He did not know wheiher his eyes had been inflamed; but there were several tole- 
rably large vessels running, not quite to the cornea, but pretty close to it. When 
patients "see yellow," it is from the serum of the blood being conveyed before the 
pupil, through the cornea. It must be accounted for in that way. In the second 
case of this occurrence which I met with, I was prepared for inflammation of the 
eye, by having noticed what I did in the first case. I looked carefully at the man's 
eye, the instant he told me that he "saw yellow," and I found, as I expected, that 
it v/as in a state of inflammation. Wbether this will always be observed wh^n 
patients "see yellow," I do not know; but it afl"ords an explanation of the circum- 
stance, and is worth investigating. If a person labouring under jaundice be blis- 
tered, the fluid from the blister is yellow; and the serous fluids within the body, 
are found to be of the same colour. 

The Blood loaded with Bile. — It is worthy of remark, that the blood of jaun- 
diced patients is loaded with bile. Hunter thinks that the artificial mixture of bile 
with the blood, produces coagulation; but I think that a quantity of bile mucli too 
small to afl'ect coagulation of the fluid, may nevertheless be suflicient to give a tinge 
to the serum. 

Interned Symptoms. — Besides these visible symptoms in jaundice, there are 
several others. Patients generally complaim of languor, and very frequently of 
drowsiness, but still more frequently of a dead weight, — a load at the epigastrium; 
and of tenderness, and sometimes actual pain, at the hypochondrium. In fact, this 
is a disease which every day occurs in conjunction with hepatitis; and is, in many- 
cases, merely a symptom of it.. There is frequently loss of appetite, nausea, and 
vomiting; and there is one curious symptom in the disease, which is very common 
indeed; and that is an itching of the whole surface. People say "they could tear 
themselves to pieces." 

Occurs at all Ages. — Jaundice, like so many other diseases, occurs both in 
young and old persons. Infants often have it a few days after birth, and some per- 
haps at birUi; and the oldest persons are liable to it. In infants, it appears to be 
produced from the very slightest causes; and it is cured with the utmost ease. In 
general, it is a slight disease, arising from slight causes; and may be cured by slight 
remedies. 

Yellow Skin not Peculiar to Jaundice. — Sometimes we see yellowness of the 
skin, not as the result of jaundice, but in fever; namely, that which is called "?/e/- 
loiv fever." The yellowness is not universal in this case. It occurs particularly 
about the neck; and it appears rather to arise from the disordered stale of the blood, 
or an altered condition of the blood as to some of its constituents;' — exactly as we 
see it in bruises. After a certain part of the blood has been absorbed from an ecchy- 
mosis, a degree of yellowness remains; but that is not jaundice. Occasionally, 
after the bites of certain serpents, and the infliction of wounds by the bite of cer- 
tain animals, the skin will become yellow; but this does not appear to be jaundice. 

Predisposing Causes. — Some people would appear to have a constant predispo- 
sition to this disease; and it may be hereditary. Persons who have been in warm 
climates, are much more predisposed to the disease than others. 

Exciting Causes. — The exciting causes of it, are any circumstances that will 
produce inflammation and congestion of the liver. Whatever will produce hepa- 
titis, or cause great congestion of the liver, will produce jaundice. It may arise, 
not only from cold and wet, and from long-continued heat, but also from the sup- 
pression of a discharge; by which a congestion of the liver will be produced. It 



DISEASES OF THE LIVER. 893 

will arise from any thing that causes an excess of bile; for occasionally the fseces, 
in this disease, are not white. Bile passes into the intestines; but so much is 
secreted, that all does not escape; and a portion goes into the blood. Malaria 
seems to have a tendency to produce it in hot climates, and in the hot seasons of 
other climates. Persons exposed to the influence of malaria, are very subject to 
have more or less jaundice among them, as well as other hepatic affections. 

Local Causes. — It may be produced by a variety of local causes; — any thing 
which will cause pressure upon the parts through which the bile is conveyed. 
Mere costiveness has been known to give rise to it. Tumours occasioned by an 
enlarged pylorus, or by an enlarged head of the pancreas, — tumours of the omen- 
tum, — diseases of the liver, — the lodgment of a calculus in the ducts, are also 
common causes of this disease. If a portion of liver becomes harder than it should 
be, and perhaps rather enlarged, the bile may be obstructed in the liver itself. 
Sometimes pregnancy causes it. I have frequently seen jaundice in pregnancy; — 
not, however, as the result of pregnancy; but as the result of inflammation of the 
liver; and which disappeared under the treatment for common inflammation, while 
the pregnancy went on. It is supposed to be occasionally produced by thick bile; 
if there be any obstruction to the bile, its fluid parts may be absorbed, and it will 
thus become inspissated; but there is no proof that this is the cause rather than 
the effect of the jaundice. It has been known to be caused by a lumbricus stick- 
ing in a duct of the liver. I mentioned, when speaking of worms in the liver, 
that a lumbricus has occasionally (as was supposed) lost its way, and wandered 
into the liver;* and if it stick there, it may cause jaundice. If tl>e ducts them- 
selves become thickened by chronic inflammation, — if they become hypertrophied, 
their canal may be so much diminished, that the bile cannot easily pass; and con- 
sequently we have jaundice. I have seen jaundice from a great many of these 
causes; and in 1829 I met with a case, in which it was occasioned by a great 
number of fatty deposits, all round the ducts. Sometimes the ducts are impervious 
from original malformation. There are a few instances of this upon record. It 
would appear sometimes to be produced by spasm. I have known some persons, 
on eating certain articles, to be seized with violent pain at the pit of the stomach; 
and the next day an attack of jaundice has appeared. It has been produced by 
mental causes. Many persons have become yellow from fright. I believe that, 
in general, people from fright look blue; but sometimes, from being exceedingly 
frightened, persons will have a fit of jaundice. Occasionally the disease has arisen, 
not from terror, but from long-continued grief and anxiety of mind. 

Enlargement of the Buds. — When the ducts have been obstructed, they are 
generally larger than they should be; and Dr. Heberden is said to have seen them 
dilated to an inch in diameter. Sometimes, however, no obstruction is found. I 
have opened several persons who have died, not from jaundice, but ivith it, in 
whom I could see no obstruction whatever; and Sir John Pringle mentions, in his 
work on Diseases of the Army, that one of the army-surgeons told liim of a case 
of jaundice, in which there was no obstruction; but in which the slightest com- 
pression caused the bile to flow.^ Andral, I find, says that he has seen the same 
occurrence. 

Artificially induced. — We may produce this disease artificially, by opening the 
abdomen, and passing a ligature round the intestines, a little below the " ductus 
communis choledochus." Portal has done this (he says) in six dogs; and they all 
became jaundiced. If we tie the lymphatic duct, the same circumstance will occur; 
and the absorbents of the liver have been seen, after such an experiment, to become 
loaded with bile. It has been said, however, that the blood from the lymphatic 
veins was found, in such an experiment, to stain paper yellow; — much more so 
than the blood from the choledochus. 

Pathology of Jaundice. — -There was a doubt at one time wheth.er, in jaundice, 
the bile found its way to the blood by means of the absorbents, or by regurgita- 

" See Page 890. 

^ " Observations on Diseases of the Army. By Sir John Pringks" 



894 DISEASES OF THE LIVER. 

lion to the veins. A short time ago, it was not supposed that the veins would 
absorb. Before the absorbents were discovered, it was supposed that the veins 
performed that office; but afterwards, no one allowed that they would absorb at 
all; and now again it is said that they do absorb." While it was believed that the 
veins did 7iot absorb, some contended that, in jaundice, the absorbents took up the 
bile; and others contended that it worked its way into the veins. Experiments 
were then made; and it was observed that the absorbents of the liver were loaded 
with bile; and that the lymphatic veins were more tinged with it than the jugulars. 
If the veins absorb as well as the absorbents (properly so called), v/e may suppose 
that, as the greater portion of bile which found its way into the whole system of 
blood, passed through the lymphatic veins, those veins would contain a greater 
portion of bile than any others. 

Prognosis. — With regard to ihepj^ognosis of this disease, it must depend entirely 
on the cause. Jaundice is nothing more, in most cases, than a symptom of some 
disease; and according to the nature of that disease must be the prognosis. Some 
are very ill in jaundice, and die with it; and others labouring under it go about 
with little indisposition; — they scarcely know that they are ill; they only look very 
yellow. In that form of jaundice in which the yellow verges to green, and which 
has been called " green jaundice,"" recovery is very rare. When we see an indi- 
vidual labouring under jaundice, with his eyes yellow enough, but with a skin 
of an olive-hue, we may (without asking a question) fear that the individual has a 
disease, from which he will not recover. Dr. Baillie says that, in the whole of 
his practice, he never saw more than two persons recover from green jaundice. 
Generally, where the jaundice is of this green hue, there is some organic disease 
of the liver; — either of the whole or of a portion of it. 

The disease sometimes lasts a very long time. The faeces are in general white; 
but very often they are bilious. Dr. Baillie says that, in green jaundice, the faeces 
are usually white, — as in other kinds of the complaint; but he has often seen them 
very pitchy. He says that there is but little pain felt; that there is seldom any 
ascites; and that he seldom knew it arise from intemperance. The reason that he 
assigns for the latter circumstance is, that it so frequently occurs in women. Some 
women, however, are intemperate enough. He considers it as a symptom of some- 
thing which is fatal. Dr. Cheyne mentions that the jaundice of children is danger- 
ous, if it be of a saffron-hue. In children the complaint is generally trifling; but 
sometimes it is not. Mr. J. Pearson (a surgeon of great practice in London, a iew 
years ago) said that he knew a family where there had been eleven children, ten of 
whom died of jaundice within the month; — the disease having begun a few days 
after birth; and that the eleventh died of the same disease at six years of age; — 
evidendy showing the hereditary nature of the disease. What was the cause of 
it in this family, 1 do not know. 

Treatment. — In the treatment of jaundice, we have first to consider whether 
any inflammation exists; — whether it is a case of hepatitis; and if it be, we must 
treat it on the common principles of inflammation of the liver; — in proportion to 
the weakness on the one hand, or the strength on the other. In cases of jaundice, 
mercury answers better than any other purgative. I have frequently made experi- 
ments, and have exhibited common purgatives in some cases, and mercury (so as 
to affect the mouth) in others; and I am sure that patients have recovered more 
quickly by the latter mode, than by the former. In mild cases, however, — where 
there is only congestion of the liver, — the disease will yield to common remedies; 
and many cases will get well of themselves. But if the disease be more severe, 
it would be right to employ mercury, and perhaps to bleed in the arm. 

Treatment of the Spasmodic Form. — The disease may be characterized more 
by spasmodic pain than by inflammation. There may be occasional pain at the 
pit of the stomach, or on the right side, rather than constant pain and tenderness; 

« Consult, on this subject, Dr. Graves's Lecture on the Absorbents; of which a new edition 
has been published. 
" SeePage 891. 



DISEASES or THE LIVER. SOS 

and in that rase the liot-bath and opium are among the best means. But in such 
cases as these, if we find the patient's pulse constantly quick and strong, one of 
the best antispasmodics we can employ is bleeding. If the pain is nol constant, 
but comes on at intervals, and not with a constant severity, we may look upon the 
disease as, to a certain extent, spasmodic; and there opium and the hot-bath will be 
very useful. But if there be general tenderness besides, and bleeding be at all 
admissible, it will answer exceedingly well. It will be more effectual, and much 
better, to combine the opium with a full dose of calomel. This will prevent con- 
stipation, and produce a free discharge from the alimentary canal. In these spas- 
modic cases, in addition to the common treatment for hepatitis, we should give a 
large dose of calomel (ten or twelve grains), and a few doses of opium; — perhaps 
two grains, or more, in a dose. A poultice over the part is also very useful. 

This sudden pain with jaundice, is no proof whatever that the case is one of 
gall-stones. Where there is no jaundice at all, but where a patient is seized with 
sudden pain at the pit of the stomach, many persons say he has gall-stones; and 
if, in addition, there be jaundice, then they consider the matter as certain. But 
mere spasm of these parts will produce this violent pain, and perhaps giddiness 
likewise. We may suspect that there are gall-stones, but frequently we have all 
the symptoms without it; and we have no right to assert that a person has gall- 
stones, unless we see them pass, or they have been discharged. When we consider 
that, from eating something which is indigestible, a person will be seized with vio- 
lent pain at the pit of the stomach, and the next day will have an attack of jaundice, 
it is clear that this occurrence may be produced without the presence of gall-stones; 
— it is obviously caused by something which has irritated the parts. 

Chronic Jaundice. — The greater number of cases of jaundice yield to purgatives, 
or to the treatment of hepatitis; and if we find such severe pain as I have now 
mentioned,^ anti-spasmodic treatment will generally get rid of it. But the disease 
sometimes lasts a long time, — becomes chronic; and it is necessary, after we find 
no more pain, — no tenderness on pressure, to make the patient take free exercise, 
to have the parts well rubbed, to recommend the use of the warm-bath, to exhibit 
mercury, — so as to produce a mild afTection of the mouth, for a greater or shorter 
length of time, — and to make a free use of purgatives. When the disease becomes 
chronic, it will frequently go away under the use of these means. The parts seem 
to i^all into an atonic state. Supposing that the affection continues in spite of all 
these means, then we generally have reason to suspect that there is disease of the 
liver. If there is induration or enlargement of the organ, or a degree of ascites, 
or any kind of dropsy; if persons waste more and more; and especially if the 
tinge becomes green, after having been the plain ordinary yellow; — then we must 
form an unfavourable prognosis, and suspect disease of the liver. In the case of 
enlargement and induration, it is pretty well proved; and then the remedies for dis- 
eased liver should be employed. Setons over the part, and the exhibition of iodine, 
will be the best means that can be resorted to; and we must keep up the patient's 
strength as much as possible. 

W^ith respect to this chronic jaundice, Van Swieten records a curious case; 
which was cured by making a man imitate Nebuchadnezzar. Van Swieten says 
that he persuaded a poor man, in an obstinate case of jaundice, to live upon grass 
for two years, except during that part of the winter when there was none to be got. 
He made him eat the tenderest grass, and also that which was first mowed; and he 
made him take that which was in flower. The man "confessed that, for some 
time, this diet did but little please him; but after a time he was well contented, and 
could easily distinguish the best pastures by the flower of the grass." This I can 
imagine. At last he became a general nuisance to the farmers; for Van Swieten 
says that he was obliged to eat his diet secretly; and that the farmers, finding he 
had so large an appetite, often gave him a quick repulse. The man, however, was 
perfectly cured. 

» See the previous Paragraph. 



S96 DISEASES OP THE LIVER. 



SECTION IV.— BILIARY CALCULI. 

Symptoms. — We can do nothing to dissolve gall-stones; but when they are 
passing, we may lessen the pain. It is said, that wlien they pass, the pulse is not 
quickened, as in inflammation; but that, on the other hand, it frequently becomes 
slow. I believe that this is generally the case; but the same circumstance will 
occur in a case of pure spasm. Sometimes however, the pulse is increased to 
above a hundred; there is sudden pain in the part; and there is vomiting. Some- 
times there is great pain, which is reheved by pressure; — -it is mere spasmodic 
pain. Sometimes there is sliivering. The patient has no increase of temperature; 
and the treatment will be the same as that for spasm; because we cannot say whe- 
ther there is a stone or not. But if the patient have passed gall-stones before, and 
the same symptoms occur again, then we are authorized in concluding that they 
arise from gall-stones. 

Usual Seat of the Gall-Stones. — These stones are found in the ducts of the 
liver itself; they are also found in the gall-bladder, in the cystic duct, and in the 
"ductus communis choledochus." If they exist in the cystic duct, of course they 
will not produce jaundice, unless they happen to be so large as to press upon the 
*' ductus choledochus," or the hepatic duct; but though they will not produce jaun- 
dice, yet they will obstruct the course of the fluid from the gall-bladder; and it will 
become distended, to a great amount, by its own secretion. There is, at St, 
Thomas's Hospital, a very extraordinary specimen; in which, from an obstruction 
in the cystic duct, the bladder went on secreting mucus, till at last there was what 
is called dropsy of the part; but no obstruction of the cystic duct can produce jaun- 
dice. There must be obstruction in some of the ducts of the liver, in order to 
produce jaundice; but gall-stones are found in all parts of the organ. 

These calculi are most frequently found in the gall-bladder itself; next to that, in 
the cystic duct; next to that, in the " ductus choledochus;" and next to that, in 
the hepatic duct. There can be no doubt, therefere, that they are generally formed 
in the gall-bladder itself. 

Their Number. — The quantity of stones found will vary, from one to an im- 
mense number. It is said by Dr. Baillie,* that a thousand have been found at 
once in the gall-bladder. The preparation is now to be seen in Dr. Hunter's col- 
lection.'' An incision is made into the bladder, to show that it is crammed full of 
stones. Dr. Baillie has given a representation of the case. I once took out of the 
gall-bladder of a patient at St. Thomas's Hospital, between three hundred and four 
hundred stones; which had given rise to no symptoms during life. The patient 
had not complained of the least })ain; nobody knew that there was any thing ex- 
traordinary in his inside; and he died of a very diff'erent disease. Nothing is more 
common than to open persons who have died of disease unconnected with the liver, 
and who have never complained of a pain in the side; and yet to find several gall- 
stones. 

External Jlspect. — These biliary calculi are sometimes rough, and sometimes 
smooth. They acquire a smooth surface from lying and rubbing against each 
other; but this very same circumstance causes them to be angular. They have a 
sharp corner and edges; although the surface between the angles may be perfectly 
smooth. Those in the centre are generally oval. 

Some of them are white, others are black; some are black externally, and white 
internally; and some have a shining and semi-transparent fracture. 

Size of Gall-Stones. — Gall-stones are seen of all sizes; — from mere grit, to the 
size of the gall-bladder itself. They will very often pass without pain; for I hRive 
found them in the motions, without any pain having occurred. If they are very 
large, they will occasionally produce no pain; — provided they lie still, and do not 
attempt to escape; but if nature make an attempt to get rid of them, the pain is 

• In his "Morbid Anatomy;" Chapter 10; Section 9. *» At Glasgow. 



DISEASES OF THE LIVER. 897 

very considerable. Dr. Heberden mentions,* that in the gall-bladder of Lord Bath 
(preceptor to George the Tliird), there was found a st^ne which weii^hed two 
drachtns; and yet that it caused no symptoms. 'I'hey were surprised to find the 
stone there. Dr. Baillie says tliat he saw one the size of a hen's egg. 

Made in which Gail-Stones escape. — They will pass through the ducts even 
when very large; for the ducts will dilate incredibly. We know that the female 
urethra may be dilated to so great an extent, that a large stone may be extracted 
from the bladder, without an incision. A very large calculus has been known to 
pass through the "ductus communis choledochus," without ulceration having been 
discovered after death. Dr. Heberden, as I have already meriti(med,'' states, that 
once tlie "ductus communis" was distended to an inch in diameter; but not unfre- 
quendy, when the stones are large, they will escape by an abscess, — ^just as pus 
will do from the liver, — either externally or internally. Adhesions may take place 
externally, between the gall-bladder and the parietal peritonaeum. An abscess 
forms; and the stone comes out through the abdominal parietes. But, more fre- 
quently, adhesions take place between the bile-passages and the intestines; into 
which the stones escape, and are discharged by stool. 

Size they may attain and yet be discharged. — It is astonishing how very large 
a calculus nature will get rid of, and yet the patient do well. A calcidus two 
inches and a quarter in length, three and a quarter in circumference, and weighing 
one ounce, two drachms, twenty-three grains, was discharged from a person who 
lived after it, and did perfectly well. Dr. Pemberton states that a stone has been 
discharged, two inches and a quarter in length, and one inch and a quarter in breadth. 
In the " Medical Gazette" for March 1, 1828,"' there is an account of a stone an 
inch and three quarters in length, three inches and a quarter in breadth, and weigh- 
ing two hundred and seventy-eight grains. A stone measuring an inch and three- 
eighths in length, and three inches and three-eighths in transverse circumference, 
is mentioned in the twelfth volume of the " Medico-Chirurgical 'JVansactions" 
(Page 255). It had passed by ulceration; but the individual died. There is a 
curious instance of one an inch and six-tenths in length, and an inch and one-tenth 
in breadth, vvliich was expelled, and the patient recovered. As it went down the 
intestinal canal, it stuck in the sigmoid flexure of the colon; and there gave all the 
signs of strangulated hernia; — so that, before its escape from the intestines, it did 
serious mischief. Yet there had been no suffering previously. It was not known 
that the cause of the disease was a stone. 

Constituents of Gall-Stones. — Some of these stones appear to be nothing more 
than inspissated bile; and these are bitter to the taste, soluble in water, and burn 
to a cinder. But the greater part of the biliary calculi are not of tliis description. 
They are of an oleaginous character; and, if melted, will take fire, and burn like 
wax. The shortest way to ascertain their nature, is to scrape them a little; and 
they very soon melt. Some are resin, some are cholesterine, and some are 
picromel. 

Internal Appearance. — Those gall-stones which are waxy (I only use the word 
in the common vulgar acceptation, — meaning " to burn like wax"), are of a greasy 
character, are laminated within, and are frequently crystallized. Sometimes, how- 
ever, they are oleaginous. Generally they are in plates, — laminated; but some- 
times there are crystallized radii, passing from wiihin outwards. Occasionally 
they are a mere amorphous mass. Now and then they have been found to contain 
phosphate of lime; but when stones in these parts contain this material, it is doubt- 
ful whether they are biliar}'^ concretions. Two cases of this kind are related by 
Anrlral: but there had been such obstruction, that no bile could have entered the 
gull-bladder, for some time. The cystic duct was obstructed; and calculi appear 
rather to have been the result of a secretion of the inner surfiice of the gall-bladder; 
— ^just as stones may be found in the urinary bladder. 

* In the "Medical Transactions, published by the College of Phy5>icians in London;" 
Volume 2; Page 134. 
«> See Page 893. c Nq. 13; Volume 1; Page 370, 

VOL. I. — 57 



898 PATHOLOGY OF THE STOMACH AND INTESTINES. 



SECTION V. DISEASES OF THE GALL-BLADDER. 

With regard to diseases of the gall-bladder itself, I may mention that it is rarely 
ulcerated. Occasionally its coats are very thick; occasionally it is hypertrophied; 
and it has been known to be completely ossified. Sometimes it will waste away; 
sometimes it will have tubercles in it; and sometimes there are hydatids in its sub- 
stance. Now and then it has been ruptured. A woman came one day to St. 
Thomas's Hospital, and fell down dead; and, on opening her, the gall-bladder was 
found to have been suddenly ruptured. Death, I understand, took place instantly. 



CHAPTER V. 
PATHOLOGY OF THE STOMACH AND INTESTINES. 

Before commencing the consideration of particular diseases of the stomach and 
intestines, it tnay be advantageous to give a short general account of the morbid 
appearances observed in this part of the body. But, in the first place, I shall direct 
attention to the varieties which are observed in the natural state of the parts; — ac- 
cording to the portion of the canal which we examine, and according to the age of 
the patient. 

Natural Appearances. — If we examine the inner surface of the stomach and in- 
testines of a living animal, that is making no effort at all, — so that its circulation is 
perfectly free, that surface is found to be rather redder than the inside of the cheeks; 
— the mucous membrane of the former, is rather redder than the mucous membrane 
of the latter. In some animals, after death, the mucous membrane is pale, or at 
the utmost only slightly coloured; but here, again, much depends on the mode in 
vv.hich the animal dies. If we kill it by putting a stoj) to respiration, these parts 
will become of a very red colour, or very dark; and there will be great congestion 
of blood. But if, on the other hand, we kill the animal by haemorrhage, these 
Vi3ry parts will look paler than they were during life. The internal surfaces of 
t(ie body, are liable to exactly the same changes of colour as the outer. If a per- 
son die from strangulation, the surface of the body will perhaps be of a dark red 
colour, — more or less; whereas, if he be bled to death, he will become pale. Now 
we are to generalize these changes; and be prepared to expect circumstances quite 
analogous in the inner surface. 

Causes of increased Redness. — If we look at the stomach during digestion, or 
if we look at the inner surface of the upper part of the small intestines during 
chylification, — when their great function is going on, — we shall find the parts red- 
der than at any other time. 'J'his, of course, will occur at different periods of the 
day; — according to the shorter or longer time that has elapsed since food was taken 
into the stomach. Any obstruction to the return of the blood, will make these 
parts redder than they should be; and perhaps darker. Haemorrhage may take 
place from the inner surface of the stomach, or from the inner surface of the intes- 
tines, — from the great accumulation of blood; and, as impediments to the circula- 
tion are very common just before death, we, more frequently than not, find these 
inner surfaces red and dark-coloured; — at any rate, partially so. 

Colour Influenced by Decomposition, Situation, and Jlge. — I mentioned for- 
merly, — when describing deceptive appearances wilh regard to inflammation, — 
that we may produce these changes at pleasure, accordingly as we examine a body 
a longer or a shorter time after deaih; — liaving first placed a certain part in a de- 
pendent situation, so that the blood may gravitate in a certain direction." If we 

» See Page 81. 



PATHOLOGY OF THE STOMACH AND INTESTINES. 899 

place a certain portion of the intestines in a dependent situation, — lower than tlie 
rest, the blood will of course gravitate to it: and if we allow a long: period to occur 
before we examine tlie intestines again, according to the length of that period, the 
situation of the parts, and the quantity of blood in the body, shall we (caeteris 
paribus) find them darker. From the natural arrangement of the parts, we gene- 
rally find that those portions of the intestines which are in the pelvis, are of a 
darker colour than the others; and the posterior surface of the stomach, is darker 
than the anterior; — merely from the gravitation of the blood; and, of course, 
darker and darker will the appearance be, according to the length of lime before 
making the examination. If the examination be delayed for a great length of time, 
— so that decomposition takes place in any degree, and the blood is allowed to 
transude from the blood-vessels, — we shall find extensive patches of red, and stains 
along the course of the veins; — just as we observe on the external surAice. If a 
still longer period transpire, the whole of the parts are red. If the blood com- 
pletely transude from the vessels, it will dye the whole substance; and, from the 
solid portions being decomposed, we shall actually find more fluid than the blood 
itself will afford. 

In persons in whom the intestines have been diseased during life, we find them 
of a paler hue lower down than higher up. The lower down we examine them, 
the greater (generally) is the paleness. They are also pale in youth, and in the 
young achilt period; but in the foetus these very parts are naturally of a rosy hue, 
and in old age they are of an ash-colour; and not only so, but the veins are seen to 
be very large. These are the chief varieties as to colour. 

Varieties in Thickness of the Mucous Membrane. — But there are, likewise, dif- 
ferent appearances wiih regard to thickness. The mucous membrane is naturally 
thickest in the duodenum, and thinnest in the colon; and the mere circumstance of 
an accumulation of blood, just before death, or after that event, will occasion it to 
appear thicker than it should be, — without any disease of that particular part; while 
it always appears thinner in persons who die in a state of anaemia, — who are bled 
to death, or who have not rallied a little for some time before death, or who die sud- 
denly in an emaciated condition. 

Consistence of the Mucous Membrane. — There is a great difference, too, in the 
consistence of the mucous membrane in different parts. Generally those which 
are by nature thickest, are also by nature firmest. At the pyloric end of the sto- 
mach, the mucous membrane is always thicker in health, and more consistent, than 
at the other extremity; and it is a natural circumstance for the mucous membrane to 
peel off, in large portions, from the inner surface of the stomach. The consistency 
of the mucous membrane varies, according to the time at which we make the ex- 
amination. It always becomes less, in proportion as time elapses after death; and, 
more particularly, if the surface of the stomach be exposed to the air. If it have 
immediate contact with the air, it loses its consistency much more quickly than it 
Otherwise would. 

Influence of the Gastric Juice. — The consistency is also variable, — according to 
the quantity of gastric juice which the stomach contains; for the gastric juice will 
soften the inner surface, and indeed the whole stomach. This softened state has 
been seen, very frequently, in persons who have died in perfect health. Where 
they have been suddenly destroyed by mechanical violence, or by any violence not 
acting till the moment of death, the mucous membrane of the stomach has been 
found sot'tened; whereas, in persons who have been weak, and in whom we might 
expect such softening from disease, we continually find no such appearances. It 
has also been found, that not merely the mucous membrane, but the whole of the 
coats of the stomach together, have been softened in these circumstances; and even 
perforation has taken place; and still further effects have been observed in the other 
abdominal viscera, from their immediate contact with the part in which perforation 
took place. On this account it was supposed, by John Hunter, that the gastric 
juice will not act on a living part; but that it has the power of acting on dead 
animal substances; and will therefore act on the stomach, when life is no longer 



900 PATHOLOGY OF THE STOMACH AND INTESTINES. 

present to resist it. There lins been a areat (UfTerence of opinion on tliis point. 
When it was first pronmlgated it was doubted. It was afierwards believed: but 
rnanv Frenr-h writers aoaiu doubt ii; though 1 believe we shall see no good rea- 
son to suppose it doubiful, if we consider that, at the same time, the parts of the 
stomach wiih which the fluid comes in contact are softened; and it is singular that 
this softening particidarly takes place at the posterior part, — where the gastric juice 
must chiefly have gone. Thus we may have considerable morbid appearances, 
without any previous disease; — simply from the effect of the gastric juice. At any 
rate, it is considered that, when the stomach is softened, we may be justified in 
saying, that the appearances are simply the effect of death; — whether the individual 
was in health before, or died from an affection of the stomach; and whether it is at 
the posterior part of the stomach or not; and whether, at the perforation, the parts 
are rubbed ofl' or not. 

Bypertrophy of the Mucous Follicles. — Many morbid appearances take place in 
the intestines, particularly in the mucous follicles. With regard to hypertrophy of 
the heart, the walls of the left ventricle are naturally thicker in children, than in 
adults; and many parts in children have been supposed to be hypertrophied, when 
the greater proportionate thickness of them was simply a natural circumstance. 
Now the mucous follicles are much more distinct in children than in adults. In 
fact, in healthy adults they are not particularly seen, except in tlie caecum and 
duodenum; and sometimes, again, at the lower part of the ileum; but in children 
they are generally distinct enougjh, through the whole length aud breadth of the 
intestines. These mucous follicles are often seen to be very large after diarrhcBa, 
and other diseases attended by irritation in the alimentary canal; but sometimes 
they certainly are very large, without our knowing that the individual had suffered 
any previous disease of the alimentary canal. 

Inflammation may not leave Redness. — There can be no doubt that a degree of 
inflammation may exist in the alimentary canal during life, and yet leave no marks 
after death. It may happen that the bleedings which were instituted, have taken 
away the redness of the part, and left it perfectly pale; although the powers of life 
were destroyed by the disease, or (as in some cases) by the remedies. At any rate, 
it is possible for the disease to kill; and yet for no redness to be discovered after 
death. We see a similar occurrence upon the surface of the body, when patients 
have had erysipelas at the time of death. It is not uncommon to see the parts far 
less red than during life; and perhaps they are not red at all. Again; we see that 
redness may exist in all these parts, without any inflammation whatever;- — that it 
may be the result of decomposition, or of some mechanical impediment. If the 
redness be of an inflammatory nature, or if it have been produced by inflammation, 
it ought to exist in the minute vessels; but still it is to be remembered that redness 
may occur there, as well as in the large ones, from mechanical obstruction. If the 
redness exist only in the larger vessels, it is mere congestion; which may arise 
from many causes, independently of inflammation. If there is mere over-distension 
of the large vessels, that cannot be considered inflammation; for if it were, it ought 
to exist in the minute vessels. But even though congestion of blood should exist 
in the latter, it would not be a sufficient reason for its being inflammation. When 
the redness arises from rnflammation, the large vessels may be over-distended too; 
but, in inflammation, the sjnall vessels are j^rs^ overcharged, and ultimately the 
large; whereas, in mechanical obstruction, the large vessels are first overcharged, 
and ultimately the small. 

Parts liable to Redness. — The redness may aff'ect the mucous membrane simply 
in its continuous surface, or it may alfect the villous coat, or it may affect the folli- 
cles, or it may aff'ect two or three of these parts together. If it affect merely the 
villous coat, we have simple red points; and it is in the stomach and lower part of 
the ileum, that this inflammatory redness is chiefly found. This redness is of all 
degrees of shade. The villous coat may be transparent or not. If it be the folli- 
cles which are inflamed and red, there are frequently red circles around them; and 



PATHOLOGY OF THE STOMACH AND INTESTINES. 901 

perhaps also on the summit. If these widen ami form a border, the follicles are 
of a uiiirorin redness. 

Hypertrophy of the Mi/cous Membrane. — The mucous membrane is sometimes 
found thickened; and sometuues it is firmer than usual, and will peel off in larjre 
poriiojis. If tills occur anywhere, it is sure to be met wiih in the stomach, and 
larije intestines. When it is hypertrophied, sometimes it is as smooth as usual; 
but sonielimes it occurs more at one spot than at another; and the ntucous mem- 
brane is llien exceedingly rough; — that is to. say, the hypertrophied paris being 
very partial, the membrane becomes rugged. It is polished eiiouiih; hut ^till it 
gives a feeling of rug^edness; — it has depressions and elevations. Sometimes the 
hypertrophy is sucii, that portions hang into the camil; — we have it really in pro- 
cesses. When it is hypertrophied, there are various dtgiees of (Consistency, and 
various degrees of colour. Sometimes, along with the hypertrophy, tliere is great 
irritation, and a great accumulation of blood. Occasionally we have hypertrophy 
of the villi, and sometimes only the follicles will be enlarged. When the latter 
occurrence takes place, sometimes the orifices of the follicles will diminish; and if 
they diiiiinibh, they will at last close, or nearly so; and then the secretion accumu- 
lates beneath, and dropsy takes place. If the contents happen to be solid, of course 
we cannot apply the word ''• dropsy f' but the follicles are distended with a soft, 
thin, caseous substance. Occasionally the mouth of the foili<des increases very 
inucli. Sometimes thev increase by ulceration; and these overgrown follicles are 
generally seen, like other rnorbid appearances, at the lower part of the ileum, 
where it ends in the et^ilon. 

Hypertrophy of the Sub-Mucous Cellular Membrane. — Sometimes it is not 
the mucous membrane which is hypertrophied, but the cellular membrane under 
it; — the sub-mucous cellular membrane. Occasionally it becomes verv bulky, or 
very hard. It falls into a state of scirrhus, and becomes as hard as cartilage. The 
disease which is called " scirrhus" — a specific induration and hypertrophy"* — fre- 
quently takes place. Sometimes, when it has begun there, the membrane on the 
Other side becomes hypertrophied too; but I believe that when scirrhus affects the 
alimentary canal, it is the cellular membrane under the mucous membrane, that is 
first attacked. The other coats will sometimes remain healthy for a great lenijih 
of lime; but hypertrophy, ulceration, and other diseases, may take place. This 
particular affection of the sub-mucous cellular membrane, is very commonly seen 
at the pylorus; bitt it seldom takes place, except after the middle period of life 
has passed. In this affection, it is common for the orifice of the pylorus to become 
lessened; and the stomach behitul frequently acquires an immense size. If hyper- 
trophy and induration (true scirrhus) take place in the small intestines, it generally 
gives rise to stricture. The canal of the intestines where it is situated, will be 
diminished; so that stricture is the consequence. We may have a stricture from 
other causes; but this is a frequent source of it. This change is rarer in the small 
intestines, than in the stomach; and rarer in any part of the large intestines, than 
in the rectum. The rectum comes next to the stomach, in point of frequency of 
this affection. 

Atrophy. — Occasionally the reverse change takes place. Instead of the aliment- 
ary canal he\\-\<s hypertrophied, it will become atrophied', — it will become much 
thinner than natural. The coals will waste away. I do not mean that they will 
be destroyed; but they will become thinner ami thinner, until the alimentary canal 
becomes quite transparent. Atrophy most commonly occurs at the splenic end of 
the stomach; and, next to that, at the lower end of the ileum. 

Softening. — Then, again, these parts sometimes soften. It is the mucous mem- 
brane that is, uiost frequently, the seat of this disease; — it will become quite pulpy, 
'i'here are all degrees of soi'tuess, till it is absolutely lost, and the disease exists in 
various directions. When the mucous membrane becomes softened, sometimes the 
Colour is quite natural, soiuelimes it becomes pale, sometimes it is a dead white, 

* See Page 197. 



902 PATHOLOGY OF THE STOMACH AND INTESTINES. 

and sometimes it is blue;-~jiist as in the case of the brain. I pointed out that, when 
the brain is softened, there is sometimes a rosy hue of the parts all round. The 
change of colour in the intestines, is sometimes produced by the loss of vital 
energy; and sometimes it is the result of inflammation. This softening is very 
common after chronic diseases; — after phthisis, for example. Sometimes, where 
we find this softening to be very great, there has been nothing more than anorexia 
(loss of appetite), and some degree of indigestion. It is common to find this state 
where persons have been dyspeptic. This affection is, in other respects, similar 
to the softening of the brain. Occasionally it is acute, — takes place rapidly and 
suddenly; and occasionally it appears to be a very chronic change. When it takes 
place as an acute affection, there is generally a red tongue and vomiting; but some- 
times I have seen it where the patient, a short time before, was in perfect health. 
The same circumstance has been observed, with regard both to the stomach and to 
the intestines. Sometimes, in the case of the intestines, the disease follows diar- 
rhoea. 

Gelatinous Softening.— -This softening, though it is most usual in the mucous 
membrane, may extend to all the coats; and the intestines, though at first sight 
they may seem healthy, yet when examined, appear like jelly. This general soft- 
ening of the stomach, is most frequent in the splenic end; and I presume that, very 
frequently, it really results from the operation of the gastric juice; but that, I ima- 
gine, is only one cause of the disease. Cruveilhier has given some good repre- 
sentations of this disease. In these cases we may brush the membrane all away. 
This softening is not to be ascribed to any decomposition of the part. In the case 
of the stomach, no doubt, it will arise from tlie gastric juice; but if it occur in 
other parts of the alimentary canal, it must be supposed to have taken place during 
life; for the intestines do not become soft by decomposition, unless a considerable 
degree of time has elapsed. The brain will soon become soft; but the intestines 
retain their consistency for a considerable time. 

Experiments on the Gastric Juice. — Some experiments were made at Stutgard 
(at least, cases were published there) in 1818, upon the effect of the gastric juice 
in producing this softening. Animals were examined before putrefaction had taken 
place, and the softness was seen in many cats and dogs; so that it appeared to 
arise from the gastric juice. If they were allowed to remain till putrefaction had 
taken place, even then there was not more softening, than in those which were 
examined sooner. The fluid taken from the inner surface of the stomachs of two 
children, who had died with this softened state of the mucous membrane, was in- 
troduced into the stomach of some dead adults; and it soon caused a solution of the 
solids; whereas, when it was put into the stomach of a live rabbit, it had no efTect. 
I consider this a great confirmation of John Hunter's opinion; — that this softening 
of the stomach is mainly attributable to death.* But it is said, that if the eighth 
pair of nerves was divided, — so that the powers of the stomach were impaired, — 
then the gastric juice occasioned softening during life; — exactly as it did in dead 
animals. If these experiments were correct, they were exceedingly curious. 

Softening the Result of Inflammation. — There can be no doubt that common 
softening of the stomach and alimentary canal, is sometimes the result of inflam- 
mation; for we see symptoms of gastritis during life, and signs of inflammation 
after death. But gelatinous softening of the stomach, is frequently seen in chil- 
dren, who have not suffered from inflammation; but who have been in a general 
ill state of health; — who have been weaned when they were not able to bear it, 
and have not been supplied with proper food afterwards. Thus it appears occa- 
sionally in a cachectic state; and very often the parts all around are perfectly 
healthy. 

Ulceration. — I will now make a few remarks respecting ulceration of the ali- 
mentary canal. This is found most frequently in the two lower fifths of the ileum; 
and, with respect to the large intestines, it is seen more frequently in the caecum 

» See Page 900. 



PATHOLOGY OF THE STOMACH AND INTESTINES. 903 

than in other parts. It is seen more frequently in the stomach, than in the jeju- 
num, or the duodenum; but it is seen in all parts of the ileum more freqnenily than 
in the stomach; and it is seen more frequently in al! parts of the large intestines, 
than in the two upper fifths of the ileunj. This ulceration may exist in the centre 
of inflammatoiy spots, or in the centre of red patches. Sometinjes we i\m\ diflused 
redness. A long tract of the intestines will be red; and we observe ulceration 
here and there. Occasionally ulceration occurs in parts more or less melted dowr; 
and frequently it takes place in hypertrophied follicles: — both in the " glanduiae 
so/i7ari«," and in the " glandulee aggregalse.''^ With regard to the " glandulas 
solitarias," when they enlarge and do not discharge their contents, they become dis- 
tended, and are more or less firm; — so that they a^'quire a conical appearance. 
They then lose their conical form, and have a central depression on their top; — 
exactly like a variolous pustule. Their orifices sometimes simply enlarge; some- 
times they ulcerate down merely to the level of the mucous membrane; sometimes 
they ulcerate below it; and then, if they run into each other, a frightful ulceration 
is produced. Of course the ulceration may go on, till the alimentary canal is per- 
forated; till there is a way through it into the cavity of the peritonseum. Ulcera- 
tion, like softening, may either be an acute or a chronic aff'ection. Occasionally 
we see ulceration in the midst of gangrene. Gangrene is a rare occurrence in 
these parts; but occasionally there is ulceration and gangrene all around. Some- 
times we see ulceration of scrofulous tubercles. There are scrofulous tubercles 
deposited under the mucous coat, in the cellular membrane; and sometimes we see 
them under the peritonaeal coat, and cellular membrane. In this situation they will 
enlarge, ulcerate, and go through the same process as in the lungs. It is rare to 
find them ulcerate outwards, towards the peritonaeum; but I have seen a few in- 
stances of this occurrence. Most frequently the tubercles ulcerate through the 
mucous membrane into the intestines. This is sometimes seen in phthisis. There 
has been a minute abscess in the cellular membrane, under the mucous coat; and 
the latter has ulcerated through. 

Ulceration is seldom the efTect of acute inflammation of the stomach; but it is a 
common result of infl.ammation of the intestines. The ulceration is sometimes 
solitary; but sometimes there is an infinite number. In the stomach, however, 
they are seldom numerous. They are of all sizes; and they take all directions. 
Some extend down the course of the canal; and some transversely. Then, as to 
the edges, we find them just as various. Sometimes they are natural; sometimes 
they are very thick; sometimes they are very hard; and sometimes they are very 
soft. The nature of the ulcerations depends upon the depth of the ulcer. If only 
the mucous membrane be ulcerated through, the case is very diff'erent from what it 
would be if the cellular and muscular coats were ulcerated too; for then we should 
have peritonitis. There is no proportion between the depth and the length of the 
ulceration. The intestine between the ulcerations may be in various conditions. 
Sometimes it is healthy, sometimes it is unhealthy. Not only the mucous, but the 
cellular coat underneath, varies much as to its condition. 

There is no doubt that these ulcers will heal; — just like ulceration in other parts 
of the body. Every now and then we find ulcers in the intestines in various stages. 
Some are open ulcers; some are half cicatrized; and others are entirely cicatrized. 
We find portions of the intestines which have evidently been in a state of ulcera- 
tion, but which have healed; and it is very interesting to meet with an ulcer half 
healed; for then there can be no doubt of the nature of the aftection. 

Perforation. — Persons who are not known to be particularly ill during life, are 
sometimes found, after death, to have an ulceration iti the intestines, or stomach. 
They have had some little illness; but perhaps no one knew of it; — tbey were in 
apparent health, when they were sudilenlv seized with violent pain in the abdomen; 
and they died from perforation having taken place, and peritonitis being set up. 
Occasionally this takes place where the patient is labouring under some other dis- 
ease in the abdomen; — that disease not having been known to exist, I ut. more 
frequently, it occurs where persons have sufieied from a gastro enter tic affjciion. 



904 DISEASES OF THE STOMACH. 

Mere softeninof will produce a perforation; — just as ulceration will do; and some- 
limes a slough will give rise to the same circumstance; though that is very rare. 
In brutes, perforation has taken place; and the coats of the intestines have some- 
limes lost their continuity by distension, occasioned by gases. In horses, this has 
been known to take place in consequence of vomiting; for vomiting will not occur 
in them, unless there be su('h a violent effort as is dangerous to animal life. It has 
occurred in human beings when the stomach has been diseased. If the stomach 
be thin, mere vomiting has sometimes caused perforation. Perforations from these 
various causes are seen, most commonly, in the stomach, and particularly at the 
lower end of the organ. There can be no doubt that some perforations take place 
after death; but when they do not, there is generally violent peritonitis. 

Rupture — Blows on the abdomen will sometimes rupture the stomach and intes- 
tines. It might be supposed that, in all cases where violent peritonitis took place 
from this circumstance, the contents of the stomach would be effused; but that is 
not the case. It is said, that sometimes very little irritation has been produced, 
and only chronic peritonitis. But I believe the cases must be very rare; — at least, 
I have never met with one. Sometimes the opening has been completely blocked 
up by nature, by means of a piece of omentum or something else; and no mischief 
has occurred. Sometimes adhesions have taken place, and a fistulous opening has 
been the consequence; so that some persons have discharged the gastric juice from 
their stomach, while others have had an artificial anus. In the case of the rectum, 
these perforations will occur; and we have what is called "fistula in ano." Some- 
times one portion of intestine will perforate into another. Two portions lie toge- 
ther; nature produces an adhesion; one of them becomes perforated; and an open- 
ing takes place in the fellow convolution. Occasionally the intestinal canal has 
been seen perforated from without. When an abscess occurs in the liver, or a 
stone from the ducts or gall-bladder has got into the intestines, these parts will 
become per orated from without. Various tumours have been known to ulcerate 
into the intestines. 



\ 



CHAPTER VI. 
DISEASES OF THE STOMACH. 

SECTION I.— ACUTE GASTRITIS. 

Symptoms. — Gastritis, or inflammation of the stomach, is characterized by an 
acute and constant pain at the pit of the stomach. This pain is increased on the 
slightest pressure; and it is likewise increased on swallowing any thing;— -particu- 
larly if it be hot, or acrid. There is generally also, — provided the disease is vio- 
lent', — a great sense of tightness across these parts. These symptoms arise simply 
from the locality of the inflammation; but there are others dependent on \\\e func- 
tion of the part which is inflamed. We have nausea, retching, and even vomiting 
itself; — especially when any thing is swallowed. Sometimes also there is hiccup 
(sinwultus). A burning sensation is generally experienced; which, for the most 
part, extends up the oesophagus, and is felt even in the pharynx. It is not uncom- 
mon for the epigastrium itself (tlie external portion of that part of the body in which 
the inflammation resides) to be hotter than the rest. There is generally thirst, 
great anxiety, and not unfrequently a feeling of great debility. The pulse is quick, 
small, and perhaps hard; but iheie is a great variety in this respect; — ^just as in 
inflammation of other parts. The acute form of gastritis, if it be violent and not 
speedily remedied, soon proves fatal. 



DISEASES or THE STOMACH. 905 

Frequently preceded by Spasm. — Very frequently, this disease is preceded by 
nierelv a spasmodic pain of the part. It is not uncommon (;is I shall mentiou par- 
ticularly when describing what is called *' disorder of the digestive organs") for 
persons to be seized with sudden pain at the pit of the stomach; — ruiuiing through 
the back; affecting respiration; drawing the patient togelher; perhaps reheved, at 
any rate not increased, by pressure; not attended by a sense of iieat, but perhaps 
by a sense of cold: and unattended by any great thirst. So far from tlie pain 
being increased by heat or stimuli, it is generally diminished by them. This is 
evidenUy a state of spasm; but after it has existed for a lojiger or shorier time, — if 
it be not remedied, or if it do not cease spontaneously, — it very frequently degene- 
rates into, or gives rise to, or is followed by, inflammation of the part. We shall 
then find the treatment we were at first adopting, highly improper. The adminis- 
tration of stimuli does harm: and if we omit the common treatment of inflamma- 
tion, the patient is very liable to slip through our fingers. We n)ust carefully 
remember, therefore, that there are two descriptions of pain attacking ihis part of 
the body; — the one entirely spasmodic, the other inflammatory; but that the spas- 
modic very frequenUy terminates in an inflammatory slate. 

Causes. — Gastritis is produced, in the first place, by the common causes of all in- 
flammations; cold applied to the body, especially when the body is heated. Some- 
limes it is produced by cold applied to the inner surface of the stomach, when the 
body is over-heated. Sometimes, when a person is very hot and takes cold drinks, 
before inflammation comes on, there is a state of extreme debility. Occasionally 
the power of the stomach seems almost destroyed; the person is very faint; the 
pulse is small; and sometimes death ensues without any reaction taking place. We 
sometimes hear of ladies dying suddenly, when they have been drinking cold 
water, or eating ices, while they were hot. The danger does not arise simply from 
being hot; for the hotter we are, the more good does cold do. It is not even the 
simple circumstance of sweating, that makes it dangerous for a person to go into 
the cold bath, or to roll himself in the snow, — which the Russians do when there 
is no necessity for it; but it is the circumstance of the individual being exhausted, 
that makes the abstraction of all stimuli dangerous." If we meet with a patient 
who has an afliection of the stomach from exhaustion, the best mode of treating it, 
is to give a large dose of opium, together with stimulants. U the person recover 
from this state, it is possible that inflammation may not arise. But sometimes, 
without such a depression as this, the application of cold to the surface when the 
body is exhausted, may produce inflammation, — just as in other cases. The exter- 
nal application of cold may produce inflammation of the bowels. 

Occasionally gastritis is produced by the sudden cessation of gout. When gout 
suddenly ceases in an extremity, inflammation of the stomach will occasionally 
arise; and that of a very dangerous character. But another state of the stomach is 
frequently induced in these circumstances; — namely, a violent spasm of the part 
(gastrodynia); — a state to be treated, perhaps, by brandy. Gastritis sometimes 
occurs sympathetically with an affection of the kidney; — when the kidney is se- 
verely affected in various ways. When a stone is on ils passage from the kidney, 
the stomach generally sympathizes; so that vomiting occurs, and sometimes real 
gastritis takes place. It will sometimes arise from sympathy with the state of the 
womb. 'J'lie womb, when diseased, frequently gives rise to nausea and vomiting; 
and sometimes the irritation may amount to inflammaiion. This state is very often 
induced by the passions of tlie mind. A sudden emotion of the mind, of a very 
disagrefcai)le character, — great grief, -^sudden surprise of an unpleasarjt description, 
— a sudden and severe shock, — will sometimes give rise to a spasmodic pain here 
(" spasm of ihe stomacdi," as it is called); ami sometimes to actual gastritis. Great 
fatigue will have the same effect. Of course it is a disease that is easily produced 
by any acrid matter. Many poisons, properly so called, produce inflammation of 
the stomacli; but any acrid matter whatever, or any stimulus (properly so called), 

» See Page 114. 



906 DISEASES OP THE STOMACH. 

— such as a large dose of cantharides, or corrosive sublimate, — or any thin^ else 
that can irritate the stomach, may produce gastritis. It occurs likewise in other 
diseases. In fevers, gastritis of more or less intensity is very common. I men- 
tioned that, in the fevers of hot countries, there is a burning heat at the pit of the 
stomach;* — deserving to be considered as active acute gastritis. 

Morbid Appearances, — On inspecting the stomach after death, the redness is 
very seldom universal. It is very seldom that the whole of the inner surface of 
the stomach is inflamed. Sometimes this is the case; but generally it only takes 
place at a particular part. When peritonitis exists, that portion which covers the 
stomach may be inflamed, — the same as any other part; but in general gastritis, 
properly so called, — gastritis independent of inflammation of the peritonaeum, — 
merely produces local eff'ects on the mucous membrane of the stomach; though 
occasionally it extends to the cellular membrane between the coats. This disease 
very seldom induces gangrene. I never myself saw such a thing; but occasionally 
gangrene does take place. Very seldom does it produce abscess; but occasionally 
an abscess has been found between the coats of the stomach. We are more likely 
to meet with gangrene of the stomach after acrid substances have been applied, 
than in any other circumstances. If caustic substances have been taken, then we 
may expect gangrene. A slough is produced, which may or may not be thrown oflf. 

Care required in determining the Cause. — This disease may arise from acrid 
or poisonous matters introduced into the stomach, without our being able to dis- 
cover any trace of them. It is very possible for a patient to have vomited every 
thing which he took, or for the ingredient to have passed into the intestines, and so 
to have escaped from the body; and yet sufficient inflammation may have been 
induced to destroy life. Although it is very possible that death may ensue from 
things taken into the stomach, we are never justified in saying that inflammation 
of that organ, — that the various morbid appearances which we see there, have been 
owing to poison, unless we prove its presence; — unless we discover it in what has 
been vomited; — unless we find it contained in the alimentary canal, or in what has 
been discharged, or in a vessel of the contents of wliich the patient clearly partook. 
If it were not for an accurate knowledge of this circumstance, we might suspect 
that poison had been taken, without there being any justifiable reason wliatever for 
the opinion; for the appearances within the stomach, may be precisely the same as 
those induced by taking poison, or some other injurious matter; when it is simply 
common inflammation, and tlie effects of it. 

Treatment. — As to the treatment of the disease, the first point is undoubtedly to 
discover the cause. It is of very great importance to know whether the disease 
has arisen from any thing taken into the stomach or not; because, if it have, our 
first object must be either to effect its removal, or to destroy its power. I need not 
say, that the most ready mode of emptying the stomach, is to employ a stomach- 
pump. This is much better than giving an emetic: because emetics add to the 
irritation, or they may fail. The most powerful medicines are those of an acrid 
kind. Sulphate of copper is one of the best; and, next to that, sulphate of zinc. 
These operate immediately, and produce litUe nausea. Ipecacuanha produces 
great nausea, and may not eflfect the purpose after all; — at least, there is less proba- 
bility of its succeeding, than in- the case of sulphate of copper. When we have 
recourse to the stomach-pump, it would be as well to employ an antidote. If a 
poisonous acid have been taken, it is better to pump in magnesia-'w^i\ex \\\-a{\ plain 
water; but if an alkali have been swallowed, then we should have recourse to 
diluted vinegar. The best plan, in all cases, is to fill the stomach with warm 
water; — to pump it in, and pump it out, till the fluid comes out quite clear, and 
we are satisfied that nothing remains. Provided a stomach-pump is not at hand, 
an emetic should be had recourse to; but notwithstanding we have done all this, 
and emptied the stomach immediately, we shall find it of the utmost importance to 
go on treating the gastritis, as though we had done nothing of the kind. After 

» See Pag:e 390. 



DISEASES OF THE STOMACH. 907 

arsenic or corrosive sublimate has been taken, and the stomach has been washed 
out, and there is no fear from the immediate eifects of the poison, gastritis may 
nevertheless exist, and destroy the patient; or, at any rate, produce great danger; 
and we must have recourse to the common treatment of gastritis. 

When the disease arises from simple cold, or after poisons, it may be necessary 
to bleed generally or locally. Cupping can hardly be borne; but leeches should 
be repeatedly applied over the part; and when we cannot employ them any more, 
blisters should be had recourse to. Cold drinks are grateful to tlie patient; and 
there can be objection to ices. There is intense heat, and a great sensation of 
thirst; and the greatest comfort imaginable seems to arise from cold draughts. The 
plan is to consult the patient's feelings. If he like cold drinks, let him have them; 
or if he like ices, there is no reason why he should be debarred from them. We 
should follow the same rule as in inflammation of the surface; — change these cold 
drinks occasionally for warm ones, and let the patient regulate the temperature. 
Of course it is necessary to keep the intestines in a free condition; and I should 
imagine it would be belter to do this by clysters, than by any other means. The 
stomach should be left as quiet as possible; and therefore I would trust this part of 
the treatment entirely to injecUons. With regard to the exhibition of mercury in 
these cases, I hardly know whether it is necessary or not, or whether it would be 
injurious or not. I have occasionally administered it where I was afraid that death 
would take place, without seeing the stomach irritated by it; but if we remove the 
cause (which is something acrid), have recourse to bleeding, give the patient cold 
drinks, and keep the bowels freely open, the inflammation of the stomach is, in 
general, disposed to subside. 

Conjoined with other Diseases. — Inflammation of the stomach is very common 
in many acute diseases. It frequently occurs in erysipelas; and is sometimes 
evanescent, — will go away without any treatment, if we keep the patient low; but 
occasionally it requires local treatment. In fevers we must look out for gastritis. 
In the continued fever of this country, — properly so called, — and many other acute 
aflfections, this disease is very likely to spring up; and therefore, in these affections, 
we should always, from time to lime, examine the state of the abdomen. 



SECTION II.— CHRONIC GASTRITIS. 

Symptoms. — Gastritis is much more frequently a chronic than an acute affection. 
When it exists in a chronic form, the symptoms are much the same as when it is 
acute; only they are less intense. There is a great sense of heat within the sto- 
mach, rising from the oesophagus into the pharynx; great thirst; tenderness of the 
part on pressure; loss of appetite; nausea; and frequent vomiting. The tongue is 
generally red somewhere; — either at the tip, tiie sides, or all over; but we may 
have inflammation of the stomach, more or less violent, without redness of the 
tongue. We must not depend on the tongue alone. There is generally redness of 
the tongue; but we are not to say that the other symptoms do not show gastritis, 
because the tongue is absolutely while, or not much affected. In these chronic 
cases, there are generally dyspeptic symptoms; — such as a great flatulence, great 
acidity, and a sense of sinking at the pit of the stomach. The latter is a very 
common symptom; and, to remove it, people generally take wine and brandy, and 
make things worse. The want of attending properly to this point, occasions very 
absurd treatment. I have seen persons, in this aflfection, have draughts of aether 
and ammonia, and things of that description; — all of which may be grateful for a 
time; but which, as patients frequently themselves say, ultimately produce great 
uneasiness. It is always right, when treating dyspepsia, to ascertain whether 
there is an inflammatory state of the stoniach; for that organ may be in a condition 
requiring stimuli of all kinds; or, on the other hand, requiring the application of 
leeches, and making ail stimuli and effervescing draughts exceedingly improper. 
Many persons labouring under dyspepsia, clearly have gastritis; for there is great 



90S DISEASES OP THE STOMACH. 

pain on pressure; and because they feel a sinkinof sensation, tliey drink wine and 
brandy, and eat meat. I have seen them g^et completely well, by chanjjinjr their 
diet, — without taking any medicine whatever; and, in other cases, by applying 
leeches. 

Treatment.— ks to the freafment of the disease, it is simple enough. Avoid 
stimuli, apply leeches from time to time, keep the bowels open, and remedy acidity, 

A very slight degree of tenderness at the epigastrium, however, is not sufficient 
to make it necessary to apply leeches, or to lower the patient. When an individual 
is subject to occasional attacks of pain in the stomach (gaslrodynia), there is always 
tenderness; — merely from the part being stretched. If we have spasms in the calf 
of the leg, next day the part is sore;-^ — merely from the muscular fibre having been 
stretched; and if nothing is done to make it worse, it will go away. There is no 
occasion to ai)ply leeches to the epigastrium, simply because it is tender. There 
has been, for a certain time, an attack of spasm; which has left a little tenderness 
of the stomach; and it will yield best to stimuli; — just as a slight degree of inflam- 
maiion of the eye, is more easily dispersed by washing it with brandy and water, 
than by any other means. But if there be much tenderness on pressure, and heat 
extending up the ihroat, then stiinulaiing remedies would be improper. It is also 
to be remembered, that a sensation of heat in these parts generally arises from acid 
in the stomach; and that by ffiving alkahne substances, we entirely remove it; but 
we also apply leeches. If, however, we give alkaline substances (such as Fnag- 
nesia and carbonate of soda), a much smaller number of leeches will destroy the 
acidity. Frequently this is the result of an inflammatory slate; and the best way 
to cure it is to employ leeches; but to prevent the acidity from doing much harm, 
we should give antacid remedies; or, if tliere be morbid irritability, such a medicine 
as prussic acid will be of great service. But of that I will speak hereafter. 

j3ccompanies other Diseases. — Chronic gastritis is an accompaniment of many 
other diseases; — ^just as it frequendy takes place after acute gastritis. It is very 
common, in diseases of the heart, for persons to have more or less gastritis; 
which, if it rise to any amount, aggravates all the other symptoms. There is 
tenderness on pressure; and this, perhaps, extends over all the parts; and we find 
that, some time before, the patient has had disease of the heart. So, again, it is 
by no means uncommon for a person in phthisis to have more or less gastritic 
affection. In various chronic diseases, gastritis comes on from time to time, and 
requires to be remedied; or the symptoms of the original disease will be increased. 
It is well to ascertain, occasionally, the state of the abdomen, when the patients 
are labouring under chronic affections; — the same as when they are suffering under 
acute. 

a. Ulceration of the Stomach. 

Absence of any Diagnostic Sign. — When gastritis has existed any time, it may 
perhaps ulcerate the stomach. Such an occurrence is by no means uncommon. I 
know of no symptom indicative of ulceration of the stomacii; and have frequently 
met with it by surprise. I have known that the patient had chronic gastritis; but 
there was no symptom that led me to suppose that, in addition to gastritis, there 
was ulceration. The symptoms are the same in both cases; — tenderness, thirst, a 
sensation of heat there, dyspepsia, and perhaps emaciation. Sometimes we find 
pain at one particular part of the stomach; but that may occur without any ulcera- 
tion. There is no certain diagnosis. We may fancy it to be the case, but our 
conjecture may be wrong; and we may find nothing but chronic inflammation. 

b. Byplure of the Stomach. 

Symptoms. — If the ulceration proceed to an aperture, there generally occurs, 
suddenly, a fresh set of symptoms. There is sudden severe pain in the epigas- 
trium; and, in a case which I saw, there was also intense coldness; so that the 
patient held a glass of boiling water to the part, without feeling it warm; — without 



DISEASES OF THE STOMACH. 909 

being at all annoyed by it. He also drank water so hot, that I could not have pnt 
it to my nmuih. Affections of the stomach sire frequently attended by a want of 
power to g^enerate heat. 

Gejierally foUoived by Peritonitis. — This pain, after it has existed for a certain 
time, is generally followed by peritonitis. 'Fhere is a paper on this subject by 
Mr. Traver?% in the eighth volume of the " Medico- Chirurgioal Transactions;"* in 
which he states that the diagnosis, in a case of this description, or in perforation of 
the intestines, would be sudden pain in one part of the abdomen (in the case of the 
stomach at the epigastrium), radiating from the part; and he considers that the pain 
would never cease. In a patient of mine, where there was an aperture of the sto- 
mach, the symptoms were these. (I had never seen her before; but slie was tall 
and very spare, and was said to have been long dyspeptic.) One day, after dinner, 
she was seized with a sudden pain in the stomach. It was impossible for me to 
tell whether this was more than a spasmodic pain; for it was not aggravated by 
pressure. I gave her laudanum, of which she took sixty drops; but, finding no 
relief, she took more; and so she went on till, in a few hours, she had taken three 
hundred drops; and after that the pain ceased. It is not correct, therefore, to say 
that the pain never ceases. I afterwards found some cases published in France, 
and also one by Dr. Carmichael Smith, in which the pain went away; and there- 
fore we are not to be sure that the stomach and intestines are not ruptured, because 
the pain ceases. After twelve or eigliteen hours, my puient again had pain 
enoug-h; for the whole of the peritoiifBum became inliamed together. This inflam- 
mation could not be removed, and she died. From the suddenness of the pain, 
the great prostration of strength, the smallness of the pulse, and the sinking of the 
patient, we may imagine that there has been a rupture of the stomach or intes- 
tines; and we are not to imagine it the less because, after a time, the pain goes 
off. If ihe patient live long enough, peritonitis occurs, from rupture of the ali- 
mentary canal; and this cannot be remedied, because there is a local disease which 
keeps it up. I mentioned before, '' that these perforations sometimes take place 
without any sudden symptoms; — that, occasionally, slow peritonitis occurs, and 
gradually leads to ulceration. 

Treatment, — In these cases of rupture, I should recommend the free exhibition 
of opium; and, when inflammation comes on, the application of leeches. These 
measures will lessen the sutFering, aUhough we can do no further good. 

Morbid Appearances. — If the destroyed [)ortion of the stomach owe its condition 
to an ulcer produced by the gastric juice, the edges are not so smooth, as in cases 
of simple ulceration; for the gastric juice does not act so very locally; but the parts 
all around suffer, and become soft. I believe that, where the stomach has been 
injured, after death, simply from the action of the gastric juice, there is a softened 
state of the parts immediately around. It should be recollected that the latter cir- 
cumstance^occurs, particularly, at the splenic end of the stomach; whereas common 
ulcers taUe place anywhere; and in the latter case, a patient, previously in good 
health, speedily perishes. Occasionally, notwitl.standing that the stomach is ulcer- 
ated, no serious mischief arises; because nature produces adhesions around the 
stomach, and glues it to the liver, the peritonaeum, or the omentum; so that, 
although the stomach is perforated, no aperture exists. Of course there is injury 
from the ulceration; but none from the perforation. 

Presence of Pus. — Pus is sometimes found withm the coats of the stomacl ; 
and sometimes it has been seen diffused throuorhout the whole of that or^an. 
Between the coats, there has been one sheet of pus; bounded by the peritonaeum 
on one side, and probably by the mucous membrane on the other; — the muscuhir 
coat having been destroyed. But sometimes it has been found between the muscu- 
lar coat and the mucous membrane, and between the muscular coat and the perito- 
naeum. Sometimes a collection of pus takes place in one particular spot. Pus 
has been found, it is said, on the inner surface of the stomach; but when we 

• Paofe 231. * See Pa^e 903. 



910 DISEASES OF THE STOMACH. 

recollect that this part is naturally covered by mncns, and that sometimes this is 
secreted in great quantity, one hardly knows whether there is really an alteration 
in the secretion. Still there is no reason why the stomach should not form pus on 
the inner surface; and no doubt it' does; exactly like other membranes; especially 
as it has been found, occasionally, on the external surface. 

Effused Fibrin. — It is a very rare thing to find ^6rm effused upon the inner 
surface of the stomach; yet there is not a mucous membrane that may not form 
fibrin, under violent inflammation. It is staled by authors, that occasionally a false 
membrane (as it is called) has been noticed on the inner surface of the stomach. I 
believe this most frequently occurs in children. It is before puberty rather than 
after it, that fibrin is formed in the cesophagus. If we find a false membrane in 
the oesophagus, it generally terminates at the cardiac orifice of the stomach. So 
rare is it for fibrin to be formed within the stomach, that even if the oesophagus has 
produced it, the false membrane has generally been seen to end at the cardia. A 
layer of fibrin sometimes occurs in the throat; but it has not often been seen to 
extend lower than the oesophagus. 



SECTION III.—STRUCTURAL DISEASES OF THE STOMACH. 

Besides common inflammation and its effects, with which we are now acquaint- 
ed, the stomach is liable to peculiar structural diseases. Scirrhus, open cancer, 
encephaloid disease, and melanosis, will occur in the stomach; and will all take 
place in various parts of it; but they most frequently take place at the cardia and 
the pylorus. This accords with the general rule that I mentioned;* — namely, that 
the orifices of cavities are most frequently the seat of structural disease. 

Symptoms of Scirrhus. — When scirrhus exists, there may be pain at the spot 
which is affected; and that pain may go through to the back, and be increased on 
taking food. Besides pain, there may be all the symptoms of indigestion; and 
there may be great nausea and vomiting; so that nothing can be retained on the 
stomach. If it be the cardia which is the seat of the affection, the food is gene- 
rally rejected immediately. I have seen an instance where, the moment the food 
reached the cardia, a heaving took place; the patient felt as if he were being de- 
stroyed by wind; and he said the complaint was nothing but wind. Sometimes 
the food will pass the cardia, and be rejected immediately, or five or ten minutes 
afterwards. But if it be the pylorus in which the disease resides, then the food 
will generally be retained for some time; — perhaps for half an hour, or more. There 
is no general rule for the time. There may be pain in the region of the cardia, or 
pain in the region of the pylorus. In the case of the cardia, we may find great 
difliculty in passing a probang into the stomach, for there may be a stricture at the 
part; but when the pylorus is afi'ected, there is not only severe pain in that region, 
but at last there is a tumour. In that case, there is generally emaciation, and a 
sallowness of look; — such as might be called 'f cancerous cachexia." The vomited 
matter is sometimes very offensive, — sometimes bloody; and sometimes the eructa- 
tions are exceedingly fetid. 

Absence of Prominent Symptoms. — Nothing, however, is more common, than 
to have dreadful disease in these parts, with scarcely any symptoms whatever. 
Every practitioner must have seen extreme disease in the stomach, — great ulcera- 
tion of it, — decided cancerous and other malignant diseases of this part, — without 
any pain worth naming; — without any vomiting till just before death, and without 
any otlier symptom than perhaps extreme weakness, paleness, and some obscure 
uneasiness about the stomach; and perhaps not even that. It is sometimes extra- 
ordinary to open stomachs, and see the disease which exists there, without any 
symptoms having taken place, or symptoms of a very slight character. When 
the pylorus is affected, we occasionally have jaundice, from [)ressure on the hepatic 

* See Page 201. 



DISEASES OF THE STOMACH. 911 

duct, or on the " ductus communis choledochus." Occasionally in this disease, 
as well as in an affection of other parts of the stomach, there is vomiting of a very^^ 
fetid secretion, and sometimes of blood; and the blood will pass through the pylo- 
rus to the intestines, so as to appear in the motions. 

There is not one of the local symptoms of this complaint, that may not be ab- 
sent. Sometimes there is no vomiting; sometimes there is no pain; and it is only 
by a very careful observation, — indeed, by considering that there are no signs of 
derangement of other organs, that we frequently make up our minds that the dis- 
ease is probably situated in the stomach. Sometimes there is very little more than 
dyspepsia; and sometimes people eat well, and are but little troubled with indi- 
gestion; but, at last, there is generally more or less hectic. 

Obscurity of the Symptoms. — These scirrhous formations and cancerous ulcer- 
ations, as well as other organic diseases, may of course exist at any part of the 
stomach, as well as at the two extremities; and the symptoms are generally the 
same. The symptoms are much less likely to be observed in the stomach, if no 
obstruction is produced. If an obstruction be produced in the pylorus, then we 
have disturbance; or if it occur in the cardia, there is great difficulty of swallow- 
ing, and great pain when the ingesta reach the part. In the case of the pylorus, 
the stomach becomes so distended, — from the difficulty with which the contents 
pass out, — that vomiting generally occurs. When there is an obstruction at the 
pylorus, — either from scirrhus (which is the most common), or any other disease, 
it is generally noticed, that the stomach acquires a very large size; — owing to the 
difficulty with which the contents pass through the pylorus. 

Morbid Appearances. — If scirrhus exist generally in the stomach, the organ 
becomes very thick throughout, and its cavity is diminished. The mucous mem- 
brane looks puckered and ulcerated. When the disease is situated about the pylo- 
rus, it may occasion the stomach to become of an immensa size; whereas, if it 
exist throughout the stomach, it may produce very great contraction; for scirrhus 
causes a shrinking, and produces a contraction of the parts all around, which spreads 
throughout the stomach; and, in the case of the pylorus, produces such a contrac- 
tion there, that the food will not pass through. Dr. Baillie mentions that, occasion- 
ally, there is simple stricture of the pylorus or the cardia, independently of malig- 
nant disease. These two parts are subject to stricture, — just as the urethra is, — 
without any organic disease whatever. 

Treatment. — With regard to the treatment of this affection, it is merely pallia- 
tive. Support the patient's strength, and give narcotics, in order to alleviate the 
suffering and vomiting. There is no medicine with which I am acquainted, that 
produces so much alleviation in these organic diseases, as hydrocyanic acid. It 
frequently arrests the vomiting for a long time; but it always lessens it very con- 
siderably. If there be very great pain, it is necessary to employ opium, in order 
to reduce it. I have used iodine in these cases; with (as I have thought) a certain 
degree of advantage. In one case of scirrhous pylorus, I exhibited iodine and 
prussic acid together; and the disease appeared to stop. I have no doubt that the 
patient laboured under scirrhous pylorus; for I felt the tumour, and the patient had 
a sallow look, and vomited for a long time. I gave him these medicines as a for- 
lorn hope, and he was much better; but, in a great number of cases, I have not 
seen any such result as this; and sometimes there has been no benefit whatever. 

With regard to stricture of the cardia, some good may be done by mechanical 
means, — by passing a bougie; — taking care not to pass one so large, as to occasion 
suffering to the patient. In the case of a contracted rectum, benefit has been said 
to be derived by the passage of a bougie. Although organic disease caniiot be 
remedied, yet the effect of it in lessening the canal may be diminished; but great 
care should be taken not to employ it in such a way a« to cause injury. 

I mentioned," with regard to stricture in the cesophagus, that sometimes there is 
a scirrhous, and sometimes only a common stricture; and that, besides these dis- 

" See Page G94. 



912 DISEASES OP THE STOMACH. 

eases, which can be treated only by a common bougie, the parts are subject to spas- 
modic stricture. The latter case occurs particularly in females; who will some- 
» times, for weeks together, be unable to swallow; and then they will swallow very 
well. These cases are to be treated by improving the general health, by the cold 
bath, and by pleasant occupation of the mind. 



SECTION IV.— H^MATEMESIS. 

There is one disease to which the stomach is very liable; and that is haemor- 
rhage. Without the presence of any malignant disease, — without any organic 
disease, — frequently without any inflammation that can be discovered, and fre- 
quently without any danger whatever, a quantity of blood is discharged into the 
stomach. It is usually dark and in large clots. When describing " hasinoptysis," 
or "spitting of blood," I stated that one could not infer, because in these cases the 
blood was black, that it was venous blood; for if arterial blood be poured forth into 
a cavity, and lie there, it will acquire a venous character." Its nature is not to be 
ascertained from the colour; but when we consider that patients will pass a vast 
quantity of blood in tliis way, it seems most probable that it proceeds from the 
veins, where the motion is very slow. We cannot but conceive that, if it came 
from the arteries, patients would suffer much more depression. We know that a 
g^reat quantity of blood is sometimes discharged from the pelvis, — flows from the 
lower part of the alimentary canal, attended with no very great loss of strength; 
and there the blood is, for the most part, black. 

Symptoms. — Hsematemesis'' is usually marked by nausea and vomiting; — if not 
by the latter, yet by the former; and by the sensation of a load at the pit of the 
stomach, — at the epigastrium and left hypochondrium. Sometimes, in addition, 
there is a great pain there on pressure. The blood, besides being tlirown up by 
vomiting, is frequently discharged by stool. 

Causes. — This disease ofcurs very frequenUy in persons who are dyspeptic; 
though I do not mean to say that this affection is a symptom of dyspepsia. It oc- 
curs far more frequendy in females, than in males; and it is common in women 
whose catamenia are suppressed or diminished. In some persons, it will return at 
intervals; and occasionally it is periodical. 

The ordinary form of the disease, — like a great discharge of blood from the 
intestines themselves, — is for the most part without danger. Persons mny die 
from it; but, for the most part, they recover. Still it may be a very dangerous 
disease. It may proceed from an idcer, and we may not be able to stop it; but, 
for the most part, it would appear t!iat great congestion has gradually taken place 
in the neighbouring parts; — in the stomach, and most probably in the liver and 
spleen, and all around; and then this blood, half out of the circulation, is poured 
forth; and nature is very much relieved by it. It is, for the most part, a passive 
hsemorrhage.*^ It sometimes arises from an obstruction in the liver and spleen; as 
well as from the want of secretion by, or discharge from, the womb. It is fre- 
quendy observed in hepatic and splenic diseases. The danger chiefly depends 
upon the source whence the haemorrhage proceeds. An aneurism of the aoria has 
sometimes opened into the stomach, and given rise to the disease. Occasionally 
this haemorrhage is only a part of the aff'eclion called "purpura haemorihagica;'* 
which I formerly described.'' 

Case. — I once saw a patient die suddenly, from this affection. I am not aware 
that he had haemorrhage before; but he had some pulmonary complaint. He sud- 
denly fell back, and died in a minute or two. Blood came from his mouth; and, 
on opening the stomach, it was found to be filled to the utmost with blood; which 
formed a large mould of the organ. I could discover no disease whatever of the 

« See Page 762. * From a<jua, blood; and iixno, to vomit. 

» See Page 139. ^ See Page 466. 



I 



DISEASES OF THE INTESTINES. 913 

part, or any vessel that let it forth. Sometimes, in this affection, the internal sur- 
face of the stomach is pale; and sometimes it is in a state of great congestion. 

Treatment. — It may be necessary to take blood from the arm; or it may be 
necessary to apply leeches plentifully all over the stomach, and then to order blis- 
ters. But for the purpose of slopping the haemorrhage, it is best to give the patient 
cold drinks; and, if possible, iced water. Give scarcely any food; and not only 
take care that what he drinks is aqueous, but that it is as cold as he can bear it. 
The oil of turpentine is one of the very best remedies that can be employed. I do 
not know that I ever failed in stopping haemorrhage of the stomach with it. It 
should be given in small quantities; — twenty or twenty-five drops, every six, or 
every four hours. If it should create sickness, it is advantageous to unite hydro- 
cyanic acid with it. They may be given conjointly; or the acid may be given a 
few minutes before. The acid has not the power of stopping the haemorrhage; 
but if there be any nausea, it enables the stomach to bear the turpentine much 
better. I have the highest possible opinion of lead, in passive haemorrhage; but 
here we can apply the oil of turpentine to the spot which is the seat of the affection; 
and although I never saw it do good in hcemorrhage from the lungs, yet it is supe- 
rior to lead in the case of the stomach and intestines. The effect of it, when it 
comes in immediate contact with the part, is very great; but still it is necessary to 
keep the patient perfectly quiet. I have had a large number of cases of this disease; 
and I believe every one of ihem has done well. I do not remember a case, where 
the turpentine had not a decided effect in stopping the hcemorrhage. 

The foregoing are the principal diseases of the stomach, — with the exception of 
dyspepsia; which is so connected with an affection of the liver and alimentary 
canal, that I will bring them altogether under one name,—" derangement of the 
digestive organs;" and will describe them hereafter. 



CHAPTER VIT. 

DISEASES OF THE INTESTINES. 

SECTION I.— ENTERITIS. 

Symptoms. — We will now pass the pylorus; and consider, first, inffamraatiou 
of the intestines. In simple enteritis, — supposing it to be active and violent, — we 
have acute deep-seated pain; and this may occur in various parts of the intestinal 
region. Although the pain is constant, yet it is aggravated at intervals; and it is 
increased on pressure. It differs from "a fit of the gripes," as it is called, — 
"pinching and purging," — in this; — that, in common "pinching," there are inter- 
vals of ease, and when the " pinching" is over, the person is comfortable; whereas, 
in enteritis, although the pain comes on at intervals, yet it is constant; — although it 
is not of uniform intensity, yet it is always present. This is an important thing 
to observe; for I have seen persons seized with tormina, which required brandy, 
or at least laudanum, to assuage it; and then, gradually, the tormina became con- 
stant; and there was pain increased on pressure; whereas, before, it was rather re- 
lieved by it. When this change takes place, laudanum and brandy would not only 
be useless, but would increase the pain; — so that bleeding would be required. I 
recollect one case, where I was with the individual the whole lime; and the series 
of changes was quite manifest. 

In this disease, where there is this sharj) fixed pain, there is usually great cos- 
tiveness. The abdomen, after a time, becomes tense; and, from the severity of the 
pain, there is anxiety of countenance. The tongue grows white, and the breathing 
VOL. I. — 58 



914 DISEASES OF THE INTESTINES. 

is quickened. Nansea and vomiting soon occur; and if complete obstruction take 
place, we may have vomiting of fasces. This occasionally happens; and, formerly, 
a particular name was given to it;—" the ileac passion" — " passio ileaca." The 
patient lies on his back, — ^^just as in peritonitis; with his body drawn forwards, and 
his limbs drawn up.* The patient lies quiet; for if he move about, he increases 
the pain. A patient is often disposed to be restless throughout; but, for some rea- 
son, he cannot. In these cases the patient keeps his body still; but tosses his 
arms about. The pulse becomes quick; and it is generally small, and sometimes 
hard. It is generally in cases of this kind, that we have what is termed a loiry 
pulse; — that is to say, the pulse is as small and as hard as a wire. A thready pulse 
is one which is as small and as soft as thread. The tongue at last grows brown; 
and ultimately (provided things go on from bad to worse) the pain ceases; the 
patient will often bear pressure; the abdomen swells, and becomes very large; and 
if we place our fingers acjross it, and strike it, the sound is as hollow as that of a 
drum. The patient therT becomes exceedingly restless, and delirious; the pulse 
becomes irregular, and very rapid; the respiration is also quickened; and death 
ensues. 

Morbid Jlppearances. — After death, very likely we may find no effusion what- 
ever; but mere redness. Sometimes, however, there is an effusion of lymph upon 
the surface, and more or less serum; — from the peritonaeal coat having suffered 
"with the rest. Owing to the great congestion, a portion of the intestines will some- 
times be almost black; — as black as any blood can be. This has continually been 
mistaken for gangrene, as Dr. Baillie mentions;'' and as I stated when speaking of 
inflammation in general;" but we find that it resists the fingers in a way that gan- 
grene would not. We know how mere congestion will make a person black in 
the face. But there may be gangrene; though it is a very rare thing. I do not 
recollect having seen it. The parts become lacerable like paper, as well as black; 
and they smell intolerably. Occasionally pus has been found in the substance of 
the intestinal coats. The mucous membrane within, and the serous membrane 
"without, are inflamed; but the chief seat of this inflammation, — producing this ob- 
struction and this violent pain,— I believe is the cellular coat of the intestines. 
The muscular fibre may be in a state o^ hypertrophy; but I have never seen it iri' 
flamed. Acute rheumatism is, for the most part, inflammation of the aponeuroses; 
— even when it appears to be the muscle itself which has been affected. Rheu- 
matism, generally speaking, afl"ects parts which are not muscular; but if the muscle 
be aflfected by it, it is only secondarily. We never have an effusion into muscle, 
or suppuration there, or any thing of the sort. It appears to me that it is the cel- 
lular membrane of the intestines, that is chiefly the seat of this disease; although 
the peritonaeal coat, and the mucous membrane, may also be inflamed. 

Diagnosis. — Enteritis is distinguished from peritonitis, by the obstruction that 
is produced, — the constipation; and the consequent effects of it, — nausea and 
vomiting; and also by the circumstance of the pain being fixed about the umbilicus, 
which is generally the seat of it; whereas, in peritonitis, it is diffused. 

Causes. — This disease is caused by any thing which will produce inflammation; 
— cold and wet applied externally, and cold internally; and it is induced by any- 
thing which occasions obstruction. If there be a hernia, and the part becomes girt, 
then we have enteritis. If the fseces become black and indurated, and will not 
pass, then we may have this disease. Whatever causes an obstruction, is sure to 
produce this affection; provided it continue sufficiently long for the disease to be 
set up. 

Treatment. — When called to a patient in this disease, we must first ascertain the 
cause of it. Examine every part of the abdomen, and see whether there is not an 
umbilical, or a ventral hernia; for patients continually have symptoms of this de- 
scription, because there is a hernia; and the hernia may be so small as to escape 
attention. A small portion of the intestines may slip down, without the patient 

» See Page 873. »> In his " Morbid Anatomyj" Chapter 8; Section 1. 

" See Page 108. 



DISEASES OF THE INTESTINES. 915 

knowing it. Great mistakes will occur, if persons do not remember that tins dis- 
ease may be the result of hernia; and that a patient may have hernia without know- 
ing it. If there be a hernia, that will be treated in the way which the surgeon 
thinks best; but if there be not, the first thing which we have to do, is to bleed the 
patient well. We should set him as upright as he can be; and bleed from a large 
orifice without any mercy. We must of course consider the patient's strength; 
but we should bleed on till we make a decided impression; — till we knock down 
the pulse, and make him faint. After this has been done, a very large dose of 
calomel should be exhibited. A large dose will clear the stomach, as well as a 
small one; and it will be more effectual in purging. After it has been taken some 
time, other purgatives should be given; but immediately after it is administered, an 
active injection should be given; so that, if possible, they may meet half-way, and 
combine; and then the disease goes away. First bleed very freely, because pur- 
gatives will not operate till we have done that; then give a large dose of calomel 
(such as a scruple) by the mouth; and then administer a strong purgative injection; 
— containing plenty of salts (combined with senna, if preferred), or extract of 
colocynth, or oil of turpentine. I would repeat the calomel, in doses of about ten 
grains, every four or six hours; — giving purgatives, in addition, from time to time, 
till the mouth is sore: and when this effect is produced, and the bowels are freely 
open, the inflammatory symptoms generally go away; and as the obstruction fre- 
quently arises from mere inflammation, if we remove the latter by bleeding, and 
produce a mercurial affection on the patient, the former will subside. 

It is also well to cover the whole abdomen with leeches. Twenty, thirty, or 
forty should be applied; and we should then give mercury till the mouth is sore, 
and follow it up by other purgatives; — such as croton-oil, which is one of the best, 
and of which a drop may be given every two or three hours. Sometimes I have 
given a drop every hour. If these measures will not open the bowels, then we 
shall find it of very great use to employ the smoke of tobacco. A tobacco-clyster 
is sometimes a dangerous thing: and therefore we should only put a drachm to a 
pint of water, throw up one half of it, and watch its effects; but the smoke of 
tobacco is very manageable. There is a little apparatus for the purpose. We 
must watch the pulse at the same time; and regulate the smoke proportionately, at 
our discretion. Sydenham was very fond of this remedy; but not more so than it 
deserved. He says that the smoke of tobacco was, by far, the most eflicacious of 
all the injections he knew. I know many practitioners who now employ this re- 
medy, with very great success. If this fail, there is no impropriety in taking the 
patient out of bed, and throwing a few pails of cold water hard against the abdo- 
men. That will sometimes open the bowels, when nothing else will. But where 
there is inflammation, and no mechanical cause that we can discover, the best mode 
is to treat it as an attack of inflammation; but in the most decided manner. Take 
care to give purgatives as abundantly as the stomach will bear them, till they pro- 
duce their effect. 

Similar Symptoms from Spasm. — This disease is called "enteritis" (from 
svts^ov, an intestine; and " itis," — inflammation); because it is an inflammation 
of the substance of the intestines. But similar symptoms, in many respects, are 
produced by mere spasm; — that is to say, perfect obstruction, together with vomit- 
ing and violent pain, though pain of a different character; and then the disease is 
termed colic; — "enteritis" being essentially injlam.mation, but "colic" beinof 
essentially spasm. When the spasm ceases, however, then inflammation may 
come on; and we then have a case of decided enteritis. 



SECTION II.— COLIC. 

Having noticed that description of obstruction of the bowels which is inflamma- 
tory, I now proceed to consider that which depends simply upon spasm. This 
obstruction of the bowels is called "colic" (from "the co/on"). 



916 DISEASES OF THE INTESTINES. 

Symptoms. — The symptoms of colic are, in the first place, constipation; with 
violent pain in the region of the intestines; — chiefly, as in other cases, about the 
umbilicus. This pain, unlike that induced by inflammation, is relieved by pres- 
sure; for there is no tenderness. • 'i'he relief upon pressure is sometimes very great; 
— at any rate, pressure is always well borne. I have sometimes raised myself on 
tip-toe, and pressed on liie abdomen with the whole weight of my body, and the 
patient has not complained at all; but, on the contrary, has felt relieved by it. The 
pain is, of course intermittent. It is not uniform; nor, indeed, is it constant. It 
will cease from time to time; the person will be perfectly easy; and then it comes 
again most terribly. In most cases there is vomiting; at any rate, there is nausea. 
The vomiting may be faecal; — the faeces have been discharged upwards, as in cases 
of inflammatory constipation. In both cases, however, this circumstance is com- 
paratively rare. The spasms, in these cases, are not confined to the intestines; for 
we frequently see them in the abdominal muscles; so that they are drawn into large 
lumps. The recti muscles become particularly contracted; and, sometimes, we 
may observe retraction of the navel. Sometimes there is tenesmus; and sometimes 
there is great contraction of the sphincter am. There is likewise violent pain felt 
in the loins; there is a high degree of flatulence; and there is no feverishness. It 
is carefully lo be remembered that this state of things, however purely spasmodic 
it may be, will frequenfly, if not relieved, run by degrees into enteritis; so that, at 
last, we have decided inflammation of the intestines. 

Causes. — Tiie causes of this disease are, in the first place, the application of cold 
when the body is overheated. This is a very common cause. Ingesta of various 
kinds, which disagree with the stomach, will give rise to it. Sometimes I have 
seen it occur from taking bad cider; but in other cases it will take place, not from 
any thing injurious in itself, but from an idiosyncrasy with regard to it. Obstruc- 
tion from any cause will produce it. If there be a hernia, colic may be induced, 
in the first instance, before inflammation comes on. Hardened fasces is another 
cause of the disease. It is a common occurrence from any of those causes which, 
after a time, produce enteritis. Sometimes we may have enteritis first, and then 
colic, and vice versa; thougli the cause of both one and the other may be the same. 
A very frequent cause of it is a particular substance; namely, lead. In some per- 
sons, a very minute portion of it wUl induce this aff'ection. A medical man told 
me tliat he had it, from a child's cot, newly painted, being placed in his bedroom. 
"VVe see the affection, every day, in painters; and in persons employed in the 
inanufacture of white lead. Individuals exposed to lead, in any way, are very sub- 
je:-t to this disease. 

Morbid Appearances. — After death, whether the disease has arisen from cold, 
from acrid ingesta, or from lead, we may find no morbid appearances whatever; 
but, on the other hand, we sometimes do. This is all a matter of chance. Some- 
times the in estines are in a state of great contraction. Sometimes they are more 
or less inflamed; because the disease has terminated in that way. Sometimes we 
find ihe cause to have been something sticking in the way, or mechanical pressure 
of some kind; or we may find intus-susception, — one part of the intestine running 
into another. With regard to the appearance of the muscles, they are emaciated, 
thin, white, and pale. I have seen the muscles so flabby and wasted, that we could 
scarcely recognize their natural appearance. They have become little more than 
tendons. When intus-susception has been the cause, we generally find that the 
upper part of the tract has passed into the lower. Dr. Baillie has given some good 
representations of intus-susception. 

Treatment. — Colic may generally be treated, very successfully, by the exhibi- 
tion of purgatives in strong doses. If the individual be stout, and the pulse will 
bear it, it is a good practice to bleed Iiim. Bleeding, within certain limits, is an 
excellent antispasmodic; — spasms of various parts of the body will very frequenfly 
cease, on taking away blood. It is not always necessary in this affection; but it 
may be successfully had recourse to, if the pulse will justify it, even though it 
may not indicate it; and it may also act beneficially in preventing inflammation. 



DISEASES OF THE INTESTINES. 917 

It is very useful to give a large dose of calomel; — to administer a srrnple repea!- 
edly, after longer or shorter intervals; and after we see that it will remain on the 
stomach, it is right to give some other purgative; — a strong dose of castor oil, or 
croton oil, or sulphate of magnesia. 

Croton Oil. — One of the best purgatives is undoubtedly croton oil; and, if we 
choose, we may begin with it; but it will be of little use to give less than a drop. 
In severe cases, I would repeat it every hour or two, till it answered the purpose. 
Some vears ago I was called to a case, where the hot-bath, and every medicine in 
common practice, had been used, except croton oil; and even of that a dose or two 
had been given. But the case was very severe, and it was necessary to overcome the 
disease speedily; and therefore I ordered a drop every hour, or half hour, till it should 
operate. After about six doses, the bowels were freely opened; and the patient 
became perfectly well. An injection of oil of turpentine will also be found exceed 
ingly serviceable. About three ounces, diffused in a pint of fluid, and forced into 
the intestines, is of great service. The warm-bath will afford great relief; but it is 
rather of use as a soothing measure, tlian in any other way. The great point is 
to give good purgatives, and croton oil is certainly one of the best; but we may 
precede it, by way of laying a foundation for its action, by a large dose of calomel. 
At the same time, whatever good may be done, we should not omit clysters; and I 
think the oil of turpentine is one of the best. 

Calomel and Opium. — Some persons always combine opium with the calomel; 
and the opium may frequently do good by alleviating the spasm. This is a case 
in which opium may act as a purgative. By relaxing the spasm, it may cause the 
bowels to open; and it is thought that it very much reduces the pain, and makes 
purgatives and calomel stay better on the stomach. It is therefore said, that we 
ought always to give a larger or a smaller dose of calomel (a scruple or five grains, 
whichever we may prefer) united with opium, and repeat it at certain intervals; but 
I have found the bowels open, just as well, without opium; and then there is no 
trouble afterwards. If we exhibit opium, after a time the bowels are disposed to 
become torpid; and I am quite sure we shall succeed as well without it as with it. 

CgIcI Effusion. — When every thing has failed, I have known this affection of the 
bowels overcome by taking the patient out of bed, and dashing two or three pails of 
cold water upon the abdomen. In the particular case to which I have alluded, — in 
which the patient had taken calomel till his mouth was sore,^ — before we began 
with the croton oil, as the object was to open the bowels immediately, he was 
taken out of bed, and soused with cold water; and he was nothing the worse for it. 
He caught no cold; but it did not open his bowels. Sometimes it will effect that 
object immediately; — ^just as it will relieve spasmodic stricture. If all other things 
fail, it should be had recourse to. 

Tobacco. — The smoke of tobacco, also, is exceedingly useful in this affection. 
It should be used as I have before mentioned.^ Some have even found the infla- 
tion of common air serviceable, by producing a great distension of the intestines. 
A case of this kind is recorded in the "Glasgow Medical Journal," of 1831. 

Clysters. — It is well, also, on another account, to administer a clyster: for some- 
times the symptoms arise from hardened faeces lodged in the rectum. I have known 
instances of that description; and, as we do not always know whether such an 
occurrence has taken place, I would invariably, on that account alone, recommend 
a clyster. Occasionally, it is discovered, especially in women, — that there is a 
mass of large hardened f?eces there; and nothing will relieve the patient, but taking 
the handle of a spoon, and picking them out. Practitioners are sometimes obliged 
to condescend to this; and thus to clean out the rectum. 

Liability of Lead Colic to Recxir. — Supposing, however, that the disease has 
arisen from lead, it has a great tendency to return. There is this tendency in all 
circumstances, but particularly in the case of lead; so that after we have once 
opened the bowels, it is necessary every day, for some time, to ascertain that the 

»^See Pa^e 915. 



918 DISEASES OP THE INTESTINES. 

bowels are still regularly opened. When the disease has arisen from lead, the 
stomach sometimes remains in a state of spasm: so that there will be an aching 
pain there, and occasional vomiting: — notwithstanding that the bowels are regu- 
larly opened. This is a state which is best relieved by prussic acid or stramonium. 

Alum. — Some German writers, and Dr. Percival (of Manchester), have praised 
alum very much. They state, that from two grains to a scruple has been given every 
six hours, with great relief. However, I should never think of depending upon 
such a remedy, in cases of colic. It may be very well after the attack is over, for 
the purpose of keeping the bowels open; but I should not think of placing any reli- 
ance on it during the fit. I know that it has been useful; for I recollect, perfectly 
well, having been consulted by a gentleman who, every six weeks or two months, 
had a violent fit of colic; so that it was necessary to put him in the hot-bath, and 
to exhibit a violent dose of purgatives. This always cured him, but left him in a 
state of great dehility; and nothing that was done prevented the recurrence of the 
attacks. I gave him, three times a day, a scruple, or half a drachm of alum, mixed 
with ipecacuanha-powder; and it entirely cured him. He took it for a month or 
six weeks. I saw him, at intervals, for three or four years afterwards; and he had 
never had another attack. I dare say that ordinary purgatives, in the case of most 
people, will do very well; but I tried alum, in this instance, with great success. 

Warmth. — It is useful, where there is a tendency to disease of the intestines, to 
put the patient on his guard with respect to cold, and to order him to wear flannel 
about the abdomen. A large roller, wound three or four times round the body, is 
exceedingly serviceable. It protects the abdomen against cold, and is always use- 
ful. In this, as in most other bowel-complaints, it is particularly necessary that the 
patient should avoid cold feet; for some individuals, if they allow their feet to 
become cold, always have an attack of colic. 



SECTION m.— PARALYSIS AFTER LEAD-COLIC. 

"When colic has been induced by lead, we sometimes find that, after the colic is 
over, the wrist will drop. The muscles situated in "the forearm, and belonging to 
the hand, become paralyzed; so that the patient has very little use of the hand,— 
perhaps none; and the muscles will, at last, waste away. It is said, by some 
writers, that the "abductor pollicis" wastes more than the other muscles; but I am 
not aware that it does. Sometimes this will occur from lead, without any colic at 
all; but generally there is colic; and this is followed by paralysis of the wrists. 

General Treatment. — This is a state that may easily be remedied. In the first 
place, withdraw the person from the poison, and prevent him, for a time, from fol- 
lowing his occupation. If he be a painter, withdraw him from the lead, or the 
lead from him. It is also of great importance that he should not wear the clothes 
which he uses in business. A quantity of lead is still remaining upon them; and 
that may, of course, keep up the disease. I have no doubt that many painters 
might avoid the complaint, if they were more cleanly; — if they wore sleeves over 
their coat; and, as soon as they had done work, regularly put off their working 
clothes. We cannot, however, persuade men to do this. They will not give them- 
selves the trouble, till they have once suffered for their negligence; and even then, 
as soon as they recover, they become careless. If patients would adopt the pre- 
cautions I have just given, no doubt many of them would escape. 

Local Treatment. — In the way of local application, electricity is one of the best 
remedies. It should be applied not only to tiie hand, but to the forearm; because 
the muscles in both parts are paralyzed. I think I have seen sparks answer better 
than shocks; and the electricity should be applied, if possible, every day. It has 
also been recommended that the patient's hand should be supported by splints; 
and that these should be used night and day, so as to keep the hands in a slate of 
constant extension. This has been recommended by Dr. Pemberton. Blisters are 
also said to be useful I have found stimulating applications, of all kinds, service- 



DISEASES or THE INTESTINES. 919 

able; but particularly electricity. When we apply stimulating applications to the 
skin, they only act on internal parts by sympathy. Friction may make the parts 
worse; but electricity will go to every spot wliich is really the seat of the disease. 
As to internal medicines, 1 have never seen them do good, except it has been stra- 
monium, or strychnine, or (which is the same thing) "nux vomica," This is a 
species of paralysis, in which I have exhibited strychnine with decided advantage. 



SECTION IV.— INTUS-SUSCEPTION. 

Most frequent in the small intestine. — Intus-susception, — the affection of which 
I spoke as sometimes giving rise to colic, ^ — generally occurs in the S7??a/^ intestines; 
or else the small intestines slip down into the large, — into the colon. However, 
intus-susception of the large intestines has been seen; for the caecum and a part of 
the colon have been found in the sigmoid flexure. Cases have been seen, in which 
the small intestines (beginning with the duodenum) have all slipped into the large 
intestines, and the caecum has protruded from the anus. These are rare cases; but 
not impossible because they are rare. 

Causes. — This disease may occur from any irritation whatever; and it has some- 
times, no doubt, been temporary; and has passed away. On opening animals, we 
may sometimes see intus-susception take place before our eyes; and then the parts 
will slip out again. 

Cohesion may occur. — However, when intus-susception has occurred, the parts 
may remain in the situation into which they have been forced; and at last cohesion 
takes place between the descending portion, and that into which it has slipped; and 
the mucous membranes may then cohere; so that complete obstruction takes place, 
and the person dies. Sometimes the part which has slipped in, has only adhered at 
the upper portion; sloughing has then taken place; and a part of the intestine has 
been discharged. 

Quantity of intestine discharged. — The quantity of intestine which, beyond all 
doubt, has been expelled in some of these cases is surprising; and yet the patient 
has done well. Dr. Baillie mentions having seen, or known, a yard of the colon 
discharged from a woman before death. He mentions another person, who lived two 
years after losing six inches of her colon. It is easy to see how this happens, with- 
out any great mischief taking place. Adhesion takes place at the upper portion of 
that which has slipped down; sloughing afterwards occurs; but the part remains con- 
tinuous as before, — only shorter. Whether the person has more frequent evacua- 
tions after the intestines have been shortened, I do not know; but it is an undoubted 
fact, that a large portion has been expelled; and yet the person has done perfectly 
well. Another case is recorded, in which twenty-three inches of the colon were 
discharged; and in another, twenty-eight inches of the small intestines; and yet re- 
covery took place. Cruveilhier mentions a case, in which eighteen inches, together 
with the mesentery, were discharged: but the person entirely recovered, after having 
exhibited signs of strangulated hernia. 

It may appear wonderful that so large a portion of intestine should be discharged; 
but the occurrence is not only mentioned by Dr. Baillie, — who, I suppose, was a 
man who never told an untruth in his life,— but Andral cites a case, where thirty 
inches of the ileum were discharged, and death did not take place for three months; 
and then it arose from peritonitis. He suspected that death took place in conse- 
quence of the cicatrix being lacerated by an accidental circumstance; and that, but for 
that occurrence, the individual would have done well. In the ninth volume of the 
"Edinburgh Medical and Surgical Journal," a surgeon mentions a case where the 
colon, the ceecum, and the meso-colon, were all discharged; but, of course, death 
took place. 

Gives rise to no peculiar iSymptoms. —Theve is no proof of the existence of this 



920 DISEASES OP THE INTESTINES. 

condition during' life. We cannot tell, in a case of colic, that the patient hag intus- 
susception. I recollect being called to a case of violent colic, which appeared to 
arise from a man drinking sour cider, and rum, and a number of other things; — 
liaving, in a thirsty fit, drunk every thing he could reach. Violent colic suddenly 
took place; and his bowels, from that moment, were confined. He had castor-oil, 
croton-oil, olive-oil, hot-baths, cold-batlis, and every thing that could be devised; 
but no evacuation was produced. He survived a fortnight; and, at the post-mortem 
examination, intus-susception was found. Portions of the intestines were perfectly 
coherent together; — forming a solid mass; so that there was no continuation between 
the upper portion of the intestines and the lower; but the circumstance was not 
known before death. There was no particular tumour to be discovered. From 
what I have read, and occasionally seen in dead bodies, I do not think that, in a 
great number of cases, there can be any sign whatever. The disease has occa- 
sionally been suspected, however; and, indeed, I suspected it in the case to which 
J have just referred. 

Treatment. — Some persons say, that we ought to cut down upon the jjarl; — that 
we are not bound to wait for the person's dying. Now the case ought to be very 
clear indeed, before a man's abdomen should be opened, and an attempt made to 
untwist his intestines directly. It has been proposed by some to cut down upon 
the part, wherever the seat of the pain is; but this is a very fallacious guide. We 
sometimes have pain at one part of the abdomen; and, after death, the obstruction 
is found to be at another. But if, after symptoms of colic, a tumour be produced, 
the surgeon might then take into consideration whether he would cut down or not. 



SECTION v.— DYSENTERY. 

I now proceed to the consideration of another disease, in which there is spasm 
and inflammation together; and in which there is both obstruction and purging. 
This disease is called " dysentery."" 

Symptoms. — The symptoms of this complaint, are a mixture of those of colic 
and enteritis; so that we have violent pains of the abdomen, called "tormina;" we 
have also a forcing down backwards, — a forcing of the rectum, which is called 
*' tenesmus;" and frequently small mucous or bloody stools, together with more 
or less retention of the faeces; so that there is an obstruction to the course of the 
faeces, but a great discharge of secretion from the inner surface of the intestines. 
The stools are scanty and irregular. The discharges are very frequent, but each 
particular discharge itself is scanty; and when the faeces do come away at all, they 
are found in hard lumps. Sydenham defines dysentery to be — " frequent mucous 
stools, with griping." Dr. Akenside, the poet, wrote on this disease;* and he 
gives the same definition as Sydenham; but he adds to it — " frequent desire;" — in 
fact, tenesmus. The blood which is discharged in this affection, may be either in 
clots, or merely in streaks; and sometimes it is discharged in very considerable 
quantity, and quite liquid. Very frequently there are shreds of fibrin expelled; 
and Sir John Pringle says, that he has seen fatty matters discharged. That I can 
believe; for I could mention the same with respect to diarrhoea. 

Acute or Chronic. — This disease may be either acute or chronic. In \\\e acute 
affection, there is violent inflammation as well as spasm; so that there is considera- 
ble feverishness, quickness of pulse, heat, thirst, pain in the abdomen, not only 
coming on in fits, like tenesmus (griping), but pain that is constant, and increased 
on pressure; together with dryness of the skin. This state may go off in a few 
days, or it may last for a month; after which time, perhaps, we may call it ''^chronic 
dysentery." 

ISature of the Evacuations. — The liver very frequently ceases to secrete, so 
that no bile at all passes away; and sometimes it is in a state of great irritation; so 

" From ^uf, with difficulty; and svtsjov, an intestine. 
b " De Dysenteria, Commentarias. London, 1764." 



W\ 



DISEASES OF THE INTESTINES, 921 

that it secretes green bile, and tlie motions are therefore green. Sometimes, how- 
ever, the motions appear to be of a pitch-like substance. Sometimes, instead of 
lliick mucus, there is thin serum; and, from there bein^ a little hjcmorrliafre, this 
serum is rather red; so that the discharge from the alimentary canal has, very 
aptly, been compared to the washings of meat. The discharge may be of all co- 
lours, and of all qualities; but the fseces are usually retained. If we procure an 
evacuation of faeces, they come away in hard lumps-; which are called "scybala," 
and are like forced-meat balls, only hard. Nature gets rid of these balls from time 
to time. The tongue is foul, and very frequently aphthae appear; — from the mu- 
cous membrane suffering. 

Frequently conjoined with Fever. — This disease is very common in hot climates; 
and most common in this country'' in hot weather. It is frequently united with the 
fevers of hot countries, and of our hot seasons; and frequently it is conjoined with 
intermittent and remittent fevers. Sometimes it precedes, and sometimes it follows 
these. Sir John Pringle and Sir Gilbert Blane both say, that it arises in camps at 
the same seasons, and in the same circum.stances, as bilious fevers. It has now 
and then, curiously enough, been observed to be vicarious with fever. It will 
cease in the army and navy, in different parts of the globe, when fevers begin; and 
%vill reappear when they cease; but, very frequently, it is united with them. It 
has been known to coexist with typhus fever; and likewise to alternate with it. 
When typhus fever prevailed (a ^ew years ago) in Ireland, dysentery prevailed at 
the same time, and occasionally alternated with it. Very frequently it occurs with 
disease of the liver; and occasionally it has been united with measles. The causes 
of hepatic disease, and the causes of fever, affect all parts of the abdomen. 

Chronic form less Violent. — The chronic form of the disease, is much less vio- 
lent than the acute; and is attended with much less pyrexia. Indeed, the pyrexia, 
in the chronic form, may at last become hectic. The intestines become diseased; 
suppuration and ulceration occur; and we have hectic fever. Sometimes, in the 
chronic form, there is no fever at all; for it degenerates into diarrhosa: so that, at 
last, the patient complains only of mucous stools and tenesmus. The faeces not 
being retained, it may degenerate into diarrhcea; so that we have dysenteric 
diarrhoea; — that is, diarrhoea characterized by great griping, and a discharge of 
mucus. It has been observed, in hot countries, that more stools take place at night, 
than during the day; and at new and full moons, than at other times. When 
speaking of remittent fever, I mentioned, that at new and full moon that fever un- 
doubtedly prevails most, and the symptoms are more intense than at other periods." 
The same has been observed with regard to dysentery. More stools take place at 
that time; — not from the direct influence of the moon; but, from the high tides that 
then take place, there is more vegetable decomposition. 

Morbid Jlppearances. — After death from the acute form of the disease, we see 
great inflammation of the intestines, — chiefly of the large ones, and particularly of 
the colon. This disease so particularly affects this part, that some have proposed 
to call it colitis., — "inflammation of the colonf^ but that would not be quite cor- 
rect; for it also affects the rectum, and likewise the small intestines. The great 
seat of the disease, however, is the colon and the rectum. Besides marks of red- 
ness and congestion, there is occasionally superficial abrasion of the mucous mem- 
brane; and sometimes deep-seated ulceration, and great distension. After the 
chronic form of the disease in the same situations, — namely, the colon and the 
rectum,— we find great redness and ulceration; but we also find that effect so 
peculiar to chronic inflammation, — great hypertrophy; — such thickness as acute 
inflammation will not induce. There is great thickness of all the coats. The 
rugae are all greatly enlarged; so that the inner surface is exceedingly rugged, and 
we see shreds of lymph (sometimes of great length) hanging upon it. Occasionally 
these changes are seen only in patches; and occasionally they are seen over a very 
great extent; and, at the same time, red patches are frequently seen in the small 

" England. •> See Page 337. 



922 DISEASES OF THE INTESTINES. 

intestines. The colon has been found, after this chronic form of the disease, as 
much as a quarter of an inch in thickness. Minute abscesses, too, are seen in the 
substance of the intestines. On opening the glands, we find them so much hyper- 
tropliied, as to look like so many warts. Besides the morbid appearances just 
mentioned, it is not uncommon to find the liver in a state of disease. It is fre- 
quently in a state of chronic inflammation; and, occasionally, in a state of abscess. 
The spleen, sometimes, is in the same predicament. The liver, however, is much 
more frequently affected than the spleen. 

Causes. — As to the causes of dysentery, all agree that it is very often produced 
by changes from heat to cold, and from cold to heat, The tendency to it is greatly 
increased by long-continued heat, and by fatigue; therefore in those counlries 
where it is continually seen, it frequently breaks out when the army has suffered 
to a great degree, or there has been a sudden vicissitude of temperature. A cold wet 
night, after an intensely hot day, will occasionally produce this aflection, in a vast num- 
ber of persons. It is a disease particularly common on board ships, and in camps. 
Some consider that one cause of it is malaria; and certainly it is a fact, that where 
malaria prevails to a great extent, dysentery is very common; but as these are wet 
situations, one hardly knows whether it is the malaria itself v/hich gives rise to it. 
I mentioned that, with the remittent fevers of hot countries, there are bilious fevers 
of all kinds.* It is also undoubtedly produced, sometimes, by bad food; and like- 
wise by bad water. This disease, for example, prevailed in the Penitentiary at 
Millbank; where there is a combination of unfavourable circumstances. The pri- 
son itself is situated in the most unwholesome place imaginable; — as if it were 
intended to carry off quickly the people who have been placed there; and I believe 
the allowance of food was not such as medical men considered to be proper. It 
coexisted there with scurvy, and various other diseases. 

Formerly prevalent in London. — Formerly dysentery was very common in 
London, but at present we seldom see it. I scarcely ever meet with a case, ex- 
cept of those who have been in hot climates; whereas, formerly, it was one of the 
greatest scourges in the metropolis. We find it treated of by Sydenham, as one 
of the diseases that came daily under his observation. It was one of the great 
causes of mortality in the city;— just as was the case with ague, plague, and scurvy. 
I presume it arose, then, from the bad quality of the food upon which people lived, 
and the bad drainage of the city. As to the ill effect of bad water, it is said that 
when the disease prevails in ships, those suffer most who are nearest the pump. 

Fruit. — It has been supposed that fruit produces the disease; but unless the 
fruit be bad, there is no reason to suppose that this is the case. Of course bad 
fruit, coming under the head of bad food, might produce it; but the mere circum- 
stance of eating fruit at the time when Nature provides it for us, does not give ri^e 
to the disease. On the contrary, there are on record many cases of fruit having 
proved exceedingly beneficial. It is mentioned by Zimmerman, in his work on 
Experience, that in 1751 a whole regiment, in the south of France, was nearly 
destroyed by dysentery. The officers purchased the entire crop of several acres 
of vineyard for the regiment; and not one man died from that time, nor was one 
more attacked. The work is well worth reading; for it is as amusing as a novel, 
and full of instruction. Tissot, a French writer, also mentions that eleven persons 
in one house were attacked with dysentery. Nine of them ate fruit and recovered; 
but the grandmother, and one darling little grandchild, had wine and spices instead, 
as being more comfortable; and both died. It was observed in Holland, that the 
worst flux which was ever known in the army, occurred at the end of July, when 
there is no fruit but strawberries, of which the men never partook; and that the 
disease ceased entirely when October arrived, and brought the grapes, of which the 
men ate very heartily. 

Bad Water. — Any cause of intestinal irritation may produce dysentery; more 
particularly when a predisposition has been given by long-continued heat, and by 

* See Pa,e:e 333. 



DISEASES OF THE INTESTINES. 923 

bad food; under which term, of course, drink is inchided. It is said, that at the 
old barracks at Cork, the troops had water contaminated by the common sewers, 
and made brackish by the tide; and dysentery prevailed. This was remedied; and 
the disease almost entirely ceased. Linnseus's friend, Rolander, had dysentery 
from drinking standing water out of a cistern of juniper wood. He ascribed the 
disease to animalcules; but the mere circumstance of its being stagnated' water, 
was sufficient to account for the disease. 

Is it contagious? — It was formerly supposed that this disease was decidedly 
contagious, and that it spread most from the stools; so that if any individual fol- 
lowed another labouring under dysentery, for the purposes of relieving nature, it 
was conceived that he was more liable to catch it, than by simply being with him. 
Whether it is contagious or not, it is impossible for me to say; but the sporadic 
cases of chronic dysentery, which w^e occasionally meet with in those who have 
come from hot climates, are certainly not contagious. I never saw any thing that 
could lead to the supposition of the disease being so. I will not presume to deny, 
that sometimes it may be contagious abroad; but many diseases are supposed to 
be contagious that are not. I think it may reasonably be doubted whether it is 
contagious. Some imagine that almost any particular disease, in particular cir- 
cumstances, may become contagious; and therefore I do not say that it never is 
contagious; but as the disease is seen in England, it certainly is not. 

Mortality in the Peninsular War. — I mentioned that this was a disease which 
prevailed particularly in camps, and in the fleets abroad.^ In the Peninsular war, 
our army lost no fewer than four thousand seven hundred and seventeen men, by 
this disease exclusively. In 1812, two thousand three hundred and forty died; in 
1813, one thousand six hundred and twenty-nine; and in 1814, seven hundred and 
forty-eight. The disease is very manageable, if taken in the first instance; but 
extreme mortality arises from the unfavourable circumstances in which men are 
placed. From the want of all comfort, and the excessive fatigue, medical men 
have little chance of doing good. 

Pathology. — With regard to the nature of the disease, it appears to be inflam- 
mation of the mucous membrane, together with spasm of the muscular fibres, 
chiefly affecting the large intestines. One ought not to say " altogether affecting the 
large intestines;" but it aflTects them much more frequently than it does the small 
intestines. The inflammation gives rise to constant pain, to sickness, pyrexia, 
and to a great discharge of mucus and blood. The spasm gives rise to occasional 
severe pain; and to the retention of the faeces. 

Prognosis. — As to the prognosis of the disease, that must depend upon the 
violence of the symptoms; but we always find it mentioned by authors, that one 
of the worst symptoms that can occur, is the discharge of worms; — as though the 
worms instinctively knew that the habitation was about to be dissolved; — and that 
therefore the sooner they quitted it the better; — just as rats are said to quit an old 
barn, and to look out for a new habitation, before they are turned loose by the de- 
struction of the present. 

Treatment. — With regard to the cure of the affection, the first thing is to re- 
move, if possible, the cause of the disease. If there be a bad quality of the ingesta 
(whether liquid or solid), or any dampness in the situation, or any contamination 
of the atmosphere, all this should be obviated; — either by removing the patient 
from it, or by removing it from the patient; otherwise we are fighting against a 
double enemy; — both the disease and its cause. 

Jintiphlogistics. — In acute dysentery, we have to treat the affection upon a de- 
cidedly antiphlogistic plan. It may be necessary to bleed vigorously in the arm; 
to apply leeches freely and repeatedly to the abdomen; to give mercury, and get 
the mouth sore; to apply cataplasms of hot moist bran to the abdomen; or, if pre- 
ferable, to apply them cold; but, in general, the moisture answers much better if it 
be warm. We must treat it as a violent active inflammation of the intestines. 

« See Page 933. 



924 DISEASES OF THE INTESTINES. 

"With rpjrard to enlomel, we shall fiiul that, altliongh all agree upon its importance 
in this (Hsease, yet that some recommend large doses at intervals, and others small 
ones. Those whf) recommend the latter, would give other purgatives (such as cas- 
tor-oil) at intervals, for the purpose of emptying the intestines; whereas those that 
give large dose^i, trust more to the calomel itself. It is highly necessary, in this 
disease, to open the bowels well. Notwithstatiding the number of evacuations, the 
fseces are altogether or greatly retained; and therefore it is !iecessary, not merely 
to employ the remedies for inflammation, but to empty the intestines thoroughly. 
Some people would give a scruple of calomel at intervals: — so as to get the mouth 
sore as quickly as possible, and at the same time to empty the alimentary canal. 
Those who give small doses, would give other purgatives in great abundance; but 
it is necessary to get the bowels open, as speedily and as effectually as possible. 
It is useful to employ opium at the same time; — on account of the great tendency 
which there is to severe spasmodic pain. The opium may be united with the 
calomel; and if we take care to make the calomel operate by means of other pur- 
gatijires, no harm can arise from it. If castor-oil will stay on the stomach, I should 
prefer that medicine to salts; because there is, perhaps, a great discharge of mucus; 
and perhaps there are watery stools rather than fseces; and castor-oil has the pro- 
perty of thoroughly emptying the alimentary canal. Emollient clysters are also of 
the very highest importance; but nothing acrid should be put into them. Clysters 
of gruel, containing a certain portion of laudanum and castor-oil, will be much 
better than clysters containing salts. The patient should be kept without food; — 
his stomach should be allowed as much repose as possible; — he should be kept 
very low. 

Ipecacuanha; Antimony. — Many persons, formerly at least, had a very high 
opinion of ipecacuanha in this disease. Dr. Akenside, the poet, in his elegant Latin 
treatise on this disease,^ recommends about three or five grains of ipecacuanha every 
six hours; and many persons still give it, and also antimony, so as to create sick- 
ness. I have no experience of any such plan. I do not see the utility of causing 
the patient to vomit in this disease; neither have I ever been able to discover the 
soothing effects of ipecacuanha. Some persons, when they give purgatives, give 
ipecacuanha; and say that it has the property of emptying the alimentary canal; 
but, after repeated trials, I cannot say that I have found that it has any peculiar 
properties, except that it makes the patient sick. I have been as successful in this 
disease as in any other, by treating it on antiphlogistic principles; — without exhi- 
biting any thing with the view of producing sickness, or any specific operation. 
Formerly, various preparations of antimony w^ere given; but I have not found them 
at all necessary. 

Treatment of Chronic Dysentery. — With regard to the chronic form of the dis- 
ease, we have to consider whether there is any inflammation still existing. There 
very frequently is. The abdomen is still tender; and it would be absurd to think 
of giving astringents, and blocking up the intestines, wliile that inflammation exists. 
The readiest way of lessening the disease is, in the first instance, to apply leeches 
freely over the abdomen, and to throw up a clyster; — taking care that the bowels 
shall be opened freely and regularly; and when we have done all this, then astrin- 
gents will be very proper. 

Jlstringents. — In chronic dysentery there frequently is no inflammation at all. 
The time arrives when there is a mere gleet of the surface, or the surface is merely 
in a state of irritation; and in that condition, opium and astringents of all kinds are 
exceedingly serviceable. But we may do infinite mischief unless we ascertain, 
before giving astringents, that there is no inflammation. If there be inflammation, 
we must treat it accordingly; — by leeches, blisters, fomentations, and things of tiiat 
description; and we must take care to see that the bowels are regularly opened, 
and the faeces discharged; because if the faeces are not discharged, and we exhibit 
astringents, we may produce inflammation, though there was none at first. But in 

* See Page 59. 



DISEASES OF THE INTESTINES. 925 

the chronic form of the disease, the faeces, at last, are discharged pretty well; and 
no purgatives are required. Still, however, the character of the acute disease so 
far remains, that there are bloody and raucous stools, a desire to go to stool, and 
tenesmus. In this form of the disease, astringents may be given safely, and may 
be either vegetable or mineral; and it is best to combine them with opium. By 
far the best astringents that I know, are kino and catechu. It may be right not to 
give the tinctures; as they may excite the pulse, and irritate the patient. It is best 
to give the infusions. Opium is very much required in this disease, to prevent 
griping^. As I before said," opium is often very safe and very useful in the acute 
form of the disease; — provided we take care to subdue inflammation, and to keep 
the bowels open; but in the chronic form, it may be given with very great safety; 
— provided the bowels be regularly open,— as is usually the case. A good mode of 
exhibiting the opium, is to give the Pulvis Catechu Corapositus. It will not irri- 
tate so much as opium alone. 

Sulphate of Copper. — When the ordinary astringents (catechu and kino) fail, 
mineral astringents will frequently cure the disease; and that which I have been 
most in the habit of employing, and with very great success, is the sulphate of 
copper. The way in which I became acquainted with its use, was from hearing a 
gentleman state that, at the Medical Society at Guy's Hospital, a case had been 
read of violent chronic diarrhosa; which yielded to nothing but copper. Dr. Sutton, 
of Greenwich, at a consultation, informed me that he had a very obstinate case; 
and that, all the other astringents having failed, it occurred to him to try this; and 
he did so with very great success. I have consequently used it; and it certainly 
is one of the best, where mineral astringents are required; but it is necessary to 
remember that we should not give it on an empty stomach; because, if it come in 
contact with the organ, it will excite vomiting. It should not be given till after 
breakfast; and that is the case with most acrid substances. If they be not given 
till the patient has had a meal, they will produce less irritation of the stomach, than 
if they come in direct contact with it; — which they must do when the stomach is 
empty. It is right to give this medicine in the form of a pill; because all acrid 
substances act more powerfully in a state of solution. If it be given in a pill, it 
comes in contact with a smaller surface; and will therefore produce less irritation 
than if it were diffused. It is generally right, also, to give it with opium; because, 
although it is an astringent, yet it is an acrid substance. It has two properties; — 
the one astringent, the other acrimonious; and therefore it is best united with opium; 
but I have frequently omitted the latter, and continued the former, with perfect 
safety. The smallest dose which it is worth while to exhibit, is a quarter of a 
grain; and we may gradually increase this to three grains; which is the largest 
dose that patients will ordinarily bear. In fact, many will not bear more than a 
grain and a half. It produces no constitutional effect. I have known a patient 
take it for tliree years, for a peculiar kind of diarrhosa, without any such result. I 
never saw such a constitutional effect arise from it, as occurs from lead or arsenic, 
or any other mineral substance. If it produce sickness, we shall find it of great 
use to give hydrocyanic acid with it. By giving from one to four drops of the acid, 
according to the necessity of the case, when the copper is taken, we shall find that 
patients will bear it without sickness or nausea; though without it, perhaps, there 
would be both. By a steady perseverance with this medicine, or with vegetable 
astringents and opium, — taking care, at the same time, to have the abdomen well 
covered with flannel; making the patient avoid cold, and every kind of ingesta 
likely to irritate the alimentary canal; — and, at the same time, supporting his 
strength, — we may effect a cure in the greater number of cases. It is a rare thing 
for me to lose a case of dysentery. I do not know how long it is since I lost one; 
but certainly it is not a very common complaint. 

Treatment of Ulcerated Intestine. — In the chronic form, if the intestines be 
ulcerated, we n ay still cure the disease; for it is only wlien there is a very great 

» At Page 924. 



926 DISEASES OF THE INTESTINES. 

degree of ulceration, that patients die from it. Ulceration of the intestines will 
heal, — ^justlike ulceration of any other part; but of course we may meet with cases, 
where medicine can do no good; — where the intestines are in a state of hypertro- 
phy, — look as if they were worm-eaten; — where the mesenteric glands are diseased; 
and frequently perforation takes place, and the patient is destroyed by peritonitis. 
A representation of such a case as this, is presented in Dr. Baillie's plates; and 
nothing can be expected to do any good in it. A surgeon would not be expected 
to cure a leg or an arm, in such a state as that. If the patient may sink from the 
disease of a part so unessential to life as an extremity, much more may he do so 
in the case of the intestines. Some persons recommend other substances in this 
affection; — such as nitric acid and muriatic acid, united with opium and astringents. 
One would expect, a priori, that such medicines would only cause irritation; but 
there is testimony in favour of muriatic acid combined with opium; and some say 
the same of nitrous acid. I have never given acids in the disease. I have known 
them, when taken in other diseases, produce a pinching in the bowels; and there- 
fore I have never ventured to give them to a patient labouring under this affection. 

Treatment of Tenesmus. — We shall find it very necessary to alleviate one 
symptom; and that is the tenesmus. If there be any tenderness about the abdomen 
at large, leeches should be applied to the anus, as well as to the front of the abdo- 
men; because tenesmus may arise from an inflammatory state. When, however, 
it does not arise from an inflammatory state, but rather from irritation than any 
thing else, opium is very useful. It is best to give it in the form of tincture, in a 
very small quantity of fluid. About four ounces of fluid is the utmost that can be 
given; because we wish it to be retained, and not to be rejected. Bulk will irritate 
as well as acrimony; and, therefore, when we are giving it to lessen the pain and 
tenesmus, as small a quantity as possible should be employed. About forty or 
fifty drops of laudanum, given in a little starch, will be one of the best injections 
of the kind. Sir James McGregor says that, in the Peninsula, he found great relief 
from injections of acetate of lead; so that we might put laudanum into a solution of 
the acetate of lead. I presume one or two grains of the latter would be enough. 
We know that lead has a soothing effect on a raw surface, or on mucous surfaces in 
general: and therefore we can conceive that this would be a proper medicine. 

Mercury in Chronic Dysentery. — I have never given mercury in the chronic 
form of the disease. I have always been able to cure the affection, as we see it in 
this country, without it; and Sir James McGregor says, that in the Peninsula it 
was worse than useless; — it was absolutely injurious, unless the liver was diseased 
at the same time. I have repeatedly watched the motions in this disease. In very 
many cases, they were quite white; and white for a month or two; — more like 
paste than any thing else; and, without giving any mercury, I have suddenly seen 
bile in them. The intestines are restored to their function; the health is improved; 
the liver begins to do its duty properly; and, without exhibiting mercury, the bile 
will return,— sometimes gradually, and sometimes suddenly. When we consider 
that mercury renders the body more susceptible of cold, and that our object is to 
soothe the patient, I would not recommend it to be given in the chronic form of 
the disease. 

Bandage of the j9bdomen. — I mentioned the necessity, in the chronic form of 
the disease, of well bandaging the patient's abdomen;* and some persons, instead 
of employing flannel, prefer straps of adhesive plaster all over the loins. This 
might be applied first, and bandages over it. 

SECTION VI.— DIARRHCEA. 

I now proceed to the consideration of that disease into which chronic dysentery 
a See Page 925. See, also, Page 918. 



DISEASES OF THE INTESTINES. 927 

degenerates; but which happens every day (indeed I might say every hour) with- 
out dysentery; — namely, "diarrhoea." 

Definition. — By " diarrhcsa" (from Stappsw, tofloio through), is meant frequent 
liquid, and rather copious, feculent stools; — not dependent upon debility of the 
sphincter ani. In dysentery the stools are not feculent. When a person is weak 
in the sphincter ani, he may have stools every ten minutes; but he would not, on 
that account, labour under diarrhosa. In this disease there is pain only at the time 
of the evacuation. It is pinching enough, and pretty sharp then; but it ceases as 
soon as the evacuation is effected; whereas, in dysentery, the griping is horrid; 
and is not lessened by the discharge of mucus and blood which characterizes the 
disease. Cullen, in his definition, says there is no preliminary fever; and that the 
disease is not contagious;* but there may be preliminary fever in diarrhcBa, inas- 
much as it is frequently inflammatory. I should be content with the definition I 
have given. 

Character of the Dejection. — The discharge, in this disease, is of all colours; — 
white, green, black, yellow, and clay-coloured; and of various colours at various 
times. It is also of all kinds of disagreeable odours; — sour, fetid, and every other 
variety of unpleasant smell. It may likewise be bloody, watery, mucous, or puru- 
lent. Occasionally, the motions can hardly be called liquid; — they are only very 
soft. Sometimes they are uniform in their tenacity or softness; and sometimes 
they differ in different portions. It appears that the discharge is chiefly an- in- 
creased secretion of the intestines, and sometimes of the liver. Sometimes the 
nature of the discharge is dependent upon some other organ. The discharge may 
be purulent; — from an abscess in the liver, or perhaps an abscess in the ovaria. 
There are all degrees of the disease, and all durations of it. 

Morbid Appearances. — After death we may sometimes find nothing unusual;-— 
it has been merely an excessive secretion; and, on the other hand, we frequently 
find all degrees of redness and congestion. Frequently the mucous membrane is 
found softened; and then it may be either red or white. Sometimes it is inflam- 
matory softening, and then it is red; and sometimes it is without any mark of in- 
flammation, and is quite lohite. Occasionally the mucous membrane is found very 
much thickened; and it is also ulcerated. Sometimes the ulceration is a mere 
superficial abrasion; and sometimes it is very deep; appearing to have begun in 
the mucous follicles. The mucous follicles may contain (as in chronic dysentery) 
curdy stuff, and sometimes pus. The follicles are frequently in a state of hyper- 
trophy; and sometimes, without being ulcerated, they contain pus. In fact, we 
may have all the various states of the intestines which I mentioned, as being seen 
after fever, and in chronic dysentery.'' These may occur in the large intestines, 
or in the small intestines, or in both; — sometimes very extensively, and sometimes 
partially. 

Causes. — The causes of the disease are, in the first place, too much food. If a 
person eats a great deal, it must find its way out; and it does. There must be 
more exportation m proportion to the importation; so that diarrhcea is very fre- 
quenUy an effort of nature; and the person would be badly off if he had not diar- 
rhoea. An alderman, I should think, would suffer severely, if he had not many 
attacks of diarrhoea, in the course of a season. Improper articles of food will give 
rise to diarrhoea. Every body knows, that if he take something which disagrees 
with him, he will suffer from it; — nature makes a proper eflbrt to get rid of it. 
Frequently new articles will occasion diarrhoea. If a person eat something to 
which he is not accustomed, although it may be excellent in its kind, it will fre- 
quently give rise to the disease. Children suffer exceedingly, if tiiey are weaned 
too early, or too suddenly. There is a peculiar kind of diarrhoea in infants, called 
*' weaning-thrush." If children be weaned before nature is ready for the change, 
or if the change be made too rapidly, diarrhoea takes place. Children cannot bear 
the sudden change from milk to common food; whereas, if they be strong, and be 

* " Dejectio frequens; morbus non contagiosus; pyrexia nulla primaria." 
" See Pages 294, 295, and 921. 



958 DISEASES OF THE INTESTINES. 

weaned gradually, tliey bear the alteration of diet very well. This is precisely 
analogous to what is observed with regard to fish. There are s«//-water and/resA- 
water molluscae; and if we put the sa//-water moUuscse into fresh water, and vice 
versa, they will die; but if we mix the water gradually, so as to lessen the saline 
quality of the water by degrees, they will live in it as well as if they had been 
always accustomed to it; and the same with regard to the yresA-water molluscae 
living in scf/^water. A new article of food is a common cause of diarrhoea, both 
in children and adults; but especially in the former. 

Cold, especially after heat, is another common cause of this complaint. The 
mind, too, has a very great effect. Fear is generally considered to operate very 
strongly on the intestines. Malaria is enumerated among the causes of this disease. 
The suppression of other discharges will sometimes produce it. If a person have 
been accustomed to a running of the leg, and it is suddenly stopped, he may think 
himself well off if he have diarrhoea; because, if he had not, he might have apo- 
plexy. Metastases are causes of it. If another disease cease, it is common to see 
diarrhoea begin. If inflammation suddenly cease, diarrhoea may occur. Dysentery 
is mentioned as one cause of it. This is an affection which is very commonly 
produced by other diseases; or it becomes a part or consequence of other diseases. 
In fever, for instance, diarrhoea is very common; — it becomes a part of the fever. 
It is very common after measles. Measles affect the intestines almost as much, I 
was going to say, as the skin; but, at any rate, they affect them in a very re- 
markable degree. So, again, in phthisis; — the same state of the body that gives 
rise to that affection, causes at least a great irritation of the alimentary canal. 

Causes of the Paroxysms, — Besides the exciting causes of the disease itself, 
there are exciting causes of paroxysms, — if I may so call them. For instance: 
when a person is labouring under diarrhoea, if he move about much, he will very 
likely be obliged to go to stool; and again, on taking food, many persons imme- 
diately have a desire for a motion. Sometimes it is warm food, and sometimes it 
is cold, which has this effect. Frequently persons can take nothing warm, without 
having a desire to go to stool; and the applicatian of cold to the surface, will bring 
on the desire in a moment. The best plan is to sit quietly by the fire without 
moving. 

Treatment. — As to the treatment of this disease, if it be slight, it is best to do 
nothing at all. It is generally a mere effort of nature, to relieve herself from some- 
thing improper, which has been taken inwardly; or from the depressive action of 
an agent applied to some other part of the body. When cold has been applied to 
the surface, nature relieves herself in this way; and if the individual do not make 
it worse, he is sure to get better. 

Diluents. — But if it be necessary to adopt any measures, mild diluents, in the 
first instance, are the best things. Every old woman knows that barley-water, 
chicken-broth, and so on, help to sooth the intestines. To these some persons 
add mild purgatives; and some a^e in the habit of giving the patient a dose of phy- 
sic, whenever he has diarrhoea; and, in general, there is no harm in it. If any 
thing acrid have been taken, it may aid nature, and the disease may cease so much 
the sooner; but if there be merely an excessive action going on, — from a depressed 
circulation of the surface, or the passions of the mind, — it is difficult to see what 
good can be done by a purgative. As the disease, however, in most instances, if 
left to itself, would cease without any remedy, a purgative has frequently the credit 
of curing it, when it deserves no credit at all. 

Opiates and Astringents. — If, however, the disease run on, it may be neces- 
sary to stop it; and, for this purpose, various opiates and astringents are given. It 
would be well, in these cases, to avoid giving tinctures; because there is frequently 
an inflammatory state; and an astringent is just as good without the alcohol, as 
ivith it. I need not enumerate chalk-mixture, catechu, kino, and all the various 
modes in which opium is given. In very severe cases, the same treatment should 
be adopted as in chronic dysentery; — the exhibition of sulphate of copper, and 
other astringents. For what I know to the contrary, we might give these 



DISEASES OF THE INTESTINES. 929 

astringents with safety at the beginning. I have done so; but it is too powerful an 
astringent to be frequently required. The sulphuric, nitric, and muriatic acids, 
united with opium, have been given in these cases, as well as in dysentery. Dr. 
Moses GriSiths, who invented a mixture of iron called "Mistura Ferri Composita," 
recommended in diarrho3a a mixture, consisting of two drachms and a half of tinc- 
ture of rhubarb, and six drachms of linseed-oil; — a portion of which was to be 
given two or three times a-day. I have known this administered with good effect. 
The rhubarb, besides being a moderate purgative, is an astringent; and the oil is a 
demulcent. The one soothes, the other astringes; and it is thus that it has a good 
efiect in chronic diarrhcea. It is also given in chronic dysentery. This remedy is 
contained in some of the Hospital-Pharmacopoeias. It is a very disagreeable remedy; 
— as vile as can be well conceived; and I myself never found it necessary to give it; 
but it is sometimes a good medicine in this disease. 

Leeches and Blisters. — It is always necessary to ascertain carefully, whether 
the disease is inflammatory; as it generally is, to a certain degree, after measles; 
and we should always press the abdomen, and see whether there is tenderness; 
because we may in vain give diluents, opiates, and astringents; and may even 
make the patient worse by them than if v/e did not give them at all, if there be a 
degree of inflammation which we do not take means to remedy. I have seen many 
cases of diarrhoea, which have resisted all the means that could be adopted; but 
which ceased presently on applying leeches to the part, or on the application of a 
blister. In fact, this disease is frequendy nothing but an inflammation of the mu- 
cous membrane; and it will cease on applying blisters. It is frequendy necessary, 
while doing this, to give opium and astringents; and we may do so with perfect 
safety, if we attend to the inflammation. Indeed, if we attend to the latter, there 
is frequendy no occasion to give the former at all; and if we do not attend to it, we 
make the patient worse by their exhibition. The first thing to be done, therefore, 
in cases of this disease, is to inquire into the cause. If the patient have been eating 
improper articles of food, w^e must change his diet; if there be any inflammation, 
we must treat it accordingly; if there be no inflammation, or not much, then we 
must exhibit opiates and astringents; and in this way the disease may be cured. 
The mildest of all astringents, is chalk-mixture and a Hide laudanum; but if that 
will not answer the purpose, we must go on to catechu, kino, and sulphate of cop- 
per; — taking care that the patient be well purged in this disease, — ^just as I men- 
tioned in chronic dysentery.^ 

Diarrhoea with ivhite Evacuations. — This is the common form of diarrhoea. Oc- 
casionally, however, we meet with some singularities in this disease. I mentioned'' 
that Dr. Baillie described a particular kind of jaundice; — remarkable for its being 
green, and for its ending unfavourably." He has also described a kind of diarrhoea, 
remarkable for the faeces being white, and likewise terminating for the most part 
fatally. It is described by him in the "Transactions of the College of Physicians."'* 
He says that, in this particular kind of diarrhoea, the stools are white, — like a mix- 
ture of lime and water; — that is to say, like thin mortar, or mortar spoiled. They 
are also frothy, of a sour smell, very copious, very numerous, and unattended with 
pain. The disease is so chronic, that it may last for years. It most commonly 
occurs, he says, in men, — not in women; and more particularly in men who have 
been in warm climates, and suflered from disease of the liver. Pie says that the 
affection may occasionally be suspended, and that the faeces will sometimes become 
brown; but the disease returns; and the motions become white again, and also 
fluid. The afl"ection is very rarely removed. The patient wastes away under it, 
and dies. 

Treatment. — This is a disease which I have occasionally seen; and though Dr. 
Baillie could not cure it, I have been successful, in two cases which I have had of 
it, by treating it in the same way as ordinary diarrhoea; — persevering steadily in 

^ See Pages 923 and 924. i> See Page 894. 

See the "Transactions of the College of Physicians;" Volume 5; Page 143. 
^ Volume 5; Page 166. 
VOL. T. — 59 



930 DISEASES OF THE INTESTINES. 

the exhibition of sulphate of copper combined with opium; and giving wine at the 
same time. Sulphate of copper alone might have done. Without giving mercury, 
the motions of these persons become bilious; — they ceased to be white; and at last 
they became firm, as well as of a proper colour. One man was a patient in the 
hospital.^ He got stout, regained his looks, and would not stay any longer. His 
disease might return a year or two afterwards; but I kept him there a considerable 
time, and he remained perfectly well. He had been in hot climates; and, in all 
respects, corresponded with Dr. Baillie's observations.* The other case occurred 
in a gentleman who had long been in India; and, after persevering with medicine 
for nearly two years, the disease (I understand) has entirely ceased. He is an old 
man, whose constitution has given way to the warmth of the climate; and he has 
had attacks first of one thing, and then of another. Dr. Baillie mentions, that he 
has tried the ordinary remedies of kino, catechu, and chalk-mixture; but that they 
have all been unsatisfactory, and have all failed. 

Discharge of Lymph. — Occasionally, in diarrhoea, very considerable shreds of 
lymph are discharged. Patients say, that they have discharged great pieces of skin; 

that they are sure the coats of their bowels are coming off; and medical men have 

thought the same thing. Dr. Baillie once believed, that he saw a portion of mucous 
membrane come away. But he afterwards detected his error; and said that it was 
nothing more than an effusion of lymph, corresponding with the effusions some- 
times found on a serous membrane; and exactly like those tubercular substances, 
which sometimes come away from the air-passages. Occasionally a large quantity 
of fibrin is secreted on the inner surface of the mucous membrane, in chronic dysen- 
tery; and it will come away in the form of large shreds, or even tubes. I have 
always seen this form of the disease marked by great pain; and have found it ex- 
ceedmgly obstinate. I have not seen more than three or four cases; but, by the 
most persevering treatment, 1 have not done any good. I have merely afforded 
temporary relief. 

SECTION VII.— DISCHARGE OF FATTY MATTERS. 

There is another discharge from the alimentary canal, more curious than that last 
described, and that is a discharge of fat, — both in a liquid and a solid state. Some- 
times it is discharged with diarrhoea; and sometimes without it. Occasionally the 
lumps come away with great pain. In other cases, it is oil that comes away, — just 
of the colour of melted butter. My attention has been attracted to it, from having 
had some cases of this description under my own care. My curiosity was excited; 
and I was led to read upon the subject. 

Sauvages^ Account of it. — I find that Sauvages, whom I mentioned as having 
been the first framer of a system of Nosology," has mentioned a *' diarrhoea adi- 
posaf and he says that he has known the bowels, after hard riding, pour forth 
adipose matter. He says that, apparently, this adipose matter had been absorbed 
by the blood-vessels; where, being mixed with the blood, it rendered the latter 
viscid. It then partly flowed into the intestinal canal; and there, as it were, 
covered the faeces with butter. 

Cases.-— \ found several very satisfactory cases of this disease. There is one of 
a woman who discharged every day, for fourteen months, a large quantity of yellow 
fat; which lay on the fseces, like melted butter. Sufficient was collected to fill a 
number of vessels, and, when thrown into the fire, it burned with a bright fiame. 
After the fseces had cooled, it concreted; and became of the consistence of absolute 
fat. But (what was singular) there was neither tenesmus, emaciation, nor colliqua- 
tive fever; and sixteen years afterwards she was in excellent health. This case is 
related by Tulpius; but he says — "What is this to an old woman who, in her 
seventieth year, voided precisely similar fat from the intestines and bladder?" These 

a St. Thomas's. " See the previous Paragraph. «^ See Page &2. 



DISEASES OP THE INTESTINES. 931 

are singular cases; but I believe them. Tulpins adds that, towards the close of 
the disease in the last case, the patient became feverish, and in consequence ema- 
ciated; and that death found her little else than a parched and juiceless corpse. I 
find another case, where a patient, for some years, had suffered pain in the stomach. 
Nothing relieved her, and she became worse; when she one day discharged about 
three pounds of fat; and from that moment speedily recovered. I find another 
case, where a patient discharged from his bowels, for two years, a large quantity 
of fatty substance. He grew thin and weak, and then died. 

In the "Edinburgh Medical Essays,"* is described a case which occurred to a 
weaver, forty years of age; who, in attempting to take up a very heavy vessel, felt 
his back-bone crack; which crack was attended with violent pain. Being unable 
to stand, he fell to the ground. The pain long continued very severe. He fancied 
that the bone was dislocated inwards; and, in order to reduce it, made one of his 
neighbours pull his abdomen backwards; while another, getting on his shoulders, 
pressed them downwards and forwards; by which he thought his loins were made 
much straighter than formerly; and he had less pain. Some days after this, a 
country bone-setter undertook to put all the bones right; — making one man pull at 
his shoulders, and the other at his legs, in a contrary direction. By this extension, 
he was put to most exquisite torture; and all his complaints were increased. Three 
months afterwards, he could just manage to crawl out of doors; and then observed 
among his excrements a whitish substance, about the bulk of a large walnut. It 
was like tallow, or hardened marrow; — being composed of small globules. It 
melted on the application of heat. During several days after this, he observed 
several pieces of the same sort of substance (of the size of kidney-beans or peas) 
come away among his faeces. He thought all those lesser pieces, if they had been 
put together, would have been equal to the large piece he passed first. 

I had, in St. Thomas's Hospital, a patient with diabetes, who had wasted away. 
For some reason or other, I happened to see his motions; and there was lying 
upon the faeces a large quantity of fatty matter, — soft fat; which, he said, was quite 
fluid when discharged. I looked at the faeces regularly every day; and there was 
always one or two tablespoonfuls of this fatty matter. I took a part of it to Dr. 
Prout, and some to Mr. Faraday. It was also seen by some of the first chemists 
in London; and they found it to be similar to fat. The question asked was — 
*' whether the patient had taken castor-oil?" But he had taken nothing of the kind, 
— nothing oleaginous. The fat ran away, in this liquid form, with his motions, 
or after them; and when he had diarrhoea, it came at the top. It was voided like 
oil; but presently concreted. His wife told me, that this was the first symptom of 
his complaint. He had formerly discharged an immense quantity of it; so that 
full one-half his motions were fat. What was curious, — the disease ceased while 
he was under my care. He died of diabetes and phthisis. I openetl him; but 
there was nothing particular to be found. The diabetes had arisen from organic 
disease of the kidneys; but there was nothing else to be found there. The intes- 
tines looked greasy enough; — they were like paper steeped in oil; but that was all. 
No oil was found in the alimentary canal. Dr. Prout tells me that, in cases of this 
kind which have come to his knowledge, there was considerable disease of the 
kidney. 

Mr. Pearson's C«se.— Mr. Pearson, of Clapham, showed me a quantity of fat 
which came from an old woman; and said he could furnish me with any quantity. 
He understood from her, that it was discharged with the urine; but he mentioned 
the case of a lady, whom he knew very well, who discharged fat both with the 
urine and with the faeces. He did not attend her; but had been in her company. 
He had been particular to have the urine by itself; and also to ascertain whether 
the fat came from the bowels or not; and he clearly ascertained that it came from 
both. In this case of his, and in my case too, I think the motions were very white. 
They seemed to be of a viscid nature. It is a curious disease. 

* Volume 5; Page 145. 



932 DISEASES OF THE INTESTINES. 

Treatment. — Mr. Howship, in his book on Morbid Anatomy, mentions the case 
of a lady, who discharged a great quantity of this fatty matter; and she was cured 
by giving her a pint of olive-oil. 'J'hat was an odd remedy. He says she was 
well from that day, though she had been long ill previously. As "facts are stub- 
born things," I gave the man under my care* four ounces of olive-oil; and the 
voiding of fat greatly diminished from that time, and soon ceased. Whether the 
circumstance was accidental or not, I cannot tell. In " Hufeland's Journal," for 
1826, is mentioned a case where a quantity of thick oily matter was vomited. 
There was extreme emaciation; together with a rapid discharge of thick oily mat- 
ter from die stomach. 

Source of Ambergris. — The spermaceti-whale is liable to this disease; — what is 
called "ambergris," being fat collected in the intestines of spermaceti-whales. As 
much as one hundred and eiglity-two pounds have been found in, or discharged 
from, the intestines of that animal; and it is said that it has never been found higher 
than six or seven feet above the anus. This fat is very often discharged, and found 
upon the-shore; but occasionally it accumulates, and the animal dies; — either from 
the accumulation, or from disease forming in the intestine.^ 



SECTION VIII.— GASTRO-INTESTINAL CONCRETIONS. 

Concretions of the alimentary canal are sometimes discharged, and sometim.es 
collected within; and as they are sometimes found in the stomach, as well as in 
the intestines, we may speak of them together; under the head of " gastro-intesti- 
nal concretions." 

Biliary and Urinary Calculi.— \n the first place, these concretions may occur 
without any fault in the gastro-inteslinal canal; — they may arise from the gall-pass- 
ages. Of course if a gall-stone escapes from the ducts, but is not voided, it will 
be found in the stomach or intestines. Dr. Marcet says, that he once found in the 
alimentary canal a stone, which came from the urinary passages. Ulceration had 
taken place; and a communication had been formed between the urinary and faecal 
passages. The rectum, in this case, was imperforate. 

Foreign Bodies. — Occasionally very hard concretions are found. They are 
often nothing more than hardened faeces; and then they are called " scybala;"'^ but 
occasionally they consist of articles which have been swallowed. I saw a man 
V'ho had swallowed nineteen clasped knives. He was not believed for some time, 
bu^ he assured me that he had swallowed them; and, to convince me, he took out 
of his pocket one of the same size as those he had already swallowed, and put it 
down his throat. I was frightened, and begged-TT:e would bring it up; but it was 
too far gone. Some persons believed him, and others did not; but at last we could 
feel them sticking in the abdomen; and ultimately they could be felt, I understand, 
in the rectum. He discharged fasces containing a large quantity of iron, — black- 
ened; and at last he died in the most horrid torments: — the knives cutting his intes- 
tines to pieces. The fastenings of the knives, as solution went on, became less and 
less secure; the handles separated; and the blades were let loose. After death, a 
great quantity of knives were found in his abdomen; — some having run through 
two or three folds of the intestines. It was a frightful sight. Considerable portions 
of the knives were discharged during life; and these, together with what were 
found after death, are preserved at Guy's Hospital. The case is described by Dr. 
Mar-cet, in the twelf h volume of the " Medico-Chirurgical Transactions."'* 

Various Medicines. — When a person has taken a great quantity of chalk-mix- 
ture, and even magnesia, concretions have sometimes been formed. In the Museum 
at St. Thomas's Hospital, there is a preparation where the intestines of a child are 

* See Page 931. 

*• A Paper by Dr. Elliotson on the Discharge of Fatty Matters from the Intestines, will be 
found in the "Medico-Chirurgical Transactions;" Volume 18; Page 67. 
•^ See Page 921. '^ See Page 52. 



DISEASES OF THE INTESTINES. 933 

completely blocked np wiih mngnesia. It iias llie appearance of hard mortar, re- 
gularly cemented; and is said to be magnesia. It is necessary, therefore, to be oti 
our guard (when exhibiting chalk, or magnesia) not to give it too long without 
ordering a purgative, — so as to carry it away. There is on record the case of a 
person who had taken magnesia for a long time, and suffered a great deal; and who 
then suddenly discharged, from the intestines, a lar^e quantity of powder of mag- 
nesia. It is a fact that, from magnesia or chalk, the intestines sometimes become 
completely blocked up. 

The sesquioxide of iron will have the same effect. When giving that medicine in 
any quantity, it is necessary to see that the bowels are regularly opened. We may 
give an immense quantity, if we attend to that point. I related a case where a man 
took nearly two pounds of it, every day, for some days, when labouring under teta- 
nus (of which he got well*); and he regularly discharged large lumps of the sesqui- 
oxide. They came away as they would from a horse, covered with mucus, and 
giving him no pain whatever; but then he had a clyster to prevent any mischief. If 
a person do not attend to his bowels, a great accumulation may take place in the 
rectum, and the individual may be obliged to pick' it out; but this must be from bad 
management. I have known cases of this sort occur, two or three times. I had 
another patient labouring under tetanus, to whom I gave this remedy, and he also 
got well; but if the nurses did not give him purgatives properly, he suffered pain in 
the rectum; — the rectum w^as distended and became dry; and he was obliged to 
pick the iron out. In his bed was found a shovelful; which he had amused him- 
self, day and night, in removing. I recollect an obstinate hysterical girl, and also 
the case of a lady, in whom a similar accumulation took place; but, in these cases, 
it arose from the patients' refusing to let us know the state of their bowels. It is 
right to know that, if we do not pay proper attention, such things may occur. 

Dr. Barlow (of Bath) mentions a case where pills of sulphate of iron were dis- 
charged, nine months after they had been taken. '' This is another general fact, 
showing that articles may remain in the alimentary canal for a long period before 
Ihey are voided. Substances which are liable to concrete should not be given, 
unless we attend to the bowels. 

Larks^ Bones. — Dr. Prout told me, that he was sent for to see a lady from whom 
some odd things had come away. She had suffered excruciating pain: and it turned 
out to be from larks' bones. This lady h.ad been in the habit of eating larks, of 
which some ladies are fond; and she munched the bones. She was a lady of title; 
but, in consequence of this lark-eating, she suffered great pain. The substances 
discharged were sent to a celebrated chemist; — in order tliat he might ascertain 
what they were. He first discovered them to be bones; and afterwards, from their 
figure, they were ascertained to be the bones of larks. 

Mustard Seeds. — It was the fashion, a few years ago, (and I believe it has not 
yet quite gone out,) for people to stuff themselves with whole mustard seeds. 
They were thought to keep tiie bowels very open. Some said it was a good 
practice; and others distributed pamphlets and tracts recommending it. A gende- 
man came to me with various odd affections of the alimentary canal, which I could 
not well understand. Two days afterwards he brought me a quantity of seeds that 
had come away; and I could not imagine what they were, till at last he told me he 
had been eating mustard seeds, but had not taken any for six weeks. Though he 
had given up the practice before he came to me, they had already accumulated in 
him; and his danger arose from that accumulation. We know that they generally 
come away whole. One gentleman told me that he sowed some of these mustard 
seeds, after they had been passed through him; and they produced just as good 
salad as if he had not used them. Fashionable people have always some whim 
about them; — they are always taking something; but I believe the day of mustard 

"See Pa2:e635. 

^ They were " Hooper's Pills," taken for amenorrhoea by a young woman, who has since 
married", and is now (184-2) the mother of heaUhy offspring." From sixty to sev^enty were col- 
lected from the stools. — Dr. Barlow. 



934 DISEASES OF THE INTESTINES. 

seed has pretty well passed by. Mustard seeds will accumulate; — ^just like other 
things. 

Hair Balls. — In cows, we very frequently find, in the alimentary canal, concre- 
tions consisting of hairs. They lick their skin; some of the hairs go down the 
throat with the saliva; and concrete together into a hard ball. They are found, not 
only in cows, but in many other animals. Millers' horses are said to be subject to 
these concretions, from the grit of the stone-dust in the mills; and particularly, it is 
said, when they are fed upon bran. The poor people in Scotland, who eat oaten 
bread, sometimes have concretions of this description, — formed of the beard of the 
oat. The outside of such concretions as these, is like velvet. 

Earthy Phosphates. — It is found that the earthy phosphates are frequently 
mixed with hair, the beards of oats, or whatever else may have been swallowed; 
and become cemented together by the phosphates and the mucus. Sometimes, 
instead of the phosphates being mixed up with the other ingredients, they form 
into a concretion around a nucleus; — ^just the same as takes place in urinary calculi. 
The ammoniacal magnesian phosphates, particularly, will form around a nucleus 
of any sort. Sometimes the nucleus has been stale fruit; sometimes a piece of 
bone; sometimes a pin that has been swallowed; and sometimes a gall-stone. We 
shall see that it is the phosphates, in particular, that are formed around a layer in 
the urinary organs. In some of these concretions, oxide of iron, oxalate of lime, 
muriate of ammonia, and muriate of lime have been found. There was a lady 
who was said to discharge a large quantity of stones, from the urinary organs; but 
"whether she told the truth, I do not know. A medical gentleman was attending 
her; and he wrote to his friends in London, to know whether they had seen similar 
wonders. It was very singular that two ladies, in different parts of the country, 
discharged similar stones; and both cases happened to come within my knowledge. 
"Whether there was any deception or not, we could not tell; but Dr. Prout consi- 
dered that, if there was not, the stones must have come from the intestines. There 
was said to be excruciating pain attending their discharge. The stones have the 
same appearances, and the same chemical qualities; they contain oxide of iron, 
and phosphate of lime. Dr. Prout considered, that many of these were too large 
to have passed from the urinary passages; and that the number the patient stated 
she had voided, must be incorrect. It is true that very large stones will pass 
through the female urethra; but they would have caused more suffering in the 
bladder than she complained of. 

Size of Concretions. — These gastro-intestinal concretions are sometimes very 
large. I recollect having read of a woman, in whose stomach they were found 
nearly as large as a hen's egg. The same writer mentions finding some, which 
weighed four ounces, in a soldier's stomach. In the colon of a young child, one 
was found which weighed two ounces and a half, and was six inches long. The 
child died in consequence of it. In the "Philosophical Transactions," for 1686, 
there is an account of a woman who discharged many, varying in size from a pea 
to a filbert; and the weight of which amounted, in two years, to five pounds. In 
the thirty-second volume of the "Philosophical Transactions," there is an account 
of a pregnant woman, who discharged some concretions that were very large. One 
of them weighed above two ounces. It is a fact, therefore, that such concretions 
do occasionally occur. Sir H. Sloane mentions a case, where two hundred were 
said to be discharged. 

These concretions are much larger in brutes, than in the human subject; and 
also more common. In a brute, one has been found weighing fifteen pounds twelve 
ounces. They chiefly occur in ruminant animals, and in horses of slow draught; 
and in millers' horses, which are fed on bran. Both in the brute and the human 
subject, these concretions are spheroidal or oblong. They take an imperfect po- 
lish, are more or less porous, and either are radiated, or have layers. Biliary con- 
cretions of both kinds occur; — some disposed in radii, and others in lamina?. 

Bezoars. — Those which are taken in small ruminant animals, — such as the ante- 
lope or the goat, — are called " bezoars." The word is said to be derived from 



CHOLERA. 935 

a Persian compound, — " pa-zahar;" — meaning *' alexipharmic" (from a%sh^i to 
repel; and ^ae^^axov, a poison). Bezoars were once so valued, on account of iheir 
supposed anti-poisonous properties, tiiat one in the East, when very fine, has been 
sold for six thousand livres;* and has been hired, in Holland and JPorlugal, at the 
rate of a ducat per day.'' I have some specimens; but some of them are probably 
artificial; for, being sold at a great price, they were imitated. They are said to 
have concentric layers; and sometimes to be crystallized. They will take a polish, 
and even have a metallic lustre. Mine have evidently been stained. Sometimes 
there is an accidental nucleus within; and they will rattle. They are found to 
consist chiefly of vegetable matter; and some have an aromatic smell; — from the 
circumstance of the animal havhig eaten aromatic herbs. It is said that it is only 
those which come from the west, that take a polish; and that the eastern have 
often a gloss of white. The mode of distinguishing the genuine from the spurious, 
is said to be this: — if we take a piece of paper rubbed over with chalk, or lime, 
and draw a genuine bezoar across it, it turns it green, or of an olive-colour; where- 
as, if it be spurious, the colour of the paper remains unchanged. However, the 
matter now possesses very little interest; since a belief in their virtue is no longer 
enterlahied. 

Symptoms ivhic/i they produce. — Concretions in the alimentary canal, if retained, 
give rise to urgent vomiting; and to violent gastrodynia, dyspepsia, colic, consti- 
pation, and death. From the obstruction which they produce, we have all the 
symptoms of enteritis, or of colic, or of strangulated hernia. The treatment, 
whether the nature of the concretion be known or not, is the same as for colic or 
enteritis: but, as I said before,"" it is well to ascertain the state of the rectum. By 
passing a clyster up the rectum, we have the means of learning whether the ob- 
struction is situated there. Sometimes these concretions have reached the rectum, 
before they have been stopped. 



CHAPTER VIII. 

CHOLERA. 

SECTION I.— Ex\GLISH CHOLERA. 

Symptoms. — Having described gastro-intestinal concretions,^ the diseases which 
I shall now proceed to consider, will all be affections both of the stomach and 
intestines; and the first which I shall mention is " cholera."^ This disease is 
characterized by a sudden attack of bilious vomiting and purging. At first the 
discharge is sometimes thin and watery; and has been called " ivhite vomit;" but 
very soon pure bile comes away; — in fact, unless there be a discharge of bile, it is 
not cholera. Besides this discharge of bile upwc^rds and downwards, the disease 
is marked by severe pain in the abdomen; with very severe spasms of the abdo- 
minal muscles, of the calves of the legs, and (in very bad cases} even of the neck 
and back. There is no riiridity (constant spasm), as in tetanus;^ but violent con- 
traction alternating with relaxation, and drawing tiie muscles up in lumps. Theie 

a About two hundred and sixty pounds sterlingr. 

^ A coin so called from being struck by duke^-; and (when in silver) worth about four 
shillings and sixpence. 

= See Page 9'23. <J See Page 03-3. 

« From ;)^oA)i, bile; and gia;, to flow. ^ See Page 628. 



936 CHaLERA. 

is great anxiety and great debility; burning heat, generally at the pit of the stomach; 
and — as may easily he supposed, from such a quantity of bile being poured forth 
— there is thirst and headache. These are the symptoms which we see, every 
autumn, in this country.* At last, however, from (his violent pain, and from this 
profuse discharge, the body becomes cold; great faintness is felt; perhaps there is 
actual syncope; the patient sinks; loses his power; becomes excessively weak; 
and then every thing occurs exactly as if haemorrhage had taken place. General 
convulsions come on; the spasm ceases; and the patient dies, as if he had lost an 
immensd" quantity of blood. 

Duration. — This affection may last only a few hours, or it may last many days. 
Every body must have seen it seize persons early in the morning; and tlie persons 
so seized be dead in the middle of the day. If it subside, it may possibly be fol- 
lowed by inflammation. I have frequently seen gastro-enteritis take place, after 
the discharge had entirely ceased. 

Nature of the Dejections. — The bile is generally found to be very acrid; and 
the vomiting and purging sometimes alternate; so that the more the patient vomits, 
the less he is purged; and vice versa. Besides the bile discharged, there is usually 
a great secretion of another fluid; — no doubt, from the stomach and intestines. 
The same state may arise, occasionally, from an overflow of the secretion of the 
mucous membrane of the stomach and intestines. 

Causes. — Intermittent and remittent fevers,'' and dysentery,'' in hot climates, very 
frequently begin as cholera; — I might say, perhaps, ivith cholera. The disease is 
common in hot climates; and in mild climates in hot weather. Cholera is parti- 
cularly induced by sudden cold, after long-continued heat; — ^just the same as in- 
flammation."^ It is observed, that occasional falls of rain are particularly followed 
by cholera, in hot seasons, and in hot climates. Dr. Macculloch ascribes this dis- 
ease to malaria;^ and probably that is one of the causes; but various things will 
excite it. Violent passion, — violent emotion of the mind, will cause ii. From the 
latter circumstance, people often vomit or are purged, and sometimes both; and the 
discharge will be green; — so that cholera is one effect of violent grief. Some 
persons have this from certain ingesta. Any acrid substance may induce vomiting, 
or purging, or both; and in this case the discharge may be green; and therefore the 
afTection may be cholera. 

Treatment. — The mode of treating this affection is, in the flrst place, to give 
plenty of chicken-broth, or any other diluent; so as to dilute the acrid bile, which 
produces such unpleasant effects on the stomach and intestines. We should also 
exhibit large doses of opium; either in the tincture, or in a solid form. Perhaps 
the latter would stay best on the stomach. It may be necessary, from the extreme 
weakness, to give brandy and other stimuli; and to have recourse to the hot-bath. 
The greater number of cases of cholera that we see, will do well if we give the 
patient warm diluents; — so as to dilute the bile, and assist nature to discharge it 
with as litUe irritation as possible to the stomach and intestines. But it is never- 
theless advisable to lessen the disease, at the same time, by exhibiting full doses of 
laudanum. AVhen the patient is weak, it may be necessary to have recourse to 
stimuli; — ^just as in the case of hfemorrhage.^ Should the disease chiefly consist 
of vomiting, it may be desirable to send the bile downwards; and calomel will then 
be the best medicine. It stays better on the stomach than any thing else. An in- 
jection may be found very useful. If the case be taken in time, and this mode of 
treatment adopted, it is very rare for patients to die. We have carefully to examine 
whether there is any congestion in the head, or any inflammation. After a time, 
these are very likely to occur; and it is necessary to treat them as we should in any 
other circumstances. After the disease, it may be necessary to give tonics, and to 
support the strength; or inflammation may come on; and then it may be necessary 
to bleed. Sometimes, after the aflection has declined, the diarrhoea continues; and 

> England. •> See Page 333. 

«= See Page 920. ^ See Page 113. 

c See Note (a) to Page 2G5. ' See Page 140. 



CHOLERA. 937 

it may be necessary to clierk it in the nsiml way. But it is requisite lo ascertain 
whether it is accompanied by inflammation or no!; for it very frequently is. 

This is cliolera, — properly so called. That disease which has so unfortunately 
received tlie same name, and respecting which so niuch has lately been said, comes 
next under our consideration. 

[Before proceeding to this, however, it vv'ill be proper to say a kw words upon 
a form of cholera frequently met with in this country, and known under the title of 

Cholera Infantum. — This disease is said to be almost peculiar to the climate of 
the United States, and is one of the most fatal to which ciiildren in our large cities 
are exposed, during the summer months. 

The disease sometimes commences with diarrhcea, soon followed by irritability 
of stomach; or the vomiting and purging may come on simultaneously at the out- 
set. The discharges from the bowels are not uniform, but their predominant cha- 
racter is that of a colourless, and nearly inodorous fluid, mixed with mucus. The 
pulse is usually frequent, the skin of the head and abdomen hot, whilst the extremi- 
ties are of the natural temperature, and in severe cases, cool or decidedly cold. The 
thirst is excessive, and towards evening there is commonly a decided exacerbation 
of fever. There is often considerable abdominal pain. 

Sometimes the attack is so violent, that death takes place in 24 hours; but this 
is unusual. Comm.only, its course is much more prolonged. Emaciation takes 
place rapidly, and goes on to such an extent, that nltimately the skin, in some 
cases, hangs in folds. The cheeks fall in, the eyes become sunken, the nose 
sharp, and the skin of the forehead tight, as if bound to the bone. The mind and 
senses become obtuse, so that the child lies unmoved by ordinary impressions, and 
will even allow flies to collect on the face without being disturbed. Sometimes 
the brain is affected at an early stage, as shown by the occurrence of stupor or 
even delirium. 

In the latter stage also, of protracted cases, the abdomen becomes tumid, the 
tongue aphthous, and the feet osdematons. 

On examination after death, it is said that the liver is generally enlarged, and 
sometimes to a great extent. Evidences of inflammation are commonly met with 
in the mucous membrane of the bowels, particularly of the small intestines and 
stomach. The rest of the abdominal viscera as well as those of the chest are 
usually healthy. Serous effusions in the ventricles of the brain have been met with 
in protracted cases. 

This disease prevails during the sun^mer months, declining upon the approach 
of cool weather. In this section of country, the months of July and August are 
those in which its greatest ravages are committed. Farther south, the period of 
its prevalence is more extended, commencing, it is said, as early as April or May, 
and extending even to November. Not only is great heat a principal element of 
its production, but also a confined and vitiated atmosphere. This is shown by the 
fact that the disease is principally met with in the larger cities, and especially in 
their most crowded portions, and amongst the poorer classes, inhabiting narrow 
lanes and alleys. Sometimes, however, the disease is met with in the country. 
The subjects of its attacks are infants during the period of the first dentition. Of 
course, it is scarcely necessary to observe that improper aliment or other irritating 
conditions may prove exciting causes, when the system is already predisposed by 
the presence of a high temperature and a vitiated atmosphere. That it is altogether 
unconnected with the malaria which gives rise to intermittents, is sufhciently evi- 
dent from the fact, that it is rare in those districts where intermittents and remit- 
ten.ts are most rife, and on the contrary commits its greatest ravages in large cities, 
where the diseases just mentioned are but little known as indigenous productions. 

Our great reliance in the treatment of this complaint is calomel, in small and 
frequently repeated doses. The eighth or even the twelfth of a grain mixed with 
gum arable or sugar, and given every hour, is most effectual in controlling the 
irritability of the stomach, and allaying the intestinal irritation. Under its use the 
stools become less frequent, and of a dark green colour. AVhen the frequency of 



938 CHOLERA. 

the discliarges has been ihns controlled, and their character altered, the calomel 
may be given less frequently or omitted altogether for a time, and again resumed 
if necessary. At the same time, the skin should be operated on by the daily use 
of a warm bath, or by immersing the lower extremities in warm water, rendered 
stimulating if necessary, by salt or mustard. When the skin is hot and dry, and 
the abdomen tender, leeches should be applied to the epigastrium; or if the iiead is 
hot, with a tendency to stupor or wandering, they should be applied behind the 
ears. Anodyne injections from time to time may be called for, to relieve the fre- 
quency and pain of ihe discharges. Cool mucilaginous drinks should be freely given, 
and when the patient has been weaned, the diet should consist of arrow-root or 
some analogous article. 

It has been already stated that small doses of calomel are our chief reliance. 
Sometimes, however, it is advisable to combine it with chalk; or we may prescribe 
the Hydrargyrum cum creta. Should the frequent watery discharges continue, 
notwithstanding these measures, we may combine the mercurial preparation with 
sugar of lead and ipecacuanha in small quantities. 

By these measures, combined with the command of free ventilation, cleanliness, 
and exercise in the open air, we may generally effect a cure, especially where the 
patient can be removed from the influence of those causes which have given rise to 
the disease. The mere removal to the country indeed, will often arrest the dis- 
ease. When this cannot be commanded, the disorder, though arrested for a lime, 
will often recur and finally assume a chronic form, in which the treatment is much 
the same as in chronic diarrhoea. Here, besides the use of the ordinary alkaline 
and astringent remedies, it is said that a few drops of the spirits of turpentine given 
three or four times a day, has sometimes been found eminently serviceable. T. S.] 



SECTION n.— EPIDEiMIC CHOLERA. 

In 1817, a disease appeared in India, in some respects like English cholera; — so 
far as there is a discharge upwards and downwards, severe pain in the abdomen, 
cramps of the extremities, and at length of the whole body, with great exhaustion. 

Impropriety of the Term " Cholera.^'' — From its resemblance, in the particulars 
just mentioned, to the disease last described,'' it was unfortunately called " cholera 
morbus;" but there is this decided difference in the two affections; — that in what 
we understand (or did understand) by " cholera," the motions are all bilious; but 
in this the motions have no bile in them whatever, but are perfectly white and 
watery. On this account, if it were necessary to give this disease a name borrowed 
from another, it would be better to call it " leucorrhosa""' than "cholera." 

Symptoms, as they appeared in India. — In the disease which broke out in India, 
the first symptoms were languor, uneasiness at the stomach, nausea, and common 
diarrhoea; and then, all at once, — about three or four o'clock in the morning, — vio- 
lent vomiting and purging occurred; though, occasionally, these took place without 
any premonitory symptoms. At the same time, or very soon afterwards, excessively 
severe spasms were felt in the extremities, and in the abdominal muscles; so as not 
only to make the patient exclaim witii agony, but sometimes to make it necessary 
to call in the aid of several persons to hold him. The countenance, in a short time, 
became ghastly; the skin shrivelled; the features contracted and elongated; the eyes 
a little suffused, lightly tinged with red, and sunk in the sockets; the lips purple, or 
of a black cast; the base of the eyelids likewise purple; the skin and the nails blue; 
and the fingers not only shrunk, but shrivelled; — exactly like the hands of an old 
washerwoman. At the same tim(% there was extreme thirst; with a great sensation 
of heat in the throat. The temperature of the whole body was excessively low; 
the tongue and the breath were cold; sometimes the tongue was quite clean, and of 
the colour of lead; but occasionally it was while, and had a tough, or (as it has 

» See Page 935. ^ From Xtuxe;, luhite', and ggw, to flow. 



CHOLERA. 939 

been described) a leathery coat; and occasionally it was covered with sordes, but 
by no means always. The pulse became exceedingly weak, and exceedingly quick; 
and at last it could not be felt at all in the wrists, though it might still be perceived 
at the heart. Extreme restlessness took place; so that the patient could scarcely 
bear the bed-clothes, and endeavoured to toss them off. The breathing, like liie 
pulse, became more rapid than in health. It was found that, in the expirations, 
only one-third of the usual quantity of carbonic acid was given off. The blood that 
was taken was found to be thick; — some say pitchy and uncoagulable. The venous 
and arterial blood were equally black; and, in the worst cases, the blood would not 
flow at all. It was likewise observed that no urine was discharged. Deafness was 
noticed as a frequent symptom; and also tenesmus. 

Occasionally, however, there was scarcely any vomiting, but extreme debility; 
together with extreme loss of bulk, shrinking of the body, the corrugated state of 
the lingers, and the violent spasms. These cases were considered to be worse than 
those in which vomiting and purging took place. This disease differs from our 
cholera, in there being danger where there are scarcely any evacuations; — the 
danger of the disease not depending upon, and not being in proportion to, the loss 
of the substance of the body. Sometimes it is said that, in addition to there being 
neither vomiting nor purging, no spasm was felt; and this was considered still 
worse. The patient was said to be "struck with death;" his pulse became imper- 
ceptible; and death very soon closed the scene. 

Irregularity in the occurrence of the Symptoms, — There was great irregularity 
as to the occurrence of these things. Patients sometimes vomited and were purged, 
before they experienced spasms; and sometimes spasms occurred at the onset of the 
disease. Occasionally, blueness of the nose and about the eyelids was not observed; 
and sometimes there was no corrugation. There was by no means uniformity in 
the symptoms. 

Precursors of Death. — Before death, it was very usual to find the spasms, the 
vomiting, and the purging cease; and for the patient to lie perfectly still, with the 
loss of the vigour of his mind, but with a perfect preservation of his reason. He 
would be conscious of all around him, but wish not to be disturbed; and he would 
take no nourishment. He would remain tranquil, as if waiting for the moment of 
death; not only would the pulse at the wrist be still, but sometimes (it is said) the 
action of the heart could not be felt. Whether the ear was employed to ascertain 
whether the heart acted or not, I do not know. I presume it is common enough, in 
different diseases, for the pulse not to be felt, when the heart still continues to beat. 
Before death, it was occasionally noticed that the temperature would return; and 
hopes of recovery were sometimes entertained; but these were, for the most part, 
unfounded; for the patient presently sunk. It was likewise observed that, after 
this extreme exhaustion, the face would sometimes become flushed, the temporal 
arteries become distended and throb, and the patient lie in a somewhat delirious or 
comatose state; — much in the condition of a person in typhus-fever. The voice 
was weak and very peculiar. The duration of the disease was sometimes only a 
couple of hours; and sometimes it would not destroy life for the greater part of a 
day. 

Morbid Appearances. — After death, an immense quantity of white turbid fluid, 
with flakes of a very white substance, were found in the stomach and in the intes- 
tines; while no fluid whatever was found in the urinary bladder, and that organ was 
contracted to the smallest possible size. These were general occurrences. It was 
usual for neither faeces nor bile to be found in the alimentary canal; but the gall- 
bladder generally (not always) was found full, and sometimes it was remarkably 
distended; — so that there was no want of bile, but none passed into the alimentary 
canal. The veins were usually found greatly distended with blood; so that the 
hepatic, intestinal, and mesenteric veins, were remarkably distended; but those of 
the spleen were not quite so full. Congestion also occurred very frequently in the 
lungs and in the head. Sometimes there was a rosiness of the external surAice of 
the alimentary canal; and sometimes of the internal surface. There was usually, 



940 CHOLERA. 

loo, a great congestion of Wood in the heart itself. The abdominal muscles were 
found, by Dr. Davy, to be flabby and red; but, of course, not inflamed. The urinary 
bladder — although containing no urine, and being so gready contracted — had gene- 
rally a sort of wJiitish mucus, with flakes, upon the inner surface. After death, one 
very remarkable phenomenon presented itself; — the temperature of the body was 
liigher than during life; so that a very high degree of heat was found, on plunging 
the hand iuto the body. Another very remarkable circumstance is mentioned: — 
the occurrence of a twitching of the dilferent muscles of the body, after the person 
was completely dead. The fingers, the toes, and every part of the face, were seen 
lo move. Observations of this description were made on two subjects; — the one a 
Cafl're, and the other a Malay. The former died twenty hours after the first seizure; 
—-the complaint bafliing the most powerful remedies. In fifteen minutes after he 
expired, the fingers of the left hand were observed to move; then the muscles of 
the inside of the left arm were contracted in a convulsive manner; and the like 
motions were slowly propagated upwards to the pectoral muscles. The muscles 
of the calves of the legs contracted in like manner; — bundles of their fibres being 
drav/n together, in a tremulous knot. The muscles of the inside of the leg and 
thigh were forcibly contracted, in a vermicular manner. The muscles of the face 
and lower jaw were similarly affected; and, finally, those of the right arm and 
right pectoral muscle. These motions increased, in extent and activity, for ten 
minutes; after which they gradually declined, and ceased twenty minutes after they 
began. With regard to the Malay, about fifteen minutes after he expired, the toes 
began to move in various directions; and the feet were made to approach each other. 
Muscular contractions were speedily propagated upwards, along tlie inside of the 
legs and thighs. The thighs were turned slowly inwards, so as to approach each 
other, and again outwards; — the whole of the lower extremities moving on the heels, 
as on pivots. These motions proceeded upwards; — producing a quivering in the 
muscles. In five minutes, the upper extremities began to be similarly affected. 
The fingers were extended, and often rigidly bent inwards; and pronation and 
supination of the hand were steadily, though slowly, performed. The same quiver- 
ings were observable as in the lower extremities; and extended to the " pectoralis 
major" muscles, and the superior margin of the "latissimus dorsi." The muscles 
of the face moved; and the head was observed to shake. The total duration of 
these appearances, was half an hour. By moving or pricking the arms or limbs, 
these contractions were rendered stronger, and were again renewed where they had 
ceased. 

This is the account which has been given by various writers, wlio witnessed 
the disease in India, I will now describe the disease which prevailed in London. 

Symptoms, as they appeared in London. — Among the patients whom I saw, 
there was great variety as to the mode of attack; and as to the order of the symp- 
toms after the disease iiad begun. With regard to the first point, some persons 
were attacked suddenly; while others had diarrhoea for some time previously. 
Those who were suddenly attacked, were generally seized early in the morning, 
after going to bed perfecUy well; and discharged, by vomiting and purging, a tur- 
bid whitish fluid, containing white flakes. There was violent pain in tiie abdomen; 
violent pain in the extremities; and dreadful cramps in the fingers, toes, arms, and 
legs. In two or three hours from the moment of the attack, I have seen the eyes 
sunk in the sockets; blueness round the base of the eyes; blueness of the nails; in 
some cases, blueness somewhere upon the extremities; in one case, blueness of the 
whole body; no discharge of urine; intense thirst; a great sensation of heat within; 
extreme restlessness; the tongue of a colour like lead; and (in tire case in which 
the body was blue ail over) covered with a white and leathery crust; a very feeble 
p\dse; and, at last, no pulse whatever in the extremities, although it could be felt 
at the heart. The pulse and the respiration were very rapid, I have counted .the 
respirations at tliirty-six in a minute. There has been a great fall of temperature; 
so that the hands, the tongue, and the breath (as it came from the body) were cold. 
On passing a thermometer into the mouth, I have found it as low as eighty-four 



CHOLERA. 941 

degrees;— ranging- only, at any rate, between eighty and ninety degrees. There 
has been a cold sweat on the extremities; and then, at last, the patient would re- 
main free from restlessness, pain, or vomiting; and would lie perfectly still, con- 
scious of every thing, but with a desire not to make the least exertion, — apparenily 
tranquil, and waiting for liis dissolution. Then, before death, I have noticed the 
temperature rise, — the coldness cease; and after death, the temperature has risen 
still more. In the case where there was such great blueness,'' no sooner had the 
patient expired, than the blueness was diminished. I did not observe whether it 
diminished before death, but I noticed it immediately afterwards; and, in an hour, 
there was nothing of the colour to be seen. There was a twitching of the muscles; 
so that one finger, after death, would be drawn in, and then another; and the lower 
jaw would move up and down; and we might see a quivering of the muscles inside 
the thighs. The voice was weak; and there was a great peculiarity in it. 

31orbi(l .Appearances. — After death, the stomach and intestines were usually 
found filled with a white fluid, containing white flakes. There were various 
appearances of the alimentary canal, both internally and externally. Sometimes 
it was rosy, and sometimes pale. The urinary bladder was empty, and exceed- 
ingly contracted. The congestion in the venous system was very great. The 
mesenteric veins were full; and the " venas cavag" appeared distended to the utmost. 
They looked like a bell-rope in a drawing-room. The heart was observed to be 
full; and the blood, botii in the ventricles and auricles, was grumous, — half coagu- 
lated. There was sometimes congestion in the head; and sometimes in the lungs. 

Identity of the Disease in India and London. — No one possessed of common 
sense can doubt, for a moment, that the disease which occurred in India, and that 
which we have seen here in England, are precisely the same. I should think no 
one can doubt, that it is different from the disease commonly called "cholera;'"* 
which is marked by a discharge of bile, and in which the danger is in proportion 
to the extent of the evacuations. It cannot be said that this disease is only a severe 
form of common cholera; because the mildest cases are not at all like common 
cholera, they are not characterized by a discharge of bile. If it were cholera, only 
very severe, the mild cases ought to be equal to the very severe ones of the com- 
mon cholera of this country. 

Is it a New Disease? — Again: it has been said that this disease is not only 
essentially common cholera, but that it is a disease we had all seen before. If it 
had previously occurred in London, I think that, from being connected with a large 
institution,'' I should have seen it; but I certainly never saw an aflection that bore 
the least analogy to it. It would not be more absurd to say, that measles and com- 
mon bronchitis are the same, because in both there are certain morbid appearances 
in the air-passages; than it is to say that, because there is vomiting and purging 
in this disease as well as in common cholera, they are the same. A variety of 
diseases of the skin, which are distinct from each other, have an appearance in 
common; and measles, scarlet-fever, and other afl'ections, were formerly all jum- 
bled together,'* No diagnosis was made between them; — simply because there was 
redness of the skin. 

The cholera which Celsus and Sydenham described, is very diflerent from this 
aflection. Sydenham says it prevails at the end of summer and during the autumn, 
as regularly as vegetation comes in spring; whereas this disease occurs at all seasons, 
and has no connection whatever with heat. Sydenham describes it as a discharge 
of hile; and not of the peculiar fluid which we see in this aff'ection. I have con- 
versed with practitioners older than myself, — with men of the greatest experience; 
and they declare that they have never met with such a disease before. 

History of the Disease. — It was thought, in India, tliat the natives suffered from 
it more than the Europeans. Thousands of natives perished near Bombay; while 
of the Europeans, who had good food and good clothing, six only were afiected. 
It was found to attack those who had the worst diet, who were the worst clothed, 

« See Page 940. »» See Page 935. 

«= Si. Thomas's Hospital. * See Page 387. 



942 CHOLERA. 

and were worst off in all respects. It was found to prevail at all temperatures, 
and all seasons; — in healthy and in unhealthy situations; both in dry and in moist 
places. It prevailed in spite of the monsoons; and not only in every direction of 
the wind, but in all hydrometric states of the atmosphere. There was great doubt 
whether it was contagious or not. Some thought it proceeded where there was no 
communication, just as well as when there was. It was found suddenly to stop 
without any apparent reason, and then to go on again; — to pass from one district to 
another, as regularly as any other disease would; and then, as soon as it ceased in 
one place, it would begin in another. It was said, that it broke out in the Mauri- 
tius, three thousand miles from the place where it had prevailed; but it was after a 
vessel had arrived from that spot. On reading the accounts of the disease as it 
appeared in different countries, we find a mass of evidence tending to prove that it 
is contagious; and then we find a mass of doubtful circumstances, which unsettle 
our minds again. 

I need not say that it turned, at last, towards Europe; and proceeded, pursuing 
a northwesterly direction, till at last it reached this country; and, with all the ob- 
servations that could be made, it is still a matter of doubt whether it is contagious or 
not. The particulars observed here and on the continent, however, perfecdy 
agreed with what I have stated; namely, that the poor were affected much more 
than the rich; and that those who were the worst fed, clothed, and lodged, all suf- 
fered in the greatest degree. We had a striking example of this, in contrasting 
its ravages in London, with those it made in Paris. Here the greater part of the 
people are well fed; — better fed than in any other part of the world. They eat 
more flesh; and that flesh is of such a quality, as is scarcely to be found in any 
other country. Besides this, they are better clothed, and more comfortable; and, 
instead of trashy wines, they have good sound ale and porter, and malt-liquor of all 
kinds. But in Paris the air is bad; the people have very little water; and the water, 
for the purposes of consumption, is very bad. The inhabitants are crowded toge- 
ther, — I know not how many families in a house, — with little ventilation. The 
streets are narrow; and, together with this, the houses are dirty. The population 
live upon what we Englishmen call trash; — not roast beef and mutton; but all sorts 
of dishes made up of bread and vegetables, with a little meat boiled in water to 
colour it, or to give it a flavour; and they drink, not good beer, but thin wine; and 
we all know that this disease has committed infinitely more ravages, — done infi- 
nitely more mischief there, than it has here. This completely accords with what 
was observed in India. 

Is it Contagious? — With regard to contagion, we have in this country many 
observations, which tend to show that the disease is contagious; and then, again, 
we have cases occurring, where we cannot imagine communication could have 
taken place. In the "Medical Gazette" (Volume 10, Page 3P), reference is 
made to a work by Dr. Hazlewood; in which several facts are mentioned, whicli 
go to show the contagiousness of the disease; and these, together with facts which 
I have noticed myself, have created a strong suspicion in my mind, that it is con- 
tagious. But while I am inclined to believe that to be the case, yet I am also 
satisfied that it will spread without contagion at all. It may spread, independently 
of contagion; but if the disease do occur in an individual, I cannot but think that 
that individual may communicate it to another. Of course we shall find a large 
number of exceptions to its speading, where we might, a priori, expect that it 
would spread. The disease has great difficulty in attacking those who are in good 
health, and well ofi'; and in this respect it differs from syphilis, itch, and small-pox; 
and therefore, though thousands may be exposed to the contagion of the disease 
(if contagion really exist), yet they will be almost sure to escape. This must be 
taken into consideration, when we consider whether the disease is contagious or 
not. If a number of persons be exposed to it, and escape, yet that is nothing 
more than we should expect. 

« No. 227; April 7, 1832. 



CHOLERA. 943 

Mortality.' — It was observed, in India, that much good was done by medical 
treatment. It is said that, at Bombay, — where there were from two hundred thou- 
sand to two liundred and twenty thousand inhabitants, — there were fifteen thousand 
nine hundred and forty-iive cases. Of these, one thousand two hundred and nine- 
ty-four took no medicine, and all died; but where medicine was employed, the 
deaths were much reduced. It was supposed there,— at least, it was so stated in 
books at the time, — that by the administration of large doses of calomel and opium, 
occasional bleeding, and the hot-bath, great good was effected; and that many lives 
were lived. Some persons gave calomel in small doses; and gave some scruples, 
with a drachm of laudanum; — altering this according to circumstances. Others 
bled their patients, when they could get blood to come; and it was said that that 
treatment, also, was very successful. Some' practitioners adopted both plans. 
Some strongly recommended the use of magnesia, and other absorbents. Indeed, 
one celebrated writer says, that magnesia and absorbent specifics have saved thou- 
sands of lives. Such was the treatment there; and the success, as I have stated, 
was considered to be very great. 

Liability of Spirit Drinkers. — It was well ascertained in London, that not only 
those who were badly off, and in bad health from some other disease, but those 
who were in the habit of drinking spirits, were very liable to the disease. I do 
not know that such an observation was made in India; but I presume that drunk- 
ards there suffered, — the same as here. In Europe, however, it is an undoubted 
fact, that that portion of the lower orders who had every thing calculated to keep 
them in good health, but who indulged in spirit-drinking, were sure to suffer; and 
this has been observed with regard to other diseases. However well persons may 
be off, yet if their body be enfeebled, they are rendered increasingly liable to the 
disease. 

Treatment. — As respects this country, I cannot but think that if all the patients 
had been left alone, the mortality would have been much the same as it has been. 
If all the persons attacked with cholera had been put into warm beds, made com- 
fortable, and left alone, — although many would have died who have been saved, — 
yet, on the whole, 1 think the mortality would not have been greater than after all 
that has been done; for we are not in the least more informed as to the proper 
remedies, than we were when the first case of cholera occurred; — we have not 
been instructed, in the least, by those who have had the disease to treat. Some 
say that they have cured the disease by bleeding; others by calomel; others by 
opium; and others, again, say that opium does harm. No doubt many poor crea- 
tures died uncomfortably, who would have died tranquilly if nothing had been done 
to them. Some were placed in hot war, or in hot air, and had opium and calomel, 
and other stimulants; which, altogether, were more than their system would bear, 
and more than would have been borne if they had been so treated even in perfect 
health. 

I am sorry to say that, of the cases I had to treat, the patients nearly all died. 
I tried two or three sorts of treatment. Some had opium and calomel, in large 
and full doses; but they died. Hot air was applied externally; and I jrot two to 
breathe hot air. I had a tube passed through boiling water; so that they might 
inhale hot air. It was found vain to attempt to warm people by hot air applied 
externally. They were nearly as cold as before; — we could not raise their tem- 
perature; and therefore I thought of making them breathe hot air; but both patients 
died, about the period that death usually takes place. It was said that saline treat- 
ment was likely to be of use; and I accordingly tried it in some patients. At first 
I exhibited half a drachm of sesquicarbonate of soda, every hour; and, thinking that 
might not be quite enough, I exhibited a drachm: in one patient at St. 'J'homas'^ 
Hospital, I ordered an injection containing an ounce of the same remedy; but the 
greater part of it came away, and the patient died. Hot air was used in this case, 
as well as in the others. 

CondUion of the Blood. — This leads me speak of the chemical qualities of the 
blood, and of the discharge from the alimentary canal. It has been said that the 



944 DISORDER OF THE DIGESTIVE ORGANS. 

contents of the latter were alkaline; but I examined that point, in several cases 
where no alkali had been taken: and so far from the observation being correct, I 
found them exceedingly add. In the case of a man who was blue from head to 
foot, and who had twitches after death,* the contents of the stomach were exceed- 
ingly acid; but the intestinal matters were less and less so, as we went downwards, 
till we got to the large intestines; and there they were natural. In the patient who 
took large doses of the carbonate of soda, and had an ounce thrown up,'' the con- 
tents of the stomach were then only neutral, while those of the intestines were 
acid. When we came to the rectum, where some of the carbonate of soda that 
had been injected still remained, they were alkaline. The cases that I have exa- 
mined, have not been numerous; but in all of them the contents have been princi- 
pally acid; and in no case were they alkaline, except in the one I have just men- 
tioned. 

Dr. O'Shaughnessy has published some observations and experiments on this 
subject. He says: — "The summary of my experiments may be described as 
denoting a great, but variable deficiency of water in the blood, in four malignant 
cholera cases; a total absence of carbonate of soda in two of them; its occurrence 
in an almost infinitesimally small proportion in one; and a remarkable diminution 
of the other saline ingredients in all." It would appear, from these four cases, 
that there is less serum in the blood; and therefore we see why it is thicker in this 
disease than in health; and that there are also less sfdine ingredients in it. He also 
says: — " In the dejections passed by one of the patients whose blood was analyzed, 
we found a preponderance of alkali; and we recovered the other saline matters 
deficient in the blood." Thus he supposes that the blood loses its saline .particles; 
that they are discharged into the intestines; and that we find them there, in the 
same proportion as the blood has lost them. But although that may be the case, 
it is not clear that the dejections are of an alkaline quality; — that is to say, that 
there is an excess of alkali in them. 

I really can say nothing satisfactory with regard to the treatment; but I know 
that patients feel intense heat within, and intense thirst; and that they find great 
comfort from cold drinks. I understand that, in Vienna, the custom was to allow 
ice; which the patients took with great avidity, and derived great cgmfort from it. 



CHAPTER IX. 

DISORDER OF THE DIGESTIVE ORGANS. 

The disease which I shall now describe, is commonly called *' indigestion;" 
but I would rather speak of it under the denomination of " disorder of the diges- 
tive organs at large;" because " indigestion" applies to affections simply of the 
stomach; whereas this affection implicates the intestines as well as the stomach; and, 
indeed, all the organs concerned, not only in chylification, but also in excretion. 

Definition. — "Indigestion" is usually termed in medicine "dyspepsia;" and is 
sometimes mentioned under the name of " apepsia;^^ — the one meaning " difficult 
digestion" (from 5i;s, with difficulty; and TtETtT-w, to concoct); and the other " no 
digestion" at all (from a, privative; and 7tf;t7^w, to concoct). However, these all 
mean precisely the same thing. We are now, therefore, to consider that derange- 
ment of the digestive organs, which is generally attended with indigestion; but 
many of the symptoms of which take place ivithout indigestion. Many persons 
will digest very well; and yet, when they have no food in the stomach, they are 
filled with wind. But this ceases on food being taken. 

• See Pages 940 and 941. ^ See the previous Paragraph. 



DISORDERS OF THE DIGESTIVE ORGANS. 945 

Sympathetic Derangement. — If any organ in the body suffer severely, the 
stomach is very much disposed to sympathize with it. The stomach, the heart, 
and the head, are particularly affected when any material derangement occurs in the 
frame, — the stomach more particularly, perhaps, than either of the others; and the 
intestines generally become more or less affected at the same time. We know 
that, in all acute diseases, — in all violent accidents, the stomach feels the shock. 
There is anorexia (loss of appetite), frequently nausea and vomiting, and either 
costiveness or purging. The fbeces generally become depraved in their quahty; 
uneasiness is usually felt in the stomach or intestines; and there is, perhaps, even 
pain and tenderness. Very frequently, the patient is rendered more uncomfortable 
by the sympathetic disturbance of the stomach and bowels, than by the original 
affection itself. In chronic diseases of the heart, liver, and lungs, for instance, 
the stomach and intestines are most materially affected. But besides these effects, 
mere sympathetic occurrences, from the derangement of other organs, — we have 
these parts deranged originally. 



SECTION L— SYMPTOMS. 

I will now proceed to consider all the symptoms, which characterize those affec- 
tions which pass, every day, under the name of " derangement of the digestive 
organs." 

Anorexia. — In the first place, loss of appetite is a very common symptom; and 
this is called, in medical language, " anorexia." Sometimes, however, the appetite 
is not lost; it is only irregular; — the patient being able to eat well one day, though 
he cannot eat another. Sometimes the anorexia amounts to loathing; — the patient 
not only cannot eat, but the idea of it disgusts him. 

Pica. — Sometimes the appetite is not simply deficient, but is depraved.^ This 
is particularly seen in females; and is called " pica" {a magpie; — an animal said 
to be subject to this complaint). Sometimes young ladies long for chalk, cinders, 
or sand; and they will bite glass, — munch it; and, when it is small enough, they 
■will swallow some of it. I saw a lady, who ate brown paper; she longed for 
something to eat, — for something that she had never eaten before; but she could 
not tell what; — nor could I. I have heard of cases where the patient longed for 
raw flesh, and even for live flesh; so that some have eaten live kittens and rats. 
This is an absolute fact. In the same way, some have been known to long for the 
contents of snuffers; and even for manure. A case is described of a man who ate 
a live pig, — leaving the intestines; but, after a little while, he ate them also. There 
is a case described, at full length, in a German work, of a boy who had such a 
longing for lime, that he ate all the mortar he could pick out of the wall; and, being 
well horsewhipped for it, he then commenced on a neighbour'' s wall. In order to 
pi/event this, however, the neighbour smeared the wall with a decoction of worm- 
wood, and the boy could no longer relish it; but he then went to the kennel in the 
street, and sucked up the sand. He had a desire for something dirty. After this 
he got to some quick lime; and was forced to drink a large quantity of water, to 
extinguish his thirst. The mucous membrane within, had a distaste for what is 
called "o-oof/ food;" but, in other respects, he was quite well. I recollect having 
read of a girl, and also of a student at Leyden, who always ate spiders when they 
could get them; and no harm arose from it. I have read of a man who disliked 
bread, and never ate it; but he was seized witli a quartan ague, and then ate a large 
quantity. He recovered from the ague; and the disgust towards bread returned. 
This disease occurs in young women (even moral ones) who do not menstruate 
well; — as I mentioned when speaking of chlorosis;* and many pregnant women 
have some strange longing of this description. Every one must have met with 
instances of women longing for what it was difficult to get; — longing for things out 

» See Pa^e 219. '' See Pages 218 and 221. 

VOL. I.— 60 ^ 



946 DISORDER OF THE DIGESTIVE ORGANS. 

of season. There was one who longed for a bit of the priest's sleeve, and contrived 
to get at it and bite it; — not caring for his excommunication. I could relate cases, 
almost without end, of this description. One dipped her bread in a tar-tub. I 
never met with these extreme cases; but every one must have read of instances of 
this nature. 

Bulimia. — Sometimes, however, the appetite is excessive; so that people will 
eat an immense quantity. This is called " bulimia."* I mentioned, when speak- 
ing of fever, that this has sometimes occurred as a temporary symptom of another 
disease.'' People will eat many pounds of meat and bread in the course of a day. 

Thirst and Foul Tongue. — Persons labouring under this affection, frequently 
complain of intense thirst; and their tongue is foul, and covered with a yellow or 
a creamy mucus. Sometimes it is white, dry, and brown; but, whatever appear- 
ance it has, it is worst in the morning. It is frequently red at the same time, — 
either at the tip or at the edges. Sometimes it is the papillae only that are red. 
They appear separate; — like granules of cayenne-pepper. Sometimes the tongue 
is red all over; and it may be moist, dry, glazed, or cracked. 

Fetid Breath. — There is frequently fcBtor of the breath. Sometimes the smell 
is sour; — sometimes it gives one the idea of sour flesh; sometimes it is like cab- 
bage-water: and occasionally it is absolutely faecal; — so that it is impossible to stand 
near the patient. I mentioned that the most horrid kind of fetid breath, frequently 
arises from a depraved secretion within the tonsils. '^ Of course we may have a 
diseased odour of the breath, from other circumstances than any of these. It will 
arise from a diseased bone; and sometimes even from carious teeth. This is not 
so disagreeable to others; but it is very unpleasant to the patient himself, — from 
there being a bad taste in his mouth. Sometimes the taste is bitter; and sometimes, 
they say, it is particularly offensive. 

Eructatians. — Eructations are very common in this affection; and these may be 
either simple or fetid. Those which are inodorous, are generally experienced 
when the stomach is empty; and probably arise from a secretion of air by the sur- 
face of the stomach; but those which are fetid arise, I presume, from the contents 
of the stomach undergoing a certain degree of fermentation, or sometimes from the 
patient being costive. It appears that a portion of the faecal odour, if not of the 
faeces, is absorbed; for some persons who are exceedingly costive, have very fetid 
eructations; which are removed by regulating their bowels. In some persons, it is 
only when certain articles are taken, that the breath becomes offensive. Sulphu- 
retted hydrogen appears to be given off from the substances in question. 

Nausea and Vomiting. — Besides these afTections, the stomach sometimes expe- 
riences attacks of nausea and vomiting. Some vomit only the food they take; 
others vomit a viscid secretion. Some vomit more or less constantly; and some 
vomit only in the morning; — and, in the latter case, it usually arises from drinking. 
When the disease has become very severe, some will vomit on the slightest motion. 

It is very common for the mouth to become filled with watery fluid; and often 
very suddenly. Sometimes the patient's mouth is constantly open. I have seen 
patients spit a pint a day. Occasionally the fluid is tasteless; but more frequently 
it is salt, or sour; and occasionally it is very acrid indeed; — containing a large 
quantity of muriatic acid. I believe it is often felt to be very cold. Patients com- 
plain of its coming up, as if it proceeded immediately from a spring. 

Independently of this fluid, there is frequently an excessive quantity of viscid 
mucus; chiefly hanging from the pharynx; and causing a constant desire, on the 
part of the patient, to hawk it up. Many cases of this description, are mistaken 
for affections of the air-passages. I was myself, for some time, completely in the 
dark respecting it; — conceiving that persons had a constant discharge from the air- 
passages, when they had nothing more th.an indigestion. The vomiting may either 
be of simple food which has become exceedingly sour and acrid, or fetid; or it may 
be of bile; so that we have every variety of vomiting;— just as we have every 

^ From Bo'j^ excessive; and i.ii/.oq^ food. *> See Page 287. 

" See Pi'ffe 700. 



DISORDER OF THE DIGESTIVE ORGANS. 947 

variety with regard to the appetite, with regard to the appearance of the tongue, 
and with regard to the eructations. 

Gasti'odynia and Pyrosis. — ^To descend lower, there is tightness and fulness of 
the abdomen; — chiefly at the epigastrium, and chiefly after meals. Frequently 
there is an aching there; and sometimes excessive pain. Occasionally this is ex- 
perienced only after meals; and occasionally only when the stomach is empty. 
This pain, if it be unaccompanied with inflammation, passes under the name of 
" gasirodynia;" and if, with this, there is a flow of fluid into the mouth, the two 
circumstances together are called "water-brash," or "pyrosis" (from TtDpow, /o 
burn). The pain is sometimes sudden,^ — comes on instandy, or at least very 
rapidly; and is excruciating. It darts back, perhaps, to the spine; and causes the 
extremities and face to become cold, the pulse to be small, and the surface pale. 
It passes under the name of "spasm of the stomach." Very frequenUy, at the 
same time, there is a larsje discharge of flatus through the oesophagus; — -flatus which 
is usually inodorous. This pain frequently runs to the left shoulder, and down the 
left arm; — like the pain experienced in " angina pectoris."* I have known it run 
down both arms, up the jaws, and along the teeth. Sudden attacks of this afl'ec- 
tion, are seen more commonly in women than in men. The pain is not always 
felt precisely in the situation of the stomach itself; but occasionally in the shoulder- 
blades, and occasionally in the ribs; — even in those which are not over the stomach; 
though the pain is dependent on that organ. In my own case, I have occasionally 
laboured under this pain severely; and I have been able to get rid of it by putting 
my fingers into my throat, and discharging a quantity of sour stuff. When the 
pain in the ribs returned again, by making so slight an effort as hardly to be called 
"vomiting," but sufficient to discharge a quantity of stuflf like bird-lime, I have 
invariably found the pain go way. If I had not paid attention to the stomach, I 
could not have believed that the pain arose from that organ. The pain is some- 
times felt even at a distance; — in the calves of the legs, for instance. Frequendy, 
when there is much disturbance of the stomach, the legs fall into a state of violent 
cramp; the most common cause of which, is the presence of acid in the stomach. 

CardiaJgia. — Besides this spasmodic pain, — which, for the most part comes on 
suddenly; or, if it exist constanUy, is attended with exacerbations; and is not in- 
creased by pressure, there is frequently injlammatorij pain; — not gastrodynia, 
but gastritic pain; so that the stomach is tender on pressure, and all ingesta pro- 
duce great agony. A sensation of heat is induced in the stomach, and up the 
throat. In some cases, there is a throbbing of the epigastrium, — a violent pul- 
sation; which no doubt has been mistaken, over and over again, for aneurism; 
and which patients themselves are inclined to believe is aneurism; because, in 
this state of things, they are much disposed to despond. This has been called 
" cardialgia;"" and has been referred, by Sauvages, to a morbid sensibility of 
the part. Dr. Baillie wrote a paper on this subject, in the fourth volume of the 
" Transactions of the College of Physicians;"'' in which he stated that he had 
been consulted, several times, on this affection; which had been supposed to 
be aneurism; but which he had not found to be so. He opened persons who died 
from some other disease, while labouring under this; and found nothing morbid. 
It is a common symptom;- — one which I have frequently been consulted upon; but 
we find no tumour. On pressing the part, we feel the shape as usual; and we 
find, at the same time, a great depression of spirits; and, more frequenUy than 
not, various symptoms of disorder of the digestive organs. On looking over Sau- 
vages, I find he has described it as a dyspeptic symptom; and has referred it to a 
morbid sensibility of the arterial system of the part. He says it is certain that the 
gastric arteries and the aorta, although not aftected with aneurism, yet, in tliose 
who are constantly hypochondriacal and hysterical, acquire an exquisite sensibility, 
and produce this state. Occasionally the heat is far beyond what I have just men- 
tioned. It is a burning pain; and patients usually speak of it as a " burning 
sensation." It arises, in most instances, from the quantity of acid produced in the 

a See Pages 866 and 867. ^ From xaj5»«, tlie heart; and aXj^o?, -paui, « Page 271. 



948 DISOHDER OF THE DIGESTIVE ORGANS. 

stomach; and if there be any inflammation of the mucous membrane, the pain will 
be proportionately severe. 

Slate of the Bowels. — The bowels are generally irregular; and, for the most 
part, they are torpid; but sometimes they are relaxed. In other cases we find an 
alternation of costiveness and relaxation; so that they are never tight. The faeces, 
too, are frequently unhealthy. Frequently they are lumpy; but they are of various 
morbid degrees of consistence, and of various morbid colours; and frequently they 
are not of their usual smell. Sometimes there is a great want of bile; and some- 
times tliere is even a degree of icterus. From the irritation of the stomach, the 
urine usually becomes high-coloured; but at other times, — especially when there 
is a great quantity of wind generated in the stomach itself, — the urine becomes ex- 
cessive in quantity, and pale; — just as in asthm'a." 

Headache. — Other parts of the body, how^ever, suffer as well as the gastro-intes- 
tinal, or (as it used to be called) the alimentary canal. There is frequently head- 
ache, — either general, or particularly in the forehead; and very frequently it is con- 
fined to one part of the forehead, — to one brow. Sometimes it is intermittent; 
and sometimes absolutely periodical. I have no doubt, however, that occasionally 
this headach does not arise from the state of the stomach; for disturbance of that 
organ may be produced by cold, or vexation of mind; and then, when it comes to 
be very severe, it will make a person sick. On the other hand, it frequently arises 
from taking into the stomach things which disagree with it. I formerly mentioned 
how hereditary this description of headache is;** — how frequently we see it in 
fathers and in children; — how frequently it occurs in many members of the same 
family. Sometimes it will come on at regular, and sometimes at irregular inter- 
vals; — disappearing, perhaps, after a certain number of years. It is so obstinate, 
that I do not recollect curing a case of it; though I have tried every thing that 
could be devised. 

Disturbance of the Nervous System. — Frequently, in this disease, there is con- 
fusion of mind. Patients cannot employ themselves as they did before. They 
cannot read long; and I have known some obliged to give up study altogether. 
Frequently there is vertigo, heaviness of the head, and sleepiness; but, on the other 
hand, when the stomach is much deranged, it is common for persons to lie awake; 
— they find it impossible to go to sleep. There is frequently, too, a ringing in the 
ears, — " tinnitus aurium;" and specks appearing before the eyes,- — " muscae voli- 
tantes." There is frequently great sadness, — great depression of spirits. Patients 
are very restless and fidgety; and sometimes their temper is very irregular: so 
that we must take care not to say many things which, at other times, we might 
say with impunity. Voltaire gives special directions to those going to ask a favour 
of the Prime Minister. He tells us to ascertain (from his valet de chamhre) 
whether he has had his bowels opened in the morning; — so much does temper 
depend upon the alimentary canal. 

The heart also sympathizes with the stomach. There is frequently palpitation 
in these cases; and sometimes an intermittent pulse. Frequently there is night- 
mare, or terrific dreams. A partial consciousness, and yet an inability to make a 
voluntary exertion, come on during sleep; but when patients can make an effort, 
they imagine they get out of this condition. Incubus is a very common symptom. 
There is frequently, too, a sense of great debility; wliich is felt particularly at the 
pit of the stomach. Patients complain of this every day; — they say they feel as 
if their inside were all gone to decay. Sometimes there is a tremor of the whole 
body. The skin likewise suflfers. It is generally dry and cold; but sometimes it 
is hot. 

Persons sometimes have merely an inability to digest food; and are very well so 
long as there is no food in the stomach. But true dyspepsia (that is to say, that 
affection which depends upon the stomach performing its functions improperly; and 
which is worse after eating, or indeed is only experienced then) is attended with 
other symptoms. There is loss of appetite, vomiting, distant pain, and the other 

a See Page 769. ^ See Page 485. 



DISORDER OF THE DIGESTIVE ORGANS. 949 

symptoms which I have mentioned;* but we frequently have these without much 
indigestion. Persons complain of a great sinking at the pit of the stomach; tliey 
will also have gastrodynia and pyrosis; and yet ihey will digest their food well, — 
have no dyspepsia; although there is derangement of the stomach. They are very 
well when they take food; and only suffer when the stomach is empty. Some of 
these things are merely called "indigestion." Some patients have none of these 
symptoms; and some may have one or other, or both together. Persons who suffer 
in this way, frequently become pale and emaciated. They live many years; but 
are never well. They are not ill enough to die; but their complexion becomes 
altered. 



SECTION II.— CAUSES. 

The causes of all these symptoms, and of all this derangement, may be heyoncl 
the stomach or intestines; — they themselves being disposed to be perfectly healthy; 
or, again, the causes may be in those very organs. 

Hernia. — In the first place, the cause may be in the groin. A hernia will pro- 
duce all these symptoms. If a person have a rupture, he is sure to be troubled 
with irregularity of bowels, costiveness, extreme flatulence, and perhaps gastrody- 
nia and indigestion. If the hernia return into the abdomen, these symptoms may 
all vanish. Any sort of pressure may have the same effect. 

Constipation. — Obstruction or costiveness, without any f\utlt in the bowels them- 
selves, — costiveness from persons neglecting to relieve their bowels, or any acci- 
dental obstruction whatever,—- may produce these symptoms. The presence of 
worms, or any injurious substances which the patient has taken, may give rise to 
them; — the stomach and bowels themselves being disposed to perform their func- 
tions properly, if these mechanical or accidental circumstances were not forced, 
upon them. 

Improper Food. — Occasionally, these symptoms entirely arise from the indivi- 
dual having taken articles, of which the stomach can make nothing, — which it can- 
not manage. These ingesta may be altogether improper for any one to take; or 
the individual may have some particular idiosyncrasy, — peculiarity of constitution. 
Some persons have a stomach, which can digest things in general very well; but 
there may be one or two things, which their stomach cannot digest; and if these be 
taken there is dyspepsia, and some intestinal derangement. We can hardly say 
that such a person is ill; because the circumstance only occurs when he has taken 
some particular article of food. I once saw a maid-servant who, whenever she 
took any kind of fruit, experienced dreadful gastrodynia; — the pain running into 
the back, and causing a rapid pulse, extreme agony, and cold sweats. She could 
digest hard salt beef, and her general food; but if she took a strawberry or a goose- 
berry, she was thrown into the state I have described. 

Excess of Food. — Of course, an excessive quantitij of food, will have the same 
effect as improper ingesta. Nature not only intends us to eat certain things, and 
not others, but she also intends us to eat a certain quantity; — and therefore, just as 
a person may have ''diarrhoea erapulosa," so they may have ''■ dyspepsia craj)u- 
losa" (from xpaiTtv'ka, a surfeit); — the stomach not being in Huilt, but having more 
given to it than it ought to have. The author of " Ecclesiaslicus" says, that 
"excess of meats bringelh sickness."" 

^ See Pages 944 to 949. 

^ " Be not unsatiable in any dainty thing: nor too greedy upon meats. For excess of meats 
bringetli sickness; and surfeiting wUl turn into choler. By surfeiting have many perished; 
but he that taketh heed, prolongeth his \\ie."— Ecclesiaslicus; Chapter SI; Verses ^\) to 3i. 
" Ecclesiaslicus" is an apocryphal book, generally aiiribuled to "Jesus, the son of Siraeh." 
The first fifteen verses of the ihirly-eighth chapter relate to sickness; and though it has no 
claims to inspiration, yet (from its undoubted antiquity) it is very curious; on accouni of the 
notices which ii give.s of " the physician" and the " apothecary.'' Express mention is made 
of " mediciiiesj" and iafasiuas of wood are plainly pointed out. We subjoin the passage:— 



950 DISORDER OF THE DIGESTIVE ORGANS. 

Imperfect Mastication. — Nature does not intend lumps of food to go into tlie 
stomach. On the contrary, she intends it to be prepared, — to pass through a cer- 
tain process before it enters the great organ of digestion; and therefore imperfect 
iTiastitication will produce dyspepsia, without any fault in the part itself. Old peo- 
ple, when they lose their teeth, or young ones when they cannot chew as before, 
and cannot live on spoon victuals, are very subject to indigestion. But, indepen- 
dently of a particular quality of food, or a great quantity, — variety, or a great dis- 
cordancy of meats, will occasionally produce dyspepsia. 

Sympathy. — Still speaking of causes unconnected with a fault in the stomach 
and intestines, we may mention " sympathy." These parts are frequently de- 
ranged through the slate of other organs. In the first place, we may refer to the 
uterus. When the uterus is pregnant, the alimentary canal is often thrown into 
disorder. Nausea, vomiting, and strange longings of appetite, will sometimes 
occur in females, the very next morning after they are impregnated; and sometimes 
these will occur at the time they quicken. There is every degree of intensity of 
these affections. They occur continually in diseases of the kidney; and frequently 
in mesenteric disease. The passions of the mind have great effect. If a person 
have eaten a good dinner, and has a violent emotion of mind, — whether joy or 
grief, or any other, — he will most probably have a fit of indigestion. Continued 
depressing passions have the same effect. Many cases of indigestion that I have 
seen, have been referable to an uneven state of mind. They have not depended on 
the stomach; but some external circumstance has weighed down the spirits; and 
the stomach has suffered in consequence of it. 

The cause, however, may reside in the alimentary canal itself. In the first place, 
there may be a real debility of the part; in the next place, there may be an inflam- 
matory state; and, thirdly, there may be organic disease. 

Debility.— Ks {o debility, Xh^iX is sometimes induced by long continued excess in 
diet and regimen. Persons who have indulged excessively, all their lives, in eating 
and drinking, may expect to be subject to dyspepsia, — to have their stomach worn 
out; but this state frequently arises from original debility of the stomach. There 
can be doubt that the stomach may be in fault; — like all other parts of the body. 
This affection will run in families, where there has been no excess whatever. We 
may see the father or the mother and the children labouring under this disease in 
various degrees; — -none having committed any fault calculated to produce it. Cer- 
tain portions of the stomach may be feeble; or the muscular fibres may become 
weak; — like muscles in other parts of the body. Some persons will have one 
muscle weak, and some another. 

Inflammation. — There may, however, be an inflammatory state; and this may 
be either primary or secondary. It may be induced like any other inflammation; 
but, in most instances, it is chronic; and is induced by constant irritation of the 
stomach. Sometimes it is a mere secondary effect. The stomach has been affected 
with weakness; till it has fallen into a state of morbid irritability, and ultimately 
into a state of inflammation. 

Organic Disease. — Sometimes, however, we have what is far worse;— o?'^«mc 

" Honour the physician with the honour due unto him; for the uses which you may have of 
him; for the Lord hath created him. For of the Most High cometh healing; and he shall 
receive honour of the king. The skill of ihe physician shall lift up his head; and in ihe sight 
of great men he shall be in great admiration. The Lord hath created medicines out of the , 
earth; and he thnt is wise will not abhor them. Was not the water made sweet with woodj 
that the virtue thereof might be known"? And he hath given men skill; that he might be 
honoured in his marvellous works. With such doth he heal men; and taketh away their 
pains. Of such doth the apothecary make a confection; and of his works there is no end; 
and from him is a sv/eet odour diffused around. My son, in thy sickness be not negligent; 
but pray unto the Lord, and he will make thee whole. Give a sweet savour; and a memo- 
rial of fine flour; and make a fat offering. Then give place to the physician; for the Lord 
hath created him. Let him not go from thee; for thou hast need of him. There is a time 
when, in their hands, there is great success. For they shall also pray unto the Lord;— that He 
would prosper that which they give for ease and remedy, — to prolong life. He that sinneth 
before his Maker, let him fall into the hands of the physician.'^ 



I 



DISORDER or THE DIGESTIVE ORGANS. 951 

disease of the stomacli; and then the indigestion, and all the other symptoms which 
I mentioned,* are irremediable. Generally it is the cardia or the pylorus which is 
affected; but sometimes (as I before slated^} there may be an ulcer in the body of 
the stomach; and this ulcer may be either simple or scirrhous. Sometimes there 
is no ulcer; but the coats of the stomach beconie thickened or softened. All liiose 
circumstances that I spoke of, when treating of organic diseases of the stomach," 
may occur. I mentioned, that the softening of the stomach has sometimes come 
on suddenly; — has appeared not to have existed above a few weeks, and sometimes 
not more than a day or two.*^ I also mentioned that this softening was sometimes 
decidedly inflammatory;® and that sometimes there was no mark of inflammation at 
all; — the parts being perfectly white. ^ 

Prognosis. — From a consideration of all the causes producing disorder of the 
digestive organs, we see that occasionally it is quite independent of the stomach 
and alimentary canal; and we have only to remove the unfavourable external cir- 
cumstance, and all goes on right again. Sometimes the causes are of a nature in- 
dependent of external circumstances, and are removable; or, if not removable, are in 
some measure controllable. In other instances, it is impossible to cure the afl'ection, 
or even to control it much. The prognosis, therefore, must also depend upon what 
we ascertain to be the cause of the disturbance. 



SECTION III.— TREATMENT. 

Removal of urgent Symptoms.— 'The first thing to be done, is to alleviate urgent 
symptoms. Suppose that any thing injurious in its quality or in its quantity is the 
cause. The shortest way then will be to give an emetic, and empty the stomach; 
and it is much the best to give one that does not produce nausea, but an evacuation. 
The sulphate of zinc is as safe as any thing that can be exhibited. The flour of 
mustard has also been exhibited, for the same purpose. But should the patient be 
of an exceedingly full habit, — for instance, a fat, short-necked, puffy, asthmatic 
alderman, fifty or sixty years of age, — it may be necessary to take away blood, 
before giving an emetic; otherwise the exhibition of the latter may cause apoplexy. 
In some cases, it might be proper to premise bleeding; but in every case it is right 
to follow up the emetic by purging. Nothing is better than eight or ten grains of 
calomel, followed up by senna and salts. We thus empty the patient above and 
below; and he is soon relieved. 

If the symptom be gastrodynia, and we cannot find any thing in the stomach that 
has occasioned it, then tincture of opium is an excellent remedy. In the continued 
form of the disease, prussic acid will answer better; hut I never saw it succeed 
when it was given for immediate effect. When we wish that, I think a full dose 
of opium is best; and laudanum will act rather more quickly than solid opium. 
Sometimes it is necessary to give a large dose in this state. Twenty drops have 
no effect; and we have to give forty, fifty, or sixty, and to repeat the dose every 
half or three-quarters of an hour; for it produces none of the specific efl'ects of 
opium. Occasionally, it is better to give the opium in plain, hot water, than in a 
tincture or brandy; because, after a violent spasm, there is sometimes inflammation. 
Occasionally, I have seen people labour under inflammation, after spasm has been 
removed; — not because they took opium, but because they took a quantity of brandy. 
Sometimes we must repeat a dose of laudanum, containing forty or sixty drops, two 
or three times, before the good effect is produced. 

If the patient labouring under this disease, however, is of full habit, it is usefiil 
to bleed. Sometimes L have seen gastrodynia cease when the bleeding was over. 
Venesection is often among the best antispasmodics. After a spasm, tenderness 
may come on; and then bleeding at the arm, or the application of leeches, may be 

"^ See Pa^es 944 to 949. " See Page 908. 

« See Pages 910 to 912. ^ See Passes 899 and 902. 

» See Page 902. f See Page 901. 



952 DISORDER OF THE DIGESTIVE ORGANS. 

necessary. But the affection frequently occurs without any marks of an inflam- 
matory state; and then laudanum is sufficient to remove it. Hot external ap- 
plications are exceedingly useful. The temperature falls in this state; and it is 
exceedingly pleasant to the patient to have a hot fomentation, or hot substances of 
various kinds applied, — not merely upon the stomach, but also to the back. I 
need not say that a hot-bath, if it can be procured, would be useful. This state is 
often called "the passage of a gall-stone;" — for no reason whatever, but that it 
comes on suddenly. We are never justified in saying, that an individual is passing 
gall-stones, unless he has passed them before, and they have been really found; 
because a pain of this description may come on in a moment, from eating an article 
which does not suit that particular individual; or an external circumstance may oc- 
casion it; and there is no difference, as regards pain, between it and the passage of 
a gall-stone. 

If the urgent symptoms that rpqnire to be removed are heartburn, acidity, and a 
scalding sensation in the stomach, rising to the throat, magnesia, the carbonate of 
soda, and things of that description are the best. They will remedy this state 
chemically in a moment, without reference to the disease itself. In the healthy 
stomach, there is muriatic acid. As soon as food is taken, muriatic acid is formed; 
and, in some persons, it is generated in such great abundance, that it produces this 
affection. If there be very fetid eructations, from something putrefying in the sto- 
mach, and if the latter be overloaded, distended with them, it is best to give an 
emetic. If there be no reason for giving an emetic, two or three drachms of the 
common solution of the chlorurets might be given; and common acids, also, will 
answer very well. These, however, are means to be resorted to only when there 
are symptoms particularly urgent that require removal. We have more to do in 
order to cure the disease; and we must lay down for the patient a system, for the 
regulation of his habits and employments. 

Cure of the Disease. — Having spoken of what ought to be done, in the way of 
lessening any very urgent symptoms that may arise in disorders of the digestive 
organs, — particularly in a violent attack of gastrodynia, — we will now consider 
what is to be done for the cure of the disease; — what is to be done in the way of 
a regular plan for the termination, or alleviation, of the complaint. In the first 
place, we must ascertain the cause of the disease; and if it be external to the sto- 
mach, we must proceed accordingly. 

During Pregn.ancy. — In females, this disorder very frequently arises from the 
state of the uterus. In pregnancy, it is very common for the stomach to fall into 
such a state of disorder, that the patient's life, for a time, is rendered miserable; 
and occasionally, from the constant vomiting, — from the inability to retain any 
food whatever on the stomach, life has really been brought into danger. In very 
extreme cases, it has been judged right even to induce premature labour, for the 
purpose of putting a stop to this great disorder. In ordinary cases, however, 
although we cannot cure the nausea and vomiting, much may generally be done 
to alleviate them; — not by removing the pregnancy of the womb, but by lessening 
the irritability of the stomach, so as to make it sympathize with the uterus as little 
as possible. Simple bleeding at the arm, has frequently been sufficient for this 
purpose; and so has the frequent application of leeches to the epigastrium. All 
those medicines which I shall hereafier mention, (when speaking of another head 
of treatment,) as calculated to lessen the morbid irritability of the stoujach, will 
here be proper; — such as strychnine, conium, and prussic acid.* It is also proper 
that the patient should take but a small quantity of food at a time. But I will 
speak more particularly of this presently.'' 

If we can ascertain that the disease (as is not uncommon) proceeds from a her- 
nia, the apj)lication of the taxis may be the only means of curing the dyspepsia. 
If we discover that there are worms, the remedies necessary to destroy lliern will 
be proper. These remedies I will consider hereafter. 

» See Pages 957 and 958. ^ See P^ge 955. 



DISORDER OF THE DIGESTIVE ORGANS. 953 

Sluggishness of the Intestines. — A''ery frequently, the stomach is not in fault; 
but there is a sluggishness of the intestines; and, as the cause is situated there, a 
regular course of purgative medicine will be found absolutely necessary. It is 
wrong to give strong purgatives. Those which open the bowels regularly, are 
best adopted for the purpose. It is astonishing how long things taken into the 
stomach and intestines, will remain quiet; and then give rise to various symptoms. 
I alluded to the circumstance before.^ Lithe " Philadelphia Journal," for 1822, 
there is an account of a coagulum of milk, which was vomited two months after it 
had been taken. I have myself seen a coagulum of milk, like bird-lime; which 
had remained some days (even a week) in the patient's stomach, and produced the 
greatest uneasiness; — the stomach not being in fault, but being oppressed by this 
particular substance. I have seen a piece of salmon vomited by an infant, a month 
after the nurse had been so foolish as to give the child that food. I mentioned, 
that Dr. Barlow (of Bath) published a case, in which pills of sulphate of iron 
were discharged, joer anum, nine months after they had been taken.* In a foreign 
journal, a case is mentioned, similar to that of Dr. Barlow's; — a case in which pills 
were vomited, a year after, they were taken. An instance is recorded, in which a 
blacksmith's son bolted thirty grapes. He did not masticate, but swallowed them 
whole; and, after three months frequent vomiting and extreme suffering, he was 
cured by an active purgative medicine. Ten of the grapes came away whole, even 
then. A case is mentioned by Bariholini, where a coagulum of milk, as large as 
a man's tongue, was discharged, after the patient had taken muriatic acid. The 
same author also mentions a case, where a patient had swallowed a swine's tooth. 
He suffered under hypochondriasis and extreme emaciation, for two years; the 
tooth was then discharged per anum; and the individual perfectly recovered. Oc- 
casionally, then, we may have disorder of the digestive organs from articles which 
Iiave been taken, and have remained in the stomach and intestines a much longer 
time than we could imagine. If, in a case of disorder of the digestive organs, we 
suspect any thing of this kind, we ought to employ strong remedies. Purgatives 
and injections, of course, are very important. 

But whether this be the cause of the disease or not, it is of the highest import- 
ance to keep the bowels regular. Nothing can be worse than to give strong purg- 
atives for this purpose; except w^here there is something considerable to be brought 
away. In a case of habitual costiveness, strong purgatives are decidedly bad; be- 
cause, when we have once acted violently on the intestines, the latter, according to 
the laws of nature, must fall into a torpid state, — go to sleep. During this condi- 
tion of repose, the faeces accumulate again; so that we have to give another strong 
dose, in order to remedy the mischief of the first. Thus the person is always 
costive, or taking strong medicines; the consequence of which is, that he is at last 
obliged to take them, or he will fall into a state of dyspepsia. 

Croton Oil. — One of the best remedies for this state, is a very minute quantity 
of croton oil, (about the twelfth, the sixth, the fourth, or the third of a drop) given 
regularly with rhubarb or colocynth; and if it should gripe, a small quantity of 
some aromatic oil may be added to it. We may order one, two, or tliree drops to 
be made up into pills; and make the patient take one every niglit. We shall soon 
find that It will produce one copious stool in the morning; and also that the medi- 
cine may be taken for two or three years, perhaps for ever, without losing its 
effect. The patient will not be under the necessity of increasing tiie dose. If, 
however, 'we give it violently, the patient will be in the same condition as if he 
had taken other purjratives; — he will be costive afterwards. 

Impropriety of Blue Pill. — Nothing can be more absurd than to give blue pill, 
calomel, and other mercurial medicines; because they have a two-fold operation. 
They not merely act as cathartics, but they also pervade the whole system; and 
thus make the patient weak and nervous. These medicines do more than we want. 
We merely require the intestines to be acted upon, and not the intestines at large 

• See Page 933. 



954 DISORDER OF THE DIGESTIVE ORGANS. 

to be put under the speoific action of meronry. Tf Mr. Abernelhy had lived a hun- 
dred years, and done good all the lime, he would not irave atoned for the mischief 
he has done, by making people take blue pill. Half the people in England have 
been led to fancy, tliat they cannot live without bine pill; which not only does no 
more good than any other purgative, but likewise renders those who take it con- 
stantly susceptible to cold; and must altogether be very injurious. 

Excessive Torpidity of the Boivels in some Persons. — I may here mention, 
that there are some persons who have naturally very torpid bowels; — to whom it 
is not natural to have a motion every day. I presume that, in ninety-nine cases 
out of a hundred, it is natural for the bowels to be emptied once in the twenty-four 
hours; but there are some who do not have a motion oftener than once in three or 
four days; and they are ill if they do. I have met with such cases. Dr. Heber- 
den knew a person who, all his life, had but one motion a month.* As a contrast 
to this. Dr. Heberdeu mentions another individual, who had twelve motions a day, 
for thirty years.* That must have been a very troublesome state of things; — a 
kind of " perpetual motion." This same individual had, after this period, a motion 
seven times a day, for seven years. Women are mnch more costive, and sufler 
this with more impunity, than men; on account of the pelvis being large, and the 
rectum distending. Nothing is more common than for women to say, that they 
have been a week, or ten days, without a motion. We must therefore take into 
account, that it may be natural for some individuals to have a motion only every 
few days. 

Watch the state of other parts of the Body, — In a case of disorder of the diges- 
tive organs, we should always examine into the state of other parts of the body; 
for this condition will take place, from sympathy, not only with the uterus, but 
with other organs. A very common cause of this disease, is disorder of the brain; 
— what is commonly called " disorder of the mind.'^ From anxiety, grief, and 
distress of mind, many persons have complaints of the stomach. So far as the 
stomach itself is concerned, they have no reason to find fault; but, from the state of 
the mind, the stomach cannot do its duty. Excessive anxiety, or grief, will not 
only take away the appetite, but will produce constant imperfection in the functions 
of the stomach; together with all those symptoms of indigestion, and derangement 
of the digestive organs, which I formerly mentioned.'' I have very frequently been 
unable to do any material good, because the complaint evidently depended upon the 
state of the mind; and very frequently I have gained credit where I deserved none, 
simply from the circumstance of the unhappy state of mind ceasing. I have very 
frequently attended young ladies, who could not digest; — who had flatulence of the 
stomach; no appetite or great appetite; every thing wrong; — simply because there 
was an anxiety respecting love affairs. They were in fear of disappointment; and 
as soon as the affair was settled, they ate, drank, and digested like other people; — 
without any inconvenience; but, on the contrary, with great benefit. I have fre- 
quendy been baffled in what appeared good rational treatment, because there was 
some grief of mind, or some constant anxiety. 

Snuff-taking before Dinner. — It is always right to look out for any particular 
habit; — to see whether the patient is in the habit of doing any thing, to which the 
disease can be attributed. Dr. Cullen mentions two cases of dyspepsia, from pa- 
tients taking snuff before dinner. In one of these two cases, the disorder of the 
stomach was gastrodynia,— aching pain of the stomach; and in the other case, there 
was a complete loss of appetite. Now both these individuals, on being particular 
not to take snuff before dinner, — taking as much as they chose when the stomach 
had something in it, recovered from their dyspepsia. The one lost his gastrodynia 
entirely; and the other recovered his appetite. 

Smoking. — With regard to myself and tobacco, although I have a stomach that 
will digest any thing in the shape of proper, good, nourishing food, yet if I smoke 
three cigars in a day, or smoke three or four successive days, it invariably produces 

» "Medical Commentaries;" Chapter 5. ^ See Pages 944 to 949. 



DISORDER OP THE DIGESTIVE ORGANS. 955 

the most extreme gastrodynia and cardialgia, — so as to make me quite miserable; 
and therefore I am compelled to be temperate in that respec:. 

Protracted J^bstinence. — Many persons have this disease, from going too long 
without food. Habit has a great deal to do liere. Some persons who breakfast at 
nine in the morning and dine at seven in the evening, — taking nothing in the mean 
time, feel no inconvenience; and others suffer the greatest inconvenience, if ihey 
fast more than four or five hours. Habit will not operate on some people, with 
regard to this point; — some persons cannot be brought to fast long; and it is vain 
for them to attempt it. They feel a sinking in the stomach; — ihey have gastro- 
dynia induced, if they do not eat frequently. Some cannot pass above four hours 
without food; and in proportion to the labour undergone, is the necessity of eating. 
In making inquiry into dyspeptic cases, therefore, we should ascertain how fre- 
quently the patients eat, and also whether they eat too much; for the stomach must 
not be blamed, because it does not do double or treble the duty that nature intended. 
It is said that, in the reign of Henry the Sixth, the people ate but twice a day; 
"whereas," says Hollinshed, " we have breakfast in the f)renoon, beverages or 
nuncheons after dinner, and thereto rear suppers when it is time to go to rest. 
Now these additional repasts, thanked be God, are very well left out; and each one 
contenteth himself with dinner and supper only." Another point is to ascertain 
whether the patient masticates his food. JMany persons gobble up their dinner, as 
a hog would do, instead of masticating it properly. 

Change of Diet. — The patient's diet should he regulated. Some nations live 
on fish; others on putrid animal matter; and others on vegetables. An eagle has 
been brought to eat bread, and a pigeon to eat meat; — the former being a bird of 
prey, and the latter a domestic bird. .John Hunter brought a hawk to live on 
bread. If these changes be accomplished slowly, they may be well borne; but 
many cases of indigestion arise from persons suddenly changing their diet. It is 
mentioned that our countrymen who were prisoners under Tippoo Saib, were fed 
during their confinement upon nothing but rice, water, and capsicums; and on 
their return, when they were liberated, they of course ate as before. The sudden- 
ness of the change, even to their former diet of meat, produced violent diarrhoea. 
Very frequently persons suffer, in this respect, from a change of food; and even 
from a change of place; — from having different bread from that to which they have 
been accustomed, and different water from that which they formerly had. We see 
the effect of habit, ev-ery day; for the lower orders, without appearing to suffer 
from it, will eat such butchers' meat, and such fish, as would disorder the stomach 
of their superiors. 

3'Iost appropriate Food.— -There can be no doubt that, generally speaking, food 
is best composed of a mixture of vegetable and animal substances. It appears from 
the teeth, and likewise from the experiments made with the solvent juice of the 
stomach, that digestion is most likely to take place with facility, and in perfection, 
if the diet consist of a portion of animal and vegetable substances. In general, too, 
the food is much better digested, if a certain degree of art be applied in its prepa- 
ration, — the art of cookery. Some persons, with weak stomachs, require tliis art 
in full perfection. They do not digest things, unless they are thoroughly boiled, 
— thoroughly pervaded by heat, — either dry heat, or heat and moisture: and even 
then they require the addition of good spices. With regard to patients labouring 
under this affection, therefore, it is necessary to ascertain whether they have made 
any change in diet; whether the meat they eat is good of the kind; whether they 
eat a proper proportion of animal and vegetable f^ood; and that they do not eat 
things raw, which might be dressed. Many person, for example, have indigestion 
only when they eat articles not thoroughly cooked; and some persons digest every- 
thing, except raw vegetables, salad, and radishes. 

Superiority of some kinds of Meat. — In general, brown and old flesh is better 
digested than young meat. Mutton is easier of digestion, for example, than veal; 
and capon than a young chicken. In general, meat that is not particularly fat, is 
better digested than when it is; and lean is better digested than fat itself. Fresh 



956 DISORDER OF THE DIGESTIVE ORGANS. 

meat, loo, is usiiall}^ better digested than salt meat. Salt hardens tlie fibre, makes 
it more compact, and less easy ofsolution. Dr. Robinson addicted himself to tak- 
ing a vomit every evening; and he found that lie brought up veal undigested; but 
when he dined on beef, very liule remained; — sliowing that the latter is of more 
easy digestion than the former; — old flesh than young. With regard to fat, it is 
a curious circumstance that some persons who can digest but few things well, can 
digest a piece of broiled bacon thorongldy; and it is now the fashion to take broiled 
bacon, as a thing;' very easy of digestion. Mr. Cunningham, a surgeon, who wrote 
an account of New South Wales, states that he knew a person, in whom the 
smallest portion of the fat of beef or mutton deranged the stomach; and she was 
forced, before she could take gravy, to allow it to gel cold, and then have it skim- 
med, and warmed again; — so that not a particle of fat remained in it. Yet she 
could eat broiled fat bacon with impunity. 

Regulate the Quantity of Fluid. — Another point to be attended to is, not to 
take much liquid food into the stomach; — not to indulge in broths and slops; 
which are so much animal matter, with water into the bargain. It is better to take 
animal food in a compact form, than in a quantity of hot water; because, no doubt, 
this q^uanlity of liquid is injurious to the stomach. It dilutes the gastric juice; and 
(we must suppose) relaxes the stomach. It must both sodden it, and diminish its 
powers. Were there no other reason than that which I have just assigned, it 
would be wrong to drink too much liquid of any sort, — even beer, and tea. One 
of the best things to drink after dinner, is a cup of very strong coffee, without any 
milk. Some persons, however, are so stimulated by this, tliat they cannot bear 
it. But, in general, it is a good rule for dyspeptic people to limit their quantity of 
drink as much as possible; to take no slops or broth; and, in preference to drink- 
ing beer or water, to take a cup of strong coffee. With regard to vegetables, waxy 
potatoes are seldom well digested; and it is necessary that greens should be tho- 
roughly boiled; — that is to say, boiled vigorously in a large quantity of water. 

Btst kinds of Wine. — Many persons are much better without beer or wine; but 
some have a stomach so languid, that it requires the stimulus of wine. We can- 
not prescribe any particular wine. For some persons, Port is best; for others, 
Sherry; and for others, again, Madeira. With some people. Port turns acid, and 
with others Sherry; but, in a great number of cases, Sherry agrees best with the 
stomach. A mixture of wine is bad; and persons will frequently bear Port, 
Sherry, or Madeira alone, when they would be made ill by taking any two of 
them together. But some add beer to a mixture of wines; and then we may expect 
a treble commotion in the stomach. Some say, that if they take a glass of brandy, 
it settles all; — it is like oil poured on the sea in a swell. But we find that many 
persons have stomachs so susceptible, that no wine can be drunk; and, indeed, 
nothing but brandy and water can be borne. Burgundy, Champagne, home-made 
and all sweet wines, generally disagree with the stomach. Still we meet with ex- 
ceptions; and we may find cases where vomiting is slopped by Champagne. All 
Rhenish wines are sour, and likewise claret; and these usually ferment in the sto- 
mach, and become acid; and therefore they are improper. Generally one wine 
• only should be taken; and that which usually answers best is Sherry. 

Impropriety of Suppers. — It is well to prevent persons labouring under thi& 
complaint from eating suppers; unless they have had an early dinner. If people 
dine at one or two o'clock, it is necessary for them to take something in the even- 
ing. Now and then, we may meet with persons who are not so well without a 
good supper. They will lie awake from irritability brought on by exhaustion, 
unless they eat suppers; and tlierefore there is no rule for these th^ngs. There 
are general rules, — such as I have now mentioned; but we must never stand up 
for them universally. We must make exceptions; and adopt what we find the 
patient's constitution requires. 

Brown Bread. — It is very proper to advise some persons to eat brown bread, 
instead of white. Many persons will not be costive, if they eat brown bread; but, 
in others, it produces a degree of heartburn, and acidity. 



i 



DISORDER OF THE DIGESTIVE ORGANS. 957 

I^esf after Dinner. — It is almost always right to advise persons to remain quiet 
after dinner; for if tliere be much moving about, digestion does not go on so well. 
It is a common saying — 

" After dinner sit awhile!" 
and it is also said — 

" After supper ride a mile!" 

This is not to digest the supper; but because the person should eat so light a sup« 
per, that he may ride a mile afterwards, without doing himself any injury. 

We thus perceive that much may be done, in the way of curing disease of the 
digestive organs, without any medicine at all; — simply by discovering the cause, 
and removing il; and this cause is very frequently some bad habit. It is absurd 
in every case of affection of the stomach, immediately to order something. AVe 
should sit down, and learn the history of the case; — ascertain if the cause is beyond 
the stomach; if it has its seat in any other organ; what is the state of the intestines; 
what is the condition of the mind; whether the patient has been fasting too long, 
or eating too much, or taking something that disagrees with him. If it arise from 
any of these causes, we may cure the disease without any medicine; — may put the 
patient in possession of a plan, which will put a stop to his ailments. I am quite 
sure that, in the greater number of cases of indigestion, the disturbance arises from 
things forced into the stomach, from the state of the mind, or from some injurious 
habit which the patient has contracted; but it is necessary to attend to all the points 
I have mentioned, with regard to diet; for some persons have such weak stomachs 
that they require a particular line of conduct. Articles which produce indigestion 
in some people, will not give rise to it in others. 

Is there Inflammation? — We may perhaps, however, have to treat disease of 
the stomach itself. Independently of all external circumstances, — of things ex- 
ternal to the stomach, the stomach itself may be in fault. Having cleared the way 
so far, we should look out for gastritis. If we find a great sensation of heat in the 
stomach, and up the throat, and if we find the part tender on pressure, the case 
must be treated like any other inflammation. Leeches frequently applied to the 
pit of the stomach, moderate purging, and mild diet, are the suitable means. 

Frussic Add. — If we find no such marks of inflammation; — if the stomach 
suffers pain when food is taken, although there is no pain on pressure; or if the 
stomach vomits, — discharges its contents, and yet there is no pain or heat; — we 
may conclude that the case is one of morbid irritability; and, for the purpose of 
lessening this, prussio acid is one of the best remedies. In gastrodynia, it answers 
exceedingly well. If there be inflammation united with this spasmodic pain, we 
must remedy that by leeches; but if there be merely spasmodic pain, or a constant 
aching at the stomach, prussic acid often answers very well. It is best to begin 
with one minim three times a day; taking care not to give it on an empty stomach; 
for a dose that will be borne very well when the stomach is full, cannot be borne 
when it is empty. All agents affect the stomach most when it is empty; — when 
they come in contact with it; — when they are not mixed with its contents, and 
consequently not diluted, and only applied partially to the organ. If we give some 
doses before meals, and others afier it, it will not produce a uniformity of effect. 
It is be.^t to equalize the dose, by giving it after meals. We may begin with a 
minim; and, in a day or two, increase it to two minims, then to three, and so on. 
Tlie symptoms of an unpleasant kind which it produces, and which are sufficient 
to make us limit the dose, are sickness, faintness, convulsions, and a little pain in 
the head. We must tell the patient of these things, and guard him agninst their 
occurrence; — desiring him, if they take place, to diminish his dose of medicine 
immediately; — not to take so large a quantity again, but -a smaller dose. 'J'hen, as 
to the dose, there is no rule whatever. I had a patient, who could not bear more 
than the fourteenth or seventeenth of a drop without uneasiness; and I had another 
who said he took seventeen minims, three times a day; but he could not get beyond 
that. I have several times seen patients, who took eight or nine minims three limes 



95S DISORDERS OF THE DIGESIJIVE ORGANS. 

a day; and even thai is a large quantity. The dose that is usually borne, varies 
from two to four minims. 

Stramonium. — Hyoscyamus, conium, and strychnine, are given for the same 
purpose; but stramonium and opium, I think, are better than any of these. I think 
stramonium is the best; because opium confines the bowels; and that is injurious in 
these cases. I have seen stramonium cure this pain in the stomach (gaslrodynia). 
There is no rule for the dose of this medicine; but it is well to begin with half a 
grain, two or three times a day; and gradually to increase it, while there are no 
unpleasant effects. These effects are pain of the head, convulsions, and giddiness; 
and if the remedy be given incautiously after these begin, we may have drowsiness, 
violent pain, violent throbbing of the temporal and carotid arteries, and sometimes 
thirst, and great dimness of sight. If the two latter symptoms are not considera- 
ble, the patient may bear them; but if convulsions, giddiness, and pain of the head 
be induced, it is well to omit the remedy immediately; and then to give a smaller 
quantity. With regard to the feeling of morbid irritability, that is much better put 
a stop to by prussic acid, than by stramonium. I have frequently seen it stopped 
by the first or second dose; but I think that the gastrodynia, — the aching of the 
stomach, is best relieved by stramonium. Prussic acid answers very well; but I 
have seen it fail, where stramonium cured the case with facility. 

Conium; Opium. — Next to stramonium, conium answers very well; but very 
frequently it requires to be given in increased doses, — up to ten, fifteen, or twenty 
grains, three times a day. Opium is also proper in these cases, if the patient's 
bowels are relaxed, and we are anxious for the medicine to have a double effect. 

Bismuth. — The trisnitrate of bismuth has been used to lessen gastrodynia; and, 
no doubt, with good effect. The Unguentum Antimonii Potassio-Tartratis has also 
been employed. It is well, in these cases, to give but a small quantity of food at 
a time; for the stomach, when much distended, falls at length into a spasmodic state. 
The more distended the stomach is, the greater effort does it make to contract, and 
the greater is the spasm; and therefore a small quantity of food is proper. 

The symptoms of morbid irritability of the stomach may be united with gaslro- 
dynia, and we must remember that the morbid irritability may, at different times, 
amount to inflammation; so that the remedies which, in the first place, were calcu- 
lated to relieve it, will no longer do so; and the remedies for inflammation must be 
employed. We are never certain, from day to day, whether the symptoms depend 
upon inflammation or morbid irritability. Occasionally we have to apply leeches, 
and the remedies proper for inflammation; at other times, those that 1 have now 
mentioned; and frequently we have to employ both; for there may be a degree of 
tenderness; — but more pain than tenderness; — so as to render both plans proper. 
Frequendy prussic acid and conium are improper; the remedies for inflammation 
being required. In other cases, the remedies for inflammation are improper; — ll.e 
patient requiring narcotics; and, again, there are other cases, where both plans are 
proper. 

Aromalics and Stimulants. — We may have another condition of the stomach; — 
where there is no gastritis,- — no inflammation, — no morbid irritability independent 
of inflammation; but where the stomach is torpid. Some persons have what is 
called " a cold stomach." They can digest their food, if they take brandy and 
cayenne pepper. Now in indolence of the stomach, aromatics are generally good; 
— mustard and cayenne pepper; and with regard to medicines, ether, camphor, 
fetid substances, and ammonia, will be found useful. Dr. Baillie says that where, 
in disorder of the stomach, a quantity of viscid mucus is discharged, the compound 
tincture of benzoin is an excellent remedy; but where there is pain on pressure, I 
would not give such a stimulating medicine. 

In disorders of the stomach, it would be absurd always to tell patients to abstain 
from wine, and to take nothing rich; for some persons digest better if they take a 
few spiced articles, and a few glasses of wine, — perhaps even a pint. Some must 
have wine, and even spirits. In some cases of this description, the application of 
galvanism to the epigastrium has been found very serviceable. In this weakness 



WORMS. 959 

and torpidity of the bowels, tonics, of various kinds, are useful; — especially iron; 
and particularly Ferri Ammonio-Cliloridum, which is one of the most stimulating 
preparations of iron. Bitters are useful; and to these, people often add soda: which 
is a good stimulant. Acids, as well as tonics, have been found useful; and they are 
often the best remedy for acidity; for they destroy that state of the stomach which 
gives rise to it. Nothing can be worse, in these cases, than for people to vomit 
and purge themselves, as they frequently do. It must weaken the alimentary canal. 
It is right to enjoin plenty of fresh air. Patients ought to avoid confinement; to 
have exercise short of fatigue; and constant pleasurable occupation, without care. 



CHAPTER X. 
WORMS. 



It has been said that nature has provided every animal with other animals to 
prey upon it; — to make a habitation of it, and derive food from it. It is even said 
that a flea has its flea; and if so, I suppose, the latter would have its flea's flea. 
How far this matter goes, it is impossible for me to say. 

Divisions. — Some of these animals evidenUy come from without, and perhaps 
exist but temporarfly; and these are called " ectozoa;"^ whereas those that colo- 
nize, establish themselves, breed a posterity, and become whole families at last, 
are termed "enlozoa.'"' 



SECTION I.— ECTOZOA. 

As instances of ectozoa (those which reside upon the skin) I may mention fleas, 
lice, bugs, and other delicate little animals. But we have also others which reside 
ivithin: some getting into the anus, some into the maxillary sinuses, some into the 
stomach and intestines, some into the biliary ducts, and some into the cellular 
membrane beneath the skin. I had a patient (an infant) who discharged about a 
dozen larvae (maggots) of the common fly, all alive. The child had suffered from 
a chronic cough; but as soon as these dozen larvae were discharged from the intes- 
tines, it lost its coui^h. I saw them myself in the napkin, — moving about in the 
faeces; — exacUy as if they had never been in the body. I understood that it had 
eaten part of a high pheasant, some months before. I have had two cases, in which 
a live caterpillar was discharged from the intestines. One of these cases occurred 
in a woman who was in the habit of eating cabbage-stalks, when site washed them 
for dinner. The moth lays its eggs on cabbage-stalks; and no doubt this patient 
has swallowed some of the eggs; and it so happened that one of them was hatched. 

Dr. Good, in his work on Medicine, gives an account of a flesh-fly (the "musca 
cibaria"), or rather the larva of it, being discharged by means of purgatives, after 
producing considerable derangement. The larva of the bee, and even live spiders, 
have been discharged downwards, from the alimentary canal, by human beings. 
Even the " triton palustris" and the ''lacerla aquatica" (the domestic and the 
/ior.se-leech) have been discharged by vomiting, and have been found in the sto- 
mach. Leeches, when they get into the stomach, will sometimes (from sucking 
the blood) attain so large a size as scarcely to be recognized. When soldiers have 
been encamped on marshy ground, it has been found dangerous for them to go to 

■ From ^Mo,, animals; and sjitoc; wi/houty or outside: 
^ From ^va., animals; and evtoj, wilhin. 



960 WORMS. 

sleep; lest leeches should get into their mouths and destroy them. Life has been 
lost from leeches crawling down the oesophagus into the stomach, sucking blood 
there, and producing fatal haemorrhage. 1 once saw two centipedes, said to have 
been vomited by a girl twelve years of age. There was no reason to suppose that 
any deception was practised. She vomited them; and the vomiting was attended 
by a tightness in the throat. The animals had lived three days when I saw them. 
The mother said that, two months previously, the girl had vomited a black beetle. 
She had palpitation of the heart, pain, and heaviness of the head. 

Dr. Duncan, in the ninth volume of his " Medical Commentaries,"'* mentions 
the case of a boy, who discharged four caterpillars after a dose of calomel. It is 
said that several crawled out at the anus afterwards; and, on exhibiting calomel 
and jalap, an incredible number came away. He likewise discharged a lumbricus. 
It was ascertained, that he had frequently gone into the garden, and eaten a young 
cabbage-leaf; — ^just as I ascertained that the woman ate the stalks of cabbage, when 
preparing the latter for dinner.'' I should not have paid much attention to these 
accounts, if I had not myself witnessed similar effects. I have no doubt that some 
persons are the sport of these insects; while in other persons they would die. In 
*' Hufeland's Journal," for 1822, there is an instance of live and dead slugs being 
discharged by vomiting and purging. In the " Medical Gazette," Dr. Alderson 
(of Hull) states that a centipede was discharged from the stomach;'^ — exactly as 
occurred in the case that I saw."^ 

Horses have what are called " bots" in the stomach, if they swallow the eggs 
of the common gad-fly. The gad-fly, at a certain period of the year, lays its eggs 
upon their coat; they lick their coat, and swallow the eggs, which attach them- 
selves to the splenic portion of the stomach. I suppose all this is natural; for I 
believe they are often found in the stomach of horses. Nature appears to have 
destined this place for their reception. When they are mature, they escape 
through the intestines, and become gad-flies. 

Numerous instances of severe headaches have arisen from insects getting into the 
nostrils, and crawling into the frontal sinuses; and also from their getting into the 
" meatus auditorius." Nothing is more tormenting, I understand, than " a flea in 
the ear." If it get into the ear, it buzzes about, and makes as much disturbance 
as a giant would; but this state may be cured in a moment. I recollect the case of 
a patient of my own, who had been in the greatest agony from this circumstance; 
but on pouring a teaspoonful of oil into the ear, the flea was quiet in a moment. I 
suppose it was suffocated. There is a kind of gad-fly which settles in the rectum; 
and it is therefore called " Eestrus hssmorrhoidalus." It has been found to make 
its way even into the womb. There is one kind called "aestrus ovis;'' — from its 
always selecting sheep. The guinea-worm comes from without, perforates the 
skin, lies for a considerable period in the cellular membrane under the skin, and is 
the source of very troublesome ulcers. 



SECTION II.— ENTOZOA. 

Their usual Situation. — As to those animals which settle regularly in the hu- 
man body, colonize, and descend from one generation of human beings to another, 
they are found both in cavities and in the substance of the body; and each of these 
"entozoa" has its particular habitation. The one called "lumbricus," always oc- 
cupies the intestines or stomach; the one called "strongyle," particularly fixes on 
the uterine organs; the one called "fluke," is found in the liver; and the "filaria," 
or "guinea-worm," is found in the cellular membrane. There are three principal 
forms of these animals, found in the living body. Those of one set are rounds — 
in cylinders or spindles; those of another set are flattened, like bobbin; and those 

» Page 223. ^ See Page 959- 

c See the " London Medical Gazette;" Volume 5; Page 306. (No. 105; December 5, 1829.) 

•• See the Previous Paragraph. 



WORMS. 961 

of the third set are globular or vesicular. It is the latter that are chiefly found in 
the substance of organs. 

Classification of Entozoa. — Linnaeus arranged them according to their situa- 
tion; — accordingly as they were found in the intestines, or in otiier viscera. Ru- 
dolphi (the naturalist) of Berlin, names them from their form; and arranges them 
into five classes. The first of these he terms "nematoidea."* He has a second 
class, which he calls "acanthocephala.'"" These are animals of the hydatid kind. 
They have no spinal canal; have distinct genital organs; are of two sexes; and are 
found only, or chiefly, in the intestines of swine. Then he has a third class; 
which is called "treraatoda."*' These are flat, with minute pores. It is said that 
these have no intestinal canal; but distinct genital organs. 'The fourth is " ces- 
toidea,'"' which include the diflerent kinds of the "taenia," or "flat worm;" and the 
fifth he calls "cystica."^ These are " hydatids." 

Cuvier makes more simple classes than these. He arranges, in separate classes, 
those which have a distinct digestive cavity, and those which have no distinct 
digestive cavity to be traced in the interior. Those of the first are called "cavi- 
taires;" because they have a digestive cavity; — regular canals and an anus; and 
those of the other are called " parenchymateux;" because they have nothing but a 
uniform structure, with no regular digestive tubes. This last class embraces all the 
classes of Rudolphi except the first; and those which have a regular digestive 
apparatus comprehend the round worm, the little ascarides, the strongyle, and the 
guinea-worm; and therefore, instead of the ^ye kinds of Rudolphi, Cuvier makes 
hnifour. 

Jlscaris Lumhricoides. — I will begin with the "cavitaires;" or, according to 
Rudolphi, the "nematoidea." The first of these was formerly termed " lumbri- 
cus;" but it is now termed "ascaris lumhricoides." This worm has external in- 
teguments. It has also muscles, a digestive apparatus, and a genital apparatus; 
and some have thought that it has a circulating and a nervous system. The mus- 
cles of this worm lie immediately under the skin. The fibres are two-fold; — both 
long and transverse. The digestive organs are quite straight. It has a triangular 
mouth, with three tubercles; the anus is at the opposite end; and the genitals fill a 
great part of the animal. Each sex is a diflferent individual; and the opening of 
the genitals is near the anus. It is from twelve to fifteen inches in length; is of a 
yellow colour; and as many as eighty of them have been discharged from one in- 
dividual. The celebrated professor Frank mentions a case, in which the intes- 
tines were absolutely crammed with them. 

Situation. — This worm is usually found in the small intestines. Occasionally 
it is found in the large ones, in the stomach, the oesophagus, the pharynx, and the 
mouth; — for I have known a person vomit one; but its proper habitation appears 
to be the small intestines. Andral says that he found a lumbricus in the pharynx. 
It got out of the small intestines into the stomacli; from the stomach into the pha- 
rynx; and then one end turned down into the larynx, and there caused sudden 
death by sufl'ocating the patient. Andral also saw several in the liver; — having 
apparenlly crept up the " ductus communis choledochus," from the duodenum. 
Dr. Baron, of Gloucester, mentions having seen a lumbricus in the ductus of the 
liver; and an old physician, who wrote on Morbid Anatomy, mentions having seen 
several worms in that situation. Andral says that he saw a liver absolutely perfo- 
rated with them; and sometimes they have perforated the intestines, and got into 
the peritonaeum. They have sometimes been known to escape externally through 
the integuments; or into the urinary bladder, or into the vagina. 

It resembles the Earth-worm. — This animal resembles the earth-worm; but the 
earth-worm is found to be less pointed; its mouth is only a small slit at the under 
part of a rounded head; and the anus is not near the extremity, but at the very 
extremity. The earth-worm is more flcshy, and more marked with ruga;; and it 

« Fromv>i,ua, a i/iread; and siht;, form. *> From axavSa, a prickle; and xe<f>aX>i, the head. 

c From T^'rjjOtit, an aperture; and u^o^fform. <* From uss-roi, a girdle; and u^o;,for7}i. 
«* From XU3-T/?, a bladder; and iiloq/forra. 
VOL. I. 31 



962 WORMS. 

lias one most distinguishing circumstance, — a quadrangular row of processes, like 
feet; which it can erect and move about. It has also three longitudinal lines at the 
upper surface; and it is an hermaphrodite. The "ascaris lumbricoides" is by far 
most common in children; and is rarer as people grow old. 

Trichocephalus. — The next worm, in point of size, is that formerly called *'tri- 
churis;"* sometimes improperly termed "the three-tailed worm." Unluckily our 
predecessors mistook the head for the tail, and it is now called "trichocephalus."" 
It is a very small worm; — about one inch and a half, or two inches, in length. It 
is of a violet-colour; and the anterior end is much finer than the posterior; — it be- 
comes a mere point for the mouth. The posterior end of the male is bent; and it 
has a straight alimentary canal, around which are placed the organs of generation. 
This worm is found lower down in the alimentary canal than the last; for it occurs 
chiefly in the cascum. There are generally several of them. It is much more 
common in infants, than in others. 

Oxyuris, — Another worm which has also an alimentary canal, is the "ascaris;"" 
or, properly speaking, the "oxyuris,"* or "drop-tail." This passes, with the 
common people, under the name of "thread-worm." It lives as low down as it 
possibly can in the rectum, and frequently makes its exit; and when it once gets 
out, it cannot get back, but shrinks up and perishes. It is far shorter than the 
others. The male is said to be about a line and a half in length; the female four 
lines. The organization is the same as in the other two kinds. It is not only 
usually found in the rectum; but it is generally surrounded by mucus. These 
worms will crawl out; and patients sometimes amuse themselves by seeing how 
many they can catch during the night; — in order that they may show their ex- 
ploits to the doctor, in the morning. I have known them to crawl out of old per- 
sons; so that they have complained that they picked tliem off their thighs in bed. 

Parenchymateux. — Worms of the other description (called " parenchymateux" 
by Cuvier^) have no digestive or other perceptible organs, except instruments of 
locomotion. They have various forms; some are spheroidal, some flat, and some 
long. They are the "acanthocephala," — with two points; the " trematoda," — 
■with a perforation; and the "cestoidea," including those of which I am now going 
to speak, — "taeniae." These are found in the substance of the body, and* in vari- 
ous cavities. Lastly, there are those which are called "hydatids" ("cystica"), 
and which are very frequently found in die substance of the body, but occasionally 
in its cavities; and sometimes they have a particular cyst. 

Tsenia. — I will now proceed to that worm, which we meet with every day in 
the living subject; and which is called " tsenise"^ This animal is never less than 
several feet in length; and sometimes many yards. One author mentions a worm 
of this kind which measured one hundred and fifty feet; and another foreign writer 
saw one three hundred feet long. Though I never saw one so long as that, yet I 
have frequendy seen seven, eight, or ten yards, come away at once. It is fine in 
structure, and has a series of articulations, — each with natural pores. Dr. Baillie^ 
says, that the last joint has no aperture. The anterior part of the worm is very fine; 
the head is square; and it has litUe retractile hooks. There is no regular organiza- 
tion within; — that is to say, there is nothing leading to a digestive tube. It is 
almost a mere amorphous mass; yet we may feel arborescent vessels about the 
joints; and a serpentine canal is sometimes seen at the edges. It moves in an 
undulatory manner. 

Varieties. — There are two kinds seen; — the one called " taenia solium;''^^ and 
the other "taenia lata.^^' That which is called '■'■tsenia solium''^ is, towards the 
head, about the third of a line broad; and has crotchets before and on each side of 

a From 0j(^, a hair; and ov^a, the tail. ^ From O^i^, a hair; and ■A.t^a.Xn, the head. 

« From aiTXBao, to move about. ^ From o\uq, sha^rp; and ov^a., tail. 

« See Page 9G1. f From rama, a fillet. 

g In his " Morbid Anatomy:" Chapter 8; Section 13. 

* From " solus," alone; because it usually infests the body singly. 

i From " latus," broad. 



woRM^. 963 

the articulations. On this account it is sometimes called *' «rmerZ (fenia." The 
other, which is called "taenia lata,''' is shorter and broader; and hns no crotchets. 
The latter usually exists in cavities, — three or four in an individual; and fronn 
twelve to fifteen feet long-. 

Most frequent in Adults. — The "tape-worm" is Tar more frequent in adults, 
than in children, and in the dog than in the human subject; but it is said that in 
the dog, and in other brutes, it differs somewhat from that observed in the human 
subject. It is more common in some countries than in others. In Switzerland, 
the water is very bad; and the " taenia soliunC is very common there. The 
" taenia lata'''' is not so common. 

Strongyle. — One kind of worm is found in the bladder; and this is called the 
^^ strongy'le.^^ The late Dr. D. D. Da-vis, of University College, London, once 
showed me a phial containing a large number of them, — all creeping about in full 
animation, — which came from the bladder of a female. She had discharged a large 
quantity of them, for a considerable time. Mr. Lawrence has described a curious 
case of this kind, in the second volume of the "Medico-Chirurgical Transactions."* 
In that case, from eight hundred to one thousand of these worms were discharged 
from the bladder in about a year. They were very hard and firm: and some were 
an inch in length. These worms cause great irritation, a frequent desire to make 
water, and sometimes bloody urine. In the fifth volume of the " Edinburgh Medical 
Essays""* (which is a very excellent work), there is an instance of one an inch in 
length, and as broad as the smallest part of a needle. It was discharged, after hav- 
ing produced bloody urine for many years. What could be done in a case of this 
description, I do not know. Whether turpentine given by the mouth would answer, 
is doubtful. It would find its way to the urinary organs, because it impregnates 
the urine; but whether in sufficient quantity to destroy the worm, I do not know. 
Whether it would be right to inject the bladder, I cannot tell; but first I should try 
an injection of olive oil; — ^just as I should kill a flea in the ear. Whether these 
worms are formed in the bladder, or come from the kidneys, I do not know. The 
point is not yet determined. 

Causes, — It is probable that a great number of those worms which I have now 
been speaking of as "entozoa," really came originally from without. Many per- 
sons, on going to particular places, have presently become subject to worms; — ^just 
like other people in that particular neighbourhood. Persons who, by accident, 
have drunk bad water, have frequently had worms from that time. There can be 
no doubt that " taeniae" may be continually traced to external sources; and with 
respect to "ascarides," a remarkable case is published" in the Second Volume of 
the "Transactions of the King's and Queen's College of Physicians in Ireland;'"^ — 
a case in which a whole family was infested with this worm; and every servant who 
came to the house, after a certain time, had it. Although medicines were taken, 
yet nothing liberated these persons from it; and at last ascarides (very similar, but 
a litde browner) were discovered in a well, from which the people derived all 
their water. The family had resided there many years, but they now found it 
necessary to change their habitation; and, from that time, nearly all of them lost 
their worms. The race was kept up in one individual. Dr. Darwin mentions that 
the fens of Lincolnshire are famed for taeniae. Sir John Pringle says, that lum- 
brici are very common in the remittent fevers of marshy countries; and that when 
they have been once introduced, it is impossible to say how long they may remain. 
They may continue for many years. It appears to be a fact, that they may be 
transmitted from generation to generation. A German writer (of authority) says, 
that he actually found worms in the intestines of a foetus. This is not at all sur- 
prising; for the germs may be easily transmittted from the mother to the offspring. 
Lamarck, the French naturalist, has found the same thing. Taeniae have been seen 
in a muddy spring; only they were rather smaller than those observed in human 

"Page 382. •» Page 289. 

•^ By Dr. John Miller Barry. * Page 390. 



964 WORMS. 

beings. The lower animnls are easily alteretl by particular circumstances; and 
tlierefore it is not surprising- that ascarides should be of a different colour and size 
in tlie body, and out of it; — in wells and in the living Rubject. I recollect being 
told by a frientl, who had travelled a great deal in Syria, that he drank some bad 
water, and was exceedingly ill for a week or so. He did not know what was the 
matter with him; when, all at once, after taking a good dose of calomel, he dis- 
charged litde more than a heap of small maggots. What they were, he was not 
naturalist enough to inform me; but he got well; and his illness could be traced to 
this external circumstance. Taeniae may come from without; and so, it would 
appear, may ascarides; as well as, in all probability, the "ascaris lumbricoides." 

Debility favourable to their Presence. — Generally speaking, these worms pre- 
vail more especially in proportion as the patient is weak. We know that persons 
who are exhausted from fever, will become tlie subjects of vermin. In extreme 
debility of the constitution, a patient may be cleaned several times a day; and, be 
covered with a fresh crop of vermin. So it is, in general, within. The more 
weakness there is of the body, the more the entozoa thrive. Bad air, bad food, 
and the want of sun, will contribute to their appearance. When rabbits are kept in 
a bad place, they become subject to hydatids; as do also sheep in wet pastures. 

Spontaneous Cessation. — There can be no doubt that children are much more 
disposed to ascarides and to lumbrici, than other persons are; and not only so, but, 
as age advances, the constitution frequently becomes so unfit for the continuance of 
these worms, that they are absolutely shaken off without any medicine. I feel no 
doubt that children cease to become the prey of worms. Thousands have ascarides 
when they are young, and never have them afterwards. This is not so common an 
occurrence with regard to lumbrici, as with regard to ascarides; but the remark is 
correct there, to a certain exient. The early period of life seems to favour these 
animals; — why, I do not know. Some of these worms occur in persons of the 
highest health. Persons with a good colour complain of worms; and they will be 
able to verify their assertion. 

Symptoms. — Worms sometimes produce the most distressing effects;— so as to 
make life a burden. At other times, they produce no symptoms at all; and a per- 
son oidy knows that he has worms, because he discharges them. I have seen many 
individuals who, to their great astonishment, discliaj:ged several feet of tape-worm; 
— not having had the least idea, previously, that there was any thing the matter with 
them. 

In enumerating the symptoms, I will begin with the head, and go downwards; 
— for the sake of assisting the memory. When worms exist in the alimentary 
canal, the symptoms usually are headache, heaviness, giddiness, depression of 
spirits, and even convulsions. Sometimes the headache is sharp; sometimes it is 
dull; and frequently there is a stabbing of the temples. Perhaps there is regular 
epilepsy; and some authors even mention tetanus. There is a black circle around 
the eyes; paleness of the far^e; more or less tumidness of the upper lip; great itch- 
ing of the nose; foulness of the tongue; thirst; offensiveness of the breath; palpita- 
jLion; dyspnosa; cou^jh; and even haemoptysis. Then (to go below the diaphragm) 
we have either anorexia, or excessive appetite; nausea; vomiting; a gnawing pain 
at the '^scrobiculus cordis;" pain, perhaps all over the abdomen, or in various parts 
of it; griping; purging; itching of the fundament and genitals; a discharge of mucus 
from the rectum; feverishness; and emaciation. The pain of the abdomen is some- 
times 1^ pricking pain; and there may be tenderness of it. Of course, we do not see 
all these symptoms in every case; and sometimes worms will exist in the alimentary 
canal, without giving rise to any symptoms whatever. 

Treatment. — As to getting rid of worms, in the first place, any brisk purgative 
may answer the purpose. A good dose of calomel and jalap is an old remedy, and 
a very excellent one. Sir John Pringle used to give twelve grains of calomel, and 
half a drachm of rhubaib. Some give gamboge; but I do not know its specific 
power. It produces nausea; and is not so good as calomel and jalap. 

Oil of Turpentine. — But besides these remedies for the expulsion of worms, we 



WORMS. 965 

employ others for the purpose of destruclion; and one of the best is, unquesiion- 
ably, oil of turpentine. In the case of ascarides, — which are easily l<no\vn from 
their crawling out, from their appearinjr in the stools, and from the extreme itcliing 
which they cause in the rectum, — it is best to give the oil of turpentine by injection. 
We thus send it immediately on the parts where the worms reside; save the patient 
the unpleasantness of a filthy dose; and save the stomach from great disturbance. 
From a drachm to half an ounce, mixed with gruel, may be given to a child; and 
it will often bring away thousands. Adults will take a larger dose in an injection; 
— an ounce or more; but perhaps a very large dose is not so well. It cans, s so 
much irritation, that it may produce an immediate expulsion. It may not lie long 
enough to kill the worms; but may be discharged from the intestines. In the case 
of other worms, the oil of turpentine should be given by the mouth; and the dose 
is then from half an ounce to three ounces. In females, half an ounce is generally 
a proper dose to begin w^iih; and it is seld m right to give more than an ounce; 
but in men, if they be not particularly delicate, it may be right to give two ounces. 
It is best not to give it fasting, lest it should create sickness, and be lost. Patients 
had better take it a couple of hours after some meal; and they ought to remain per- 
fectly quiet; — lest vomiting should be induced. It may be taken pure; — in the 
same way as a glass of spirits; or in gruel, or in any thing else which the patient 
chooses. The effect it generally produces, is that of making the patient sick, 
purging him violently, making him giddy, and causing extreme vertigo. These 
symptoms w^ill all go off; but occasionally the medicine will not purge itself away; 
and therefore, it is best to give a dose of castor-oil; and to repeat it every hour or 
two, till the medicine passes freely. It rarely affects the urinary organs; but some- 
times it does. Now and then we have bloody urine, a frequent desire to make 
water, and great pain; but, in general, these effects do not occur; and when they 
do, there is usually an idiosyncrasy; and they will occur from the smallest doses. 
Large doses usually w^ork themselves off; but where they do not, I have seen these 
effects. Where the remedy does not produce irritation, it has been absorbed; and 
the urine has smelt strongly of it, for some days. 

History of the Use of Oil of Turpentinp. — The history of our knowledge of 
this medicine is rather curious. So far as I have read, it appears that its use, in 
the cure of w^orms, was first mentioned in 1792, by a general practitioner at Putney, 
named Maiden.* A man had been long accustomed to pass tape-worm; and a friend 
advised him to take oil of turpentine. He took two drachms; and, to his great 
astonishment, discharged five yards of tape-worm, and several pieces afterwards. 
At the time Mr. Maiden WTote, which was three years and a half afterwards, he 
was quite well. This fact w^as lost sight of, — not in the least attended to, till a 
paper was published, in 1811, in the " Medico-Chirurgical Transactions,'"' by a 
physician at Durham." It gives an accounf^ of a sailor, who had been in the habit 
of taking gin to expel a taenia; but at last it failed; and he took a glass of oil of 
turpentine; — thinking that that was stronger. It was quite successful. What is 
very ^'urious, after this paper was written. Dr. Walker, in 1817, published a paper 
in the "Transactions of the London Medical Society,^ in which Mr. Maiden's 
account was contained;* and claimed the discovery of the remedy. The circum- 
stance was forgotten; and the Society allowed the second paper to be published. 
Oil of turpentine is one of the best remedies that we have. It will expel all sorts 
of worms; — ascarides, lumbrici, ttenife, and all the others. Occasionally it w'ilL 
fail; but we should give it in large doses, and take care that it finds its way out. 
We should follow it up with a dose of castor-oil every two hours; otherwise the 
patient may be brought into some datiger. I have seen a degree of danger produced 
in a child, from inflammation of the intestines cominor on; but it w^ent awav in a 



a See " Memoirs of the Medical Society of London;" Volume 4; Page -il9. 

"• Volume 2\ Pa2:e 2-1. <= Dr. Jiihn Ralph Fen wick. 

* At Page 25. " « See Volume 1; Pari 2; Page lU. 



966 WORMS. 

few hours. The oil of turpentine has been particularly used in the case of tape- 
worm in the intestines; but it is equally good in the case of other kinds of worms. 

Dolichos Fruriens. — The " dolichos pruriens" (" cowhage" or "cowiich") 
has been used, particularly against the lumbriei; and the best account I can give of 
that remedy, is to be found in a work, written some years ago, by a general prac- 
titioner of the name of Chamberlain." The pubes, or small spicu'lse of the doli- 
chos, are scraped off, and made into an electuary with treacle, or confection of 
senna; and. the electuary may be given in almost any quantity. As good a mode 
of exhibiting it as can be adopted, is to thi(;ken it to a proper consistency with 
treacle; and to let the patient take a tea-spoonful of it, two or three times a day. 
We should occasionally give a purgative. 1 have found the oil of turpentine so 
efficacious, that I have not had much recourse to " cow-itch." A woman, at St. 
Thomas's Hospital, took a drachm of the pubes of dohchos, twice a day, for five 
days; and afterwards a purgative was given to her. The only inconvenience which 
my patient experienced, was a tingling in the mouth; but when it had once got into 
the alimentary canal, no further unpleasant symptom arose. 

Pomegranate-Root Bark. — The bark of pomegranate-root has also been par- 
ticularly recommended. Half a drachm may be given every half hour, till vertigo 
is produced. A good account of this is given, in the eleventh volume of the 
" Medico-Chirurgical Transactions.'"' It has the effect of producing giddiness, 
sickness, convulsions, pain in the hpad, and purging. There is no rule for the 
quantity that will produce these effects; and therefore it is well to give half a 
drachm of the powdered bark, in some water, every half hour, till the patient 
begins to feel sickness, or is purged. It is for the taenia that this is particularly 
recommended; and there can be no doubt of its virtue. These are the only things 
with which I am practically acquainted. 

Other Remedies. — Steel-filings have been mentioned; and a woman once look 
an ounce and a half in a day. 'J'hey purged off with a cathartic; but without any 
sensible effect whatever. A number of medicines are recommended in books on 
Materia Medica. The bark and shoots of the "bastard cabbage-tree," and of the 
fern, have been particularly spoken of as a remedy for taenia. Indian pink (which 
is an acrid narcotic) has undoubtedly been useful. In the first volume of the 
"Transactions of the College of Physicians in London, "•= is recorded'' the case of 
a man who look two pounds of common salt, in four pints of water; and, by that 
means, got rid of an immense number of ascarides. It is well known that salt is 
rather a preservative against worms. The flukes which are found in sheep come, 
it would appear, from stagnant water; and it is said that, by given the sheep plenty 
of salt, we may prevent them from becoming the victims of fluke. Electricity has 
been employed, — the passing of shocks through the abdomen; and now and then 
a worm has come away. It has been rendered uneasy, and has endeavoured to 
escape. 

Restore the General Health. — But besides those means which are necessary to 
expel the worms, it is of the highest importance to restore the health. There can 
be no doubt that worms derange the health; and if we can get rid of them, health 
will return. But tiiey are frequently present on account of bad health; and there- 
fore, thougli it is necessary to expel them by common purgatives (which often 
answer very well), we must, at the same time, endeavour (by all the means in our 
power) to restore the health; to take care that the patient has wholesome food, and 
to put the digestive organs into the best possible order. If this be done, worms 
will frequently disapj)ear, without any other means being employed. Without 
g ving any purgative medicinesvvhatever, — v/ithout doing any thing to expel or 
(Ijstroy worms, in a great number of cases wliere children have become their prey, 

a "Treatise on ihe Efficacy of Cowhagc, in Diseases occasioned by Worms, &c. By 
William Chamberlain," 
»> Pa^e 301. <> At Page 54. 

^ Ey Dr. William Heberden, 



WORMS. 967 

they will spontaneously cease. Children are far more subject to ascarides and 
lumbrici than adults; and a great number of children have them at a particular time; 
but as puberty arrives, the constitution is less favourable as a habitation for worms; 
and they cease spontaneously. Most of us have been freed from worms spontane- 
ously; although they may have been a great torment to us at the younger period of 
life."' 

Entozoa originally Ectozoa? — Before concluding the subject of these worms, 
T should state that we are not quite certain with regard to some of these, whether 
they deserve the name of "ectozoa" or "entozoa." Those that reside and breed 
within ("entozoa") have particular residences. Some invade the alimentary canal 
generally; and others reside in particular parts of the canal. The same thing has 
been observed with respect to those which reside on the surface. Whether they 
have an external origin or not, we are not quite certain. Then, again, there are 
some vermin (small lice) which live only in the head; and it is said that they will 
not thrive anywhere else. There are others which live only on the body; and it 
is said, that if we put them into the hair of the head, they die. These have been 
vulgarly named " crab-lice;" but scientifically they are called " pediculi pubis." 
They thrive only on the pubes. 

Chigoes. — There is a particular kind of flea, — very large, — a sort of giant, — 
which passes under the name of " chigoe." This is found particularly among the 
negroes, and is a source of great trouble to them; for it is so powerful, that it gets 
under the skin, and there burrows, and forms a bag, in which it lays its eggs; — the 
result of which is a very troublesome ulcer. I had a patient at St. Thomas's Hos- 
pital, who had lost the nail, and the extremity of each great toe, through chigoes. 
There was a cicatrix running across the toe; which cicatrix had been occasioned 
by this animal. The negroes are very expert at taking them out, in whomsoever 
they occur. The great point is to remove the bag entirely; for if any part remain, 
an oozing occurs, and no good is done. There is a story told of a person, who was 
anxious to have it put to the test, whether chigoes were a particular sort of flea, or 
only a variety of the common kind; and he therefore let one which had got under 
the skin, go on burrowing; in order that he might observe its increase and habits. 
The consequence was not only a troublesome ulcer, but mortification. A gentle- 
man, who has been much in the West Indies, is of opinion that that kind of ele- 
phantiasis which is called " Barbadoes-Leg,"^ — in which the skin becomes exceed- 
ingly hypertrophied, — and that disease of the scrotum in which the skin and the 
subjacent cellular membrane are excessively hypertrophied (just such a case as 
occurred in the Chinese at Guy's HospitaP), all arise from chigoes. Whether he 
is right in his opinion, or what grounds he has for it, I will not pretend to say; 
but he is a man of very careful observation." 

^ See Page 471. 

* This refers to Hoo Loo, an unfortunate Chinese; who came over to this country, ex- 
pressly to have a large tumour removed from the scrotum. The operation was performed 
at Guy's Hospital- but the patient did not survive. An account of this case will be found 
in the " Lancet," for April 16, 1831 (No. 398; Volume 2, 1830-1; Page 86). Mr. Liston 
has, in his Museum, an enormous tumour of this kind, which he removed successfully. 

'^ The late Dr. Fletcher, of Edinburgh, with the view of assisting the raemorv, used to 
include in a table all the parasitic animals (twelve in number) to which the human body is 
liable. We give this table below. The nomenclature adopted is that of Rudolphi; but we 
have added a few S3^nonymes. 

L Cystica (Hydatids). 

1. Cysticercus Cellulosus (Bladder-tailed Hydatid). 

2. Eehinococcus Humanus (Acephalocysl). 
II. Nematoidea (Cylindrical Worms). 

3. Hamularia Subcompressa. 

4. Ascaris Lumbricoides (Lumbricus). 

5. Trichocephalus Dispar (Trichuri> Vulgaris; Long Thread- Worm). 

6. Oxyuris Vermiculnris (Ascaris Vermicularis; Thread, or Maw-Wormj, . 

7. Sirongylus Gigas (Urinary Worm). 

8. Filaria Medinensis (Dracaneuius; Guinea-Worm, or Hair-Worm). 



963 WORMS. 

III. Trematoda (Tntermediate "Worms). 

9. Dystoma Hepaticum (^Fasciola Hepatica; Fluke). 

10. Polystoma Ping^uicola (Fat-Wormj, 

IV. Cestoidea (Tape-Worms). 

11. Boihriocephalus Laius (Taenia Osculis Snperficialibu?; Broad Worm). 

12. Taenia Solium (Taenia Osculis Marginalibns; Long Worm). 

Succinct remarks by Dr. Fletcher on the localities inhabited by these different animals, 
together with various other interesting particulars respecting them, will be found in the 
" London Medical and Surgical Journal," for June 17, 1837. (Page 318.) 



BOOK VI. 
DISEASES OP THE UEIMEY ORGANS. 



CHAPTER I. 
DISEASES OF THE KIDNEY. 

SECTION I.— NEPHRITIS. 

According to the rule which I have hitherto observed,^ the first disease which 
I shall describe among those of the urinary orj^ans, will be inflammation; and in- 
flammation of the kidney; called " nephritis."^ 

Symptoms. — In this disease there is pain in the loins; but it is usually experi- 
enced on one side only. On account of the great sympathy that exists between 
the kidney and the stomach, there is very frequently nausea and vomiting. In 
inflammation of the heart and lungs, there is no vomiting; but in inflammation of 
the kidney, we generally have more or less disturbance of the stomach;— either 
nausea, or absolute vomiting. From sympathy among difl'erent parts of the uri- 
nary system, there is usually a frequent desire to make water. The pain is not 
confined to the loins; but runs along the ureter, towards tlie bladder. The testicle 
of that side is generally painful and drawn up; and very frequently indeed it is 
swelled. There is also numbness in the inner part of the thigh; — I presume from 
an alTection of the anterior crural nerve. The pain is seldom felt at the back of 
the thigh. It does not run down tiiat part of the limb, like sciatica; but is felt 
anteriorly, — along the course of the ureter, down the testis, and down the inner 
part of the thigh; where the anterior crural nerve is situated. The testis, indeed, 
is sometimes not only swelled, but sore to the touch; and sometimes it, as well as 
the inner part of the thigh, experiences a sensation of numbness. The urine is 
generally scanty and red; — following the course that is usually observed in any 
active inflammatory disease; and, the kidney being the part affected, it is more 
scanty and of a deeper red in nephritis, than in other inflammations. On the other 
hand, the urine is sometimes not deficient in quantity; and occasionally it is found 
to be very pale. 

Diagnosis from Rheumatism. — In a rheumatic afl^ection of the loins, the pain 
is usually felt on both sides; and it is felt to a great extent; — it generally affects a 
large surface. It runs to the hip; and, if it extend at all, it proceeds down the 
outer part of the thigh; — taking the course of the sciatic nerve. There is not a 
frequent desire to make water; there is no pain in the course of the ureter, no en- 
largement of the testicle, nor any pain in the inside of the thigh. Motion, in that 
disease, very frequently produces pain: — perhaps extending to the thigh, and espe- 

From v£<f>^o;, the kidneys and "ids," i7ijlammati07i. 



970 DISEASES OF THE KIDNEY. 

daily about the joint and the " trochanter major." The latter is not only painful, 
but perhaps hot and swollen. Very often there is rheumatism in other parts; and, 
very frequently, there is profuse sweating. The absence of all urinary symptoms 
(if I may so call them), and the situation of the pain, — in addition to the common 
symptoms of acute rheumatism,— -enable us, in general, to distinguish the disease 
perfectly. I was able in one instance to make an accurate diagnosis, where some 
little difficulty was thrown around the case. In St. Thomas's Hospital there was 
a man, who had been there, six or eight months previously, for a decided affection 
of one kidney. There was pain in one part of the back, extending down the 
ureter; the testis was retracted; and there was an affection of the urine. The case 
was treated as nephritis. But he now came in with what was decided rheumalism. 
There was pain on the outer side, lower down than the kidney. It did not extend 
in the course of the ureter; but ran down the course of the sciatic nerve, and par- 
ticularly affected the joint, which was painful on motion; — showing the effect of 
rheumatism. He did not make water more frequently than he ought; but there 
was pain in one point anteriorly. That, however, arose from an evident circum- 
stance; it was in the situation of the glands, which were inflamed. He was treated 
by acupuncture, and making his mouth sore; and he speedily got rid of the disease. 

Causes. — Nephritis may be produced by cold, like any other inflammation; but 
it is rarely an idiopathic disease. It is more frequently the result either of mecha- 
nical violence, or of some acrid matter which has been taken, such as turpentine or 
cantharides. Or it is the result of stones existing in the kidney, or of some dispo- 
sition perhaps to gout. 

Termination. — If the disease go on to great violence, suppuration may occur. 
There is then less pain; rigors may be experienced by the patient; and pus may 
appear in his urine. The discharge may take place in that direction; or it may 
present itself at the back; — giving the appearance of a lumbar abscess, perhaps. 
Sometimes, however, it has been known to open into the intestines. Various 
terminations have occurred; all of which we may imagine beforehand. The pus 
has sometimes been collected into an abscess; and sometimes it has appeared in 
separate portions; — forming so many minute specks, with which the organ has 
been studded. 

Treatment. — The treatment of the disease consists in bleeding at the arm; cup- 
ping on the loins, — either alone or after general bleeding; purging, especially by 
calomel; putting the patient into a warm bath; and low diet. If the kidneys sup- 
purate, it is necessary to treat it as any other suppuration. We must support the 
strength; tranquillize the patient by anodynes; and perhaps give " uva ursi." Some 
recommend this drug; but whether it has any particular virtue, I do not know. 
The common treatment of suppuration, in any part of the body, is that which is 
required. 

SECTION II.— HiEMATURIA. 

Causes. — The kidneys are subject to haemorrhage; and when blood appears in 
the urine, the disease is called " haematuria."* Blood may appear in the urine 
from an affection of the kidneys, or of the ureters, or of the bladder, or of the 
urethra, or of some other part opening into the kidney. The blood is occasionally 
diffused through the urine; — the urine contains a sediment, which is evidently a 
mass of blood; and sometimes blood is discharged without any urine. 

Diagnosis. — If the urine be red in consequence of the presence of blood, I think 
we may always distinguish it by the eye. It is not of a deep orange-colour: but is 
of downright red. We may always distinguish it from the most red^sediment, 
produced by feverishnes and inflammation. It is a true red; — such as no one, I 
should think, can mistake; but if we have any doubt, we may dip a rag into it; 
and we shall find it stained red; — without any tinge of yellow, or any orange-tint; 

» From rtjfta, blood; and cy^ev, urine. 



DISEASES OF THE KIDNEY. 971 

as is the case in the highest-coloured urine if no blood be present. Frequently 
blood is discharged so pure, or in such a quantity, tliat (independently of the colour) 
we ascertain its presence at once. But we have another point to ascertain. After 
havinff distinguished whether it is blood or not, we have also to jfind out whence it 
comes; — whether from the kidney, or some other part. If it be furnished by the 
urethra, the latter will present evident symptoms of disease. It is common in vio- 
lent gonorrhoea, in stricture, and when a bougie is passed. There can be no diffi- 
culty, I think, in ascertaining whetlier the haemorrhage comes from the urethra; the 
point most difficult to ascertain is, whether it comes from the kidney oi from the 
bladder. It is rare for haemorrhage to take place from the ureter. 

I presume the mode of disiinguisljing between haemorrhage from the kidney, and 
that from the bladder, would be by observing where the other symptoms reside; — 
whether in the loins, or down in the pelvis. Sometimes, I believe, it is imi)ossible 
to take an accurate diagnosis. I recollect having a case of "fungus liasmalodes" 
of the bladder, which was productive of no pain, nor of any irritation whatever. 
The only symptom the man had, was a discharge of blood from the urinary pass- 
ages. I could make out no disease at all. He died under the repeated haemor- 
rhages; and, at the autopsy, a fungus was found shooting from the bladder. But if 
there be any symptoms besides the bleeding, emaciation, and debility, we should 
observe whether they are situated in the loins or about the bladder. If they are 
in the loins, there will be pain there, most likely sickness, and perhaps tenderness 
in the region of the kidney. If the symptoms are in the bladder, we have pain 
about the pelvis, and a frequent desire to make water; — far more so than in the 
other case; — there will be far greater irritation. But it is to be remembered, that 
disease of the bladder and urethra will cause pain in the kidney; and that disease 
of the kidney will cause irritation about the bladder, as well as the symptoms I 
have mentioned about the testicle.* The latter show how distant the symptoms 
may be, when the kidney is itself affected; but, generally, the greater intensity of 
the symptoms at one spot rather than at another, will remove all difficulty. 

General Treatment. — Hffimaturia is sometimes easily cured; or, on the other hand, 
it may be very dangerous; — all depends upon the cause. It is sometimes inflamma- 
tory, and is attended with a quick pulse, a dry tongue, and even retraction of the 
testicle. It will then give way to the common treatment for nephritis.'' A bleed- 
ing (ir two, or purging, will generally get rid of it. When it is inflammatory, it is 
acute; and generally arises from some evident cause, — a " cold," or a blow, or some 
acrid substances that have been taken. The most common of the latter (and, in- 
deed, the only ones that I ever saw produce it) are turpentine and canlharides. 
When it has arisen from these, it would be well to take plenty of diluents and 
demulcent substances. AVater, with a quantity of gum in it, and mucilaginous 
matters in general, should be employed in addition to anti-inflammatory treatment. 

Treatment of Passive Hdsmaturia. — Sometimes, however, this haemorrhage is 
entirely passive;— not accompanied by any signs of inflammation. It sometimes 
occurs wnth typhus fever, sometimes with small-pox, and sometimes with " pur- 
pura haemorrhagica;" — both in cases where that disease arises entirely from debi- 
lity, as well as when it is inflammatory. In these circumstances the treatment 
for passive haemorrhage must be adopted; and turpentine will be found very useful; 
— not in large, but in small doses; — from twenty to twenty-five drops, every four 
or six hours. Of course the system requires support; and the common treatment 
of passive inflammation must be adopted, at the same time that we employ this 
specific remedy. 

Arising from Chronic Disease of the Kidney. — When haemorrhage takes place 
in chronic disease of the kidney; when we liave seen chronic disease ))rcviously 
existing; when we suspect the presence of calculi in the kidney, or a cancerous 
affection of the organ, or any other structural disease, — the same treatment must be 
adopted. We cannot, in general, lower the patient. If there be symptoms of in- 

^ See Page 9G9. 



972 DISEASES OF THE KIDNEY. 

flammation, we must act accordingly; but, in general, the administration of turpen- 
tine in small doses (carefully watching it lest it should irritate the kidneys), — toge- 
ther with the exhibition of opiates to relieve the pain and procure rest, and giving 
the patient good support, — is all that is needful. The treatment will give no 
difficulty at all. We have only to treat it in the same way as we should treat 
haemorrhage from other parts. Consider what is the patient's strength, on the one 
hand, or his debility, on the other; — consider whether there are symptoms of active 
inflammation, or how far the haemorrhage appears to be passive only. If the dis- 
ease be not inflammatory, oil of turpentine is of as great use here, as in hsemorrhage 
from the alimentary canal; but it is necessary that we should carefully watch the 
patient; because that which is passive to-day, may, through sudden excitement, be 
active to-morrow. 

Hematuria from suppressed Discharges. — This haemorrhage occurs, some- 
times, in a curious way. Like other haemorrhages, it has occurred where the 
menses have been suspended. I once saw an instance of its occurrence, after hae- 
moptysis had been cured. Occasionally it will take place in men, and also in 
women; but more frequently in men who have been subject to a discharge of blood 
from the haemorrhoidal vessels. When that discharge is stopped, they are in the 
predicament of a woman who is in a state of amenorrhcea. Generally speaking, 
these cases are not dangerous; but they require antiphlogistic treatment. If the 
naturaPdischarge of menstruation has ceased; and inflammatory haematuria has 
supervened, it may be right to attempt to bring it back again. 



SECTION ill.— ORGANIC DISEASES OF THE KIDNEY. 

Hypertrophy. — The kidney is subject also to chronic inflammation; but we 
usually see the effects of chronic inflammation in the form of organic disease. 
Occasionally the kidney becomes enlarged. There is no particular alteration of 
structure; but the organ is evidently hypertrophied, and is perhaps firmer than 
usual. I presume that over-nourishment is, more or less, of an inflammatory 
nature; and that, from the great activity of the circulation, deposition has taken 
place. 

Turgescence. — Sometimes the kidney will become very turgid, and very red; 
— merely as the result of a difficulty in the circulation. Sometimes, after great 
dyspnoea, — after obstruction of the heart, — after obstruction of the lungs, the kid- 
ney, on being cut open, has been found full of blood; — so that we might, at first, 
mistake the appearance for that of active inflammation. But if there be active in- 
flammation, the kidney is generally found soft; whereas the effect of chronic 
inflammation of this organ, is either induration or hypertrophy. 

Paleness.— Frequently the kidney, instead of being red, is pale. After death 
has occurred from chronic disease, the body is generally found to be wasted; and 
not only are the brain, and the muscles pale, but the kidney likewise. The kidney, 
however, is sometimes pale through disease of its own; and then it is generally 
firmer and harder than it should be. When I mentioned induration as a common 
effect of inflammation, I spoke both of red and of pale induration,* and each of 
these kinds occurs in the kidney. 

Mottled Kidney. — But the kidney is sometimes very red, or very pale, only in 
spots; and then we have what is called " a mottled kidney." Morbid paleness 
usually occurs in the cortical part; but sometimes the whole kidney is in this con- 
dition. Hypertrophy, attended with redness, — -when it is partial, occurs in the 
cortical portion; and that also will give rise to a mottled appearance. We may 
have a mottled appearance from one part becoming morbidly pale, while the other 
remains natural; or it may arise from one part becoming morbidly red, while the 
other retains its natural paleness. 

» See Pa<?e 176. 



DISEASES OF THE KIDNEY. 973 

Granular Kidney. — Occasionally the kidney is granulated. Small grains, more 
or less firm, are seen in different parts. Whether this is local hypertrophy or not, 
I do not know; but it is found most frequently in the cortical portion. These 
grains are of all numbers, and of all sizes. 

Softening. — Occasionally the kidney becomes excessively soft; so that we may 
breai^ it up with our fingers; and this, I presume, may occur very rapidly. I have 
no cases in point to support lliis opinion; but, judging from what occurs in the 
spleen'and liver, I should think that the softening may be very rapid. I know that 
softening of the spleen or liver, will take place in the course of a few days. A 
person, in perfect health, may be suddenly taken ill and die; and we shall find 
these parts so soft, that we can run our finger through them in every direction, — 
break them up in a moment; and therefore I can conceive that the kidney may 
become soft either in an acute^ or in a chronic way. When this organ is soft, 
there is the usual difference; — that is to say, the softness is sometimes accompanied 
with redness, and sometimes with paleness. Sometimes there is inflammatory 
softening; and sometimes this change appears to take place without any connection 
with inflammation. 

Atrophy. — The kidney will sometimes waste. If one kidney waste, it is usual 
for the olher to double its natural size; — in order to perform the duty of both. 
Nothing is more common, than to find one kidney enlarged, in proportion as the 
other is diminished. This wasting of the kidney will sometimes proceed to such 
an extent, that we can scarcely find any remains of the organ. I have met with 
cases where the kidney was discovered with the greatest difficulty; so that those 
who have first examined the body, have said that there was but one kidney. What 
is termed "a horseshoe kidney," is where there is only one. That, however, is 
a rare case; but the organ is sometimes wasted to a less size than that of a horse- 
bean. Atrophy of the kidney sometimes takes place, without any ascertainable 
cause. Sometimes it is the result of inflammation; sometimes it is the result of 
abscess. A great discharge wmH cause atrophy of part of the organ. We produce 
counter-irritation, for the purpose of lessening morbid growths, and morbid activity 
of the circulation; and if, without morbid growths and morbid activity, a discharge 
takes place by suppuration, the activity of the part is diminished, and wasting is a 
very common circumstance. An abscess, therefore, will occasion a part to waste; 
according to the general principles on which we employ setons and issues. But 
pressure will have the same effect. The pressure occasioned by a tumour in the 
neiglibourhood of the kidney, has been seen to produce atrophy of the organ. It 
is stated, by authors, that atrophy of the kidney is sometimes partial; so tliat the 
medullary portion only is wasted, and the pelvis becomes a mere bag. Sometimes 
the cortical part is wasted; so that tlie cones witliin the kidney nearly touch the 
external fibrous membrane; — there being only a thin layer of cortical substance 
between. Thus, we see, there are various degrees of atrophy; and they have all 
been considered as a frequent result of inflammation. 

Serous Cysts. — We have, however, other organic disease of the kidney. In 
the cortical substance, serous cysts are very common; and, by their pressure and 
growth, they will cause an atrophy of it. As they increase, they cause more and 
more atrophy; till there is little more than a bag left. Cruveilhier has given a very 
good representation of these cysts. They are found more commonly in the kidney 
and liver, than in any other parts of the body. Serous cysts are sometimes found 
under the external membrane of the kidney. 

Fatty Degeneration. — The kidney has sometimes been seen converted to fat. 
A great deposition of fat, I presume, has taken i)lace in the cellular membrane, 
under the external coat; and the rest has wasted. Sometimes it has been converted 
into jelly. A peculiar substance of this kind is occasionally formed in the kidney, 
which sometimes contains a great quantity of it; — causing atrophy of the organ 
itself. 

Malignant Disease. — Occasionally encephaloid disease occurs in this part. We 



974 FUNCTIONAL DISORDERS OF THE KIDNEY. 

may have great disorganization of the kidney; — we may have tubercles of various 
kinds; and even scrofulous tubercles have been found here. 

Symptoms of Organic Disease. — All these diseases may occur with very obscure 
symptoms; but sometimes they occasion dull pain in the region of the kidney, to- 
gether with more or less disturbance of the stomach. The diagnosis is generally 
difficult; unless the pain be very local, and the urine very much affected. Even 
then, — when we have satisfactorily made out that there must be organic disease, — 
it must be very difficult, if not impossible, to say what that organic disease is. 
Scirrhus is said to occur in the kidney; but whether the affection is scirrhus, can- 
cer, encephaloid disease, or a mixture of these, or a scrofulous suppuration, it must 
be difficult to determine. If organic disease occur in a young person, and there is 
not much pain, we may suspect that it is encephaloid. If there be strong marks of 
scrofula; — if the ends of the fingers be enlarged; — if there be mesenteiic disease, or 
phthisis, — we may suspect that the affection of the kidney is of a scrofulous nature. 
If the person be advanced in life, we may suspect scirrhus or cancer. The par- 
ticular nature of the organic alteration, however, can make no difference as to the 
treatment; which must be conducted on general principles. Dr. Baillie states that, 
according to his observations, the kidneys are more frequently affected in men than 
in women. 

Diseases of the Renal Capsules. — The renal capsules are rarely diseased, except 
from scrofula; but I have frequently seen them in that condition. Sometimes they 
are indurated; and the induration may amount to cartilage, or even to bone. As to 
the symptoms, nothing can be said on that subject. 



CHAPTER II. 

FUNCTIONAL DISORDERS OF THE KIDNEY. 

Having spoken of those diseases which are the result of inflammation of the 
kidney,"* and of structural diseases,* I will now proceed to consider functional 
disorders of that organ. The kidney is subject to an increase and to a diminution 
of its secretion. It is liable to secrete morbid urine; — to secrete a substance which 
it ought not to form in that particular v/ay; or which, if it be produced, should pass 
off with the urine. Besides these affections, the urinary organs are sometimes 
infested by worms. 

SECTION I.— ISCHURIA. 

Varieties. — The first disease which I shall mention, is a diminution of the secre- 
tion; and this is called "ischuria." 'The suppression of urine, the absence o{ nvme^ 
or the diminution of urine, when it occurs in the kidney, is called "ischuria re- 
nalis.^^ If urine be found in the kidney, but cannot escape from it, owing to some 
obstruction in the ureters^ — then it is called "ischuria ureterica.^^ If there be 
some obstruction in the bladder, it is then termed "ischuria •yes^caZzs." If there 
be obstruction in the urethra, it is denominated "ischuria urethralis.^^ There is 
no analogy in these different words. If the urine be suppressed, — that is to say, if 
none he formed, — we call it ^^suppression of urine;" if, however, it be formed, but 
cannot escape, we call \i '■^retention of urine;" so that "ischuria renalis'^ and 
"ischuria vesicalis^^ are not at all analogous; and young beginners are often laughed 

a See Page 969. '' See Page 972. 

/ 



FUNCTIONAL DISORDERS OF THE KIDNEY. 975 

at in the hospital-wards, for spying ''sitppressio?!,'' when they ought to say ^^reteji- 
tion,^' and vice versa. 

Symptoms. — The suppression of urine, — a deficiency of tlie secretion, — may 
be entirely inflammatory; and then we have symptoms of nephritis,^ and must 
treat it as inflammation." But sometimes this complaint is unconnected with any 
symptoms of inflammation of the part; and it certainly is then a curious affection; 
for it is usually followed by apoplexy. No urine is made, or scarcely any; and, 
at last, absolutely none. There is no fulness of the bladder; and when we pass an 
instrument, — to ascertain whether it is a case of retention or not, — we find that 
the organ is empty. In general, the patient very soon becomes drowsy; which 
drowsiness increases, till he becomes decidedly apoplectic, and perhaps dies. In 
the "London Medical Dictionary," Dr. Parr mentions a case, where no urine 
was made for six weeks; and Haller quotes an instance, in which it was said that 
no urine formed for twenty-two weeks. These are very chronic cases; and one 
cannot answer for the truth of that which Haller alludes to. I presume he men- 
tions it on the authority of another. The disease has sometimes been ushered in 
with rigors, and sometimes not. Sometimes it has occurred without any par- 
ticular symptom, till coma has made its appearance. Following the course of dis- 
eases of the kidney, it occurs more frequently in men than in women. •" It usually 
takes place in fat people; and especially in those who are upwards of fifty years 
of age. 

Excretion from other Organs. — When the urine has been suppressed in this 
way, it has occasionally escaped from some other part of the body; and when the 
urine has not been suppressed, but (though formed) has not been able to escape, — 
in consequence of some obstruction, — it has been absorbed; and has passed off by 
some odier organ. I know instances where it has been vomited; and I saw a case 
where it passed from the skin, — particularly the palms of the hands. Persons in 
these circumstances, — who have made no urine, or whose urine (when secreted) 
could not escape, — have occasionally vomited a fluid, which had the smell, and 
taste, and all other quaUties of urine. Others have passed it in the form of perspi- 
ration. There can be no doubt of the truth of these cases. I presume that, in the 
latter case, the fluid has been absorbed, and re-secreted; and, in the former case, it 
has been secreted originally, and has not been absorbed at all. 

Termination in Spoplexy. — In "ischuria renalis," it is very common for the 
individual to become apoplectic; and it is, therefore, a very dangerous disease. I 
have had but one case of it, and that occurred after a person had taken (by mistake) 
a quantity of corrosive sublimate. Proper means had been used, and no harm was 
thought likely to occur; but, after a certain time, the urine became suppressed. I 
think the individual had hemiplegia; but I recollect perfecdy, that he became 
drowsy; and the drowsiness increased till, at length, he became decidedly apo- 
pletic, and died. One might imagine, in such a case, that the same occurrence 
must have happened as when the urine has been vomited, or has been thrown off 
by perspiration; — namely, that the urine was re-secreted into the ventricles of the 
brain; or that, if no urine was secreted, that an excessive quantity o{ Jiidd would 
be found within the brain. Nothing of the kind, however, was discovered in this 
case. There was not only no urine in the head; but no excess o{ fluid, either in 
or upon the brain. That was a result for which we were not prepared. 

Treatment. — The proper mode of treatinsr these cases is to give cantharides. I 
do not know whether oil of turpentine has been tried. In tlie case I saw,*^ a blister 
was applied, and cantharides were given internally; but the patient died within a 
few liours of its exhibition. However, a friend of mine had two cases which oc- 
curred nearly together, in olil people; and one of them was so bad, that Sir Astley 
Cooper, who was called in, had little hope of saving life; but he treated the case in 
a way wliich, lie said, had been found siiecessl'ul; and the patient got perfectly well.' 
In the second case, my friend adopted the same plan; and it was attended with the 

« See Page 9G9. »> See Page 971. 

•^ See Page 974. ^ See the previous Paragraph. 



976 FUNCTIONAL DISORDERS OF THE KIDNEY. 

same success. In the latter case, it appears that the kidney had become torpid; 
but not through inflammation. Whether other diureties would answer, I do not 
know; but it is said that cantharides should be given internally, and a large blister 
applied to the loins, — in order that the medicine may have more eflect; because 
the surface has much influence over the internal parts. When it is exhibited in- 
ternally, it should be in the solid form; because the tincture is a most uncertain 
preparation. We should give a grain once or twice a day, or every eight hours; 
whichever we choose. A grain is a pretty strong dose; but, in a case of this de- 
scription, there is no time to be lost, for apoplexy may soon come on; and there- 
fore we should repeat the dose, as long as it does no harm. I have given ten, 
lifteen, or twenty drops of the tincture, without any eff'ect; and, at last, I have 
been obliged to give two or three drachms. The tincture, I presume, was not good; 
but it has been so common an occurrence, with me, to find the tincture either bad 
from its nature, or bad from its being so continually ill made, that I place no confi- 
dence in it, in a case of life and death, where there is no time to be lost. 



SECTION II.— DIABETES. 

Etymology. — The term " diabetes'^'' is derived from the Greek word 6tai3atj/a, 
— to stream through; — the disease being characterized by the " streaming away" 
of a considerable quantity of water. This affection, on account of the excess of 
fluid, has sometimes been called " hydrops ad matulam," — " chamber-pot dropsy;" 
but as there is an accumulation of fluid, it cannot, without great impropriety, be 
called " dropsy y In dropsy there is an accumulation of fluid; — not merely a 
formation of it. It is formed faster than it comes away, and therefore is termed 
" dropsy;" but as, in diabetes, the water comes away, the word dropsy has been 
applied to it with the greatest absurdity. 

Definition. — The word '^ diabetes^^ is usually employed to signify chronic ex- 
cess of urine. A person would not be said to have diabetes, if he merely made a 
large quantity of urine for a day or two. The fluid may be either of a natural 
quality, or it may contain sugar. As, however, ihere is no distinct single name 
for that disease in which sugar is formed in the urine, and as it is sometimes formed 
without the urine being at all in excess, it would be well, perhaps, to restrict the 
term "• diabetes^^ solely to saccharine urine, and to give such a name as ^^ poly- 
uria'''^ to that form of the disease, in which there is merely excessive quantity. 
But we find '^ diabetes^ ^ employed to signify a chronic excess of urine, whether 
there be sugar in it or not; — the one being called " diabetes insipidus,^^ and the 
other " diabetes mellitus,'^ — " /ionei/-like," — sweet to the taste. It was to an ex- 
cessive quantity of urine, that the ancients applied this term; for it does not 
appear that they were at all aware, that the urine was ever sweet. I believe it 
was Dr. Willis, the English physician, who first pointed out that, in this disease, 
the urine is sometimes saccharine. The terra is certainly employed by the ancients 
simply to denote a chronic excess of urine. 

Excess of Urine in Various Diseases. — There is frequently a temporary excess 
of urine, in various diseases. In asthma, for example, a large quantity of pale 
urine is frequenfly made. So, again, in hysterical and dyspeptic people, this is 
often the case. Fright likewise will cause a tem{)orary excessive quantity of urine; 
so that persons who have been waiting anxiously to be called into a room, have 
been obliged to walk out twenty times in the course of an hour. Long-continued 
grief and anxiety have the same effect. I have known persons, from leaving oflf 
some of their clothes, make a considerable quantity of urine; and it has been 
remedied by wearing their usual quantity of clothes again. 

Diabetes Insipidus. — But, independently of the circumstances I have now 
mentioned, there is sometimes formed an excessive quantity of urine; not at all 

* From woXu?, much; and ov^ov^ iLrine. 



FUNCTIONAL DISORDERS OF THE KIDNEY. 977 

impregnated with sugar, and occurring without any evident cause. This form of the 
disease, — which (as it sometimes has been) might as well be called " polyuria," — 
is occasionally followed by that form in which the urine contains sugar. i3ut some- 
times it exists alone; and I believe that, not unfrequenlly, after a length of time, it 
will cease. This incipient diabetes is more common in women, than in men. The 
urine is very pale, in general; and if it continue, thirst and dryness of skin are me- 
chanically produced. An excessive secretion of water is going on in one part of 
the body; and there is therefore less water for the secretion of the mouth and skin. 
From the loss which the body sustains, there is also weakness and hunger. This 
condition may frequently be recovered from, by wearing warm clothing, employing 
the hot-bath, or going to a warm climate; and by the exhibition of iron. Persons 
who have laboured under this form of the disease have, by medical men who have 
not properly examined the urine, been said to be cured of diabetes; as though they 
had had the saccharine form of the disease. 

Diabetes 31ellitus. — In " diabetes mellitus," or true diabetes, there is sugar in 
the fluid; and generally there is also an excessive quantity of fluid. The general 
symptoms that I just now mentioned, are produced in this afl'ection. From the loss 
which the body sustains, there is great debility; from the body losing its nourish- 
ment, there is hunger; and from the want of fluid, there is thirst and dryness of 
skin. The hunger is sometimes excessive; so that the patient not only feels very 
hungry at the usual time of his meals, but he feels hungry during the greater part 
of the day. The food which the patient takes, does him (he says) "no good;" 
and he is presenUy anxious for more. Patients generally complain of a sinking at 
the pit of the stomach; and the uneasiness there occasionally amounts to aching. 
The thirst is sometimes so great, that many quarts of fluid are drunk in the course 
of the day; and the skin is sometimes so dry, that the hair falls ofl^. The feet and 
hands are frequently cold; there is lowness of spirits; and, in almost every case, 
peevishness and fretfulness. There is also one very remarkable symptom; — the 
loss of sexual power and desire. I have never found this symptom absent; and 
sometimes it has been the very first symptom noticed by the patient. I never had 
a patient labouring under diabetes, in whom the feeling of sexual power and desire 
had not ceased entirel}', or become very much impaired. This symptom is not 
noticed by all authors; and a patient, of course, will not mention it; but, on mak- 
ing a point of inquiring into it, we shall (I believe) nearly always find it to be a 
fact. There is also frequenUy pain of the loins; but whether it arises from an 
affection of the kidney, or is merely a symptom of debility, I do not know. Al- 
though the whole body becomes emaciated, there is frequently a3dema of the legs; 
and usually there is costiveness. From the deficiency of fluid in the alimentary 
canal, there is not only dryness of the skin, and thirst, but the tongue is sometimes 
white and clammy. Frequently, however, it is smooth and red; and the saliva 
and mucus are excessively tenacious; — so that the patient is very much annoyed. 
The gums sometimes become very red, and slightly ulcerated. The saliva is occa- 
sionally sweet; and so likewise is the breath. Dr. Latham says, that the body 
smells like hay. I have not observed this; but the breath frequently has sweet 
smells; — has something of the odour mentioned by Dr. Latham. Very often there 
is redness and soreness of the end of the urethra. I have seen even phimosis;* 
which may arise, perhaps, from the irritating quality of the fluid. We usually 
find the pulse quick, — perhaps full; and at last it becomes weak. There is a hectic 
appearance in the patient's face; — we frequenfly find a flush upon his cheek, as well 
as quickness of the pulse; and, at last, we have decided hectic. In many cases 
there is great sweating, — I have frequenfly seen it. Phthisis is a very common 
termination of this complaint. Lideed, the majority of diabetic patients whom I 
have attended, have died of phthisis. The urine has a particular odour, which is 
not perceived by smelling the pot; but if we parfly fill a phial with it, and keep it 

* From <}){ju«, to tie up. 
VOL. I.— 62 



978 FUNCTIONAL DISORDERS OF THE KIDNEY. 

corked for a little time, on withdrawing the cork, we may perceive a pecnliar smell, 
— something like peppermint. It has also a sweet taste; which we may ascertain 
by desiring the patient to taste for himself. Generally the urine is clear, and of a 
lemon-colour. Besides the presence of sugar, there is usually a diseased secretion 
altogether. 

Quantify of Urine voided. — Professor Frank, of Vienna, saw a case in which, 
on an average, forty pints of urine were made in a day. There were sometimes 
as much as fifty-two pints. He says that other authors have mentioned fifty-two 
pints being discharged. He also states that he saw a case, in which the quantity 
voided, in a few days, exceeded the whole weight of the body. Usually, however, 
the quantity of urine discharged, is from six to twenty pints per diem. On the 
other hand, the urine is sometimes very little increased in quantity; and sometimes 
not at all. Professor Frank mentions a few cases of this disease, where the quantity 
was not increased; but it contained so much sugar, that from two pints of fluid six 
ounces of saccharine matter were obtained. One patient of mine made, at last, 
but three pints of urine in a day; — which was less fluid than he drank. Dr. 
Heberden mentions a case, in which the urine made was double the quantity of 
the fluid drunk. Such are the varieties as to the quantity of urine. 

Quantity of Sugar.'— Wiih regard to the quantity of saccharine matter, Dr. 
Dobson procured an ounce of saccharine extract, by evaporating a pint of urine. 
Cruikshank obtained three ounces and a quarter from thirty-six ounces troy; and 
found the specific gravity to be 1"040. From ten pints of urine, he obtained a 
pound and a quarter of solid extract. Dr. Prout, from a pint of urine, — 'the specific 
gravity of which was 1-050, — obtained two ounces of thick stuff"; and from this 
he procured one ounce and a half of sugar. Frank says that, from twenty-four 
pints of urine, he obtained twenty-six ounces of saccharine extract. The sugar 
obtained from urine, is like that procured from grapes. 

Fermentation of the Urine. — From the presence of sugar, the urine undergoes 
a vinous fermentation; so that, at a certain time, if it be thrown into the fire, it 
burns; — ^just as if it had been spirits. Still later, the urine becomes quite sour. 
The usual changes which sugar is capable of producing go on; that is to say, we 
have vinous and acid fermentation. 

Deficiency of the other Constituents. — These, however, are not the only cir- 
cumstances in this disease; for there is frequently but little urea in the urine; — little 
lithic acid, and little of the usual salts. Not that they are absent; for I saw them 
all myself in a patient's urine, which contained a large quantity of sugar. But it 
is said that, in general, they are very deficient; and deficient in proportion to the 
quantity of sugar formed. 

Specific Gravity of the Urine. — The weight of the urine, in this disease, de- 
pends upon the quantity of sugar; and the quantity of sugar is such as to augment 
the weight very considerably. The specific gravity of healthy urine is generally 
from 1-010 to 1-018; but that of c?i«6e/ic urine is from 1-030 to 1-050; and I think 
I have seen it still higher. This excessive weight, as I have just said, depends on 
the presence of sugar. 

Cause of the Presence of Sugar. — It has heen supposed, that the presence of 
*the sugar is dependent upon the deficiency of urea; and urea and sugar contain 
exactly the same quantity oUiydrogen; while the quantity of carbon and oxygen^ 
in sugar, is twice that of those substances in urea. It has therefore been supposed, 
that there is only a morbid change undergone in the composition of the urine; — 
that instead of urea^ we have sugar. However, this is certainly not accurate; 
because I have seen a large quantity of sugar in the urine, where there was like- 
wise a considerable quantity of urea. Still, it frequently does happen that, in 
proportion as the one is deficient, the other is abundant. It is by no means proved, 
I think, that sugar is merely altered urea; and those have mistaken the matter who 
say, that urea is absent in diabetic urine; for sometimes a large quantity of urea is 
found in true diabetes; where, of course, there is a large quantity of sugar. 



FUNCTIONAL DISORDERS OF THE KIDNEY. 979 

Fenppearance of Albumen.— \^ \\-\e disease take a favourable course, Dnpuytren 
and Thenard assert that, before the salts and urea appear again, albumen is found. 
Dr. Prout mentions, that the worst form of diabetes is where the urine is albumi- 
nous; — where, besides sugfar, we find albuminous flocculi in the urine. In a fatal 
case of mine, not long before death, there were albuminous flocculi. These floc- 
culi increase the fermentation, which the urine experiences from the sugar. 

Condition of the Blood, — It is pretty certain that no sugar is found in the blood 
of these patients. Dr. Prout, who is very nice in his examination of these things, 
says that he has sometimes seen something like sugar; but true sugar has been 
looked for, by a large number of chemists, in vain. 

In this disease, the blood is sometimes of an unnatural appearance. It is said^ 
by Dr. Watts, of Glasgow, (who, I dare say, may be depended upon,) to be a little 
like treacle, and of a bluish colour; but this is not an invariable circumstance; for 
I have not noticed it myself. The serum of the blood had a white fluid swimming 
upon it; and the blood was bufl^ed. I mention this to show, that we may have 
these things, at the same time that the urine contains sugar. There is no connec- 
tion between them; only the presence of one does not exclude the possibility of 
the other being present also. I may mention that Vauquelin found no sugar in 
the blood of a person, whose urine actually contained one-seventh part of sugar. 
He also says that he found no urea in the blood of this individual; though he gave 
him a large quantity by the mouth, for some days. He also states that an opposite 
occurrence takes place here, to what is observed in scurvy; — namely, that the blood 
will not putrefy so soon as in health. In one case of my own, — the only case (I 
believe) in which experiments were made, — it was found that the more sugar the 
urine contained, the larger was the quantity of carbon discharged from the lungs. 

Duration and Termination. — This disease may last many years; and it may 
prove fatal by phthisis; — that is to say, it may induce phthisis, or be followed by 
it. The fact may be expressed in any way we choose, — diabetic patients fre- 
quently die phthisical. They sometimes die from mere exhaustion, occasioned 
by the disease; and sometimes they die suddenly; but the most common termina- 
tions are phthisis, and mere exhaustion. It may destroy a patient in a year or two, 
or it may remit; and I believe it may cease, or be cured. Dr. Gregory* used to 
say that he knew a case, where the saccharine quality of the urine ceased in two 
days, and did not return; but whether the observations were made with all the 
accuracy that we require, in modern times, I do not know. Usually the appear- 
ance of sugar, and the excessive quantity of urine, decline together; — that is to 
say, in proportion as the quantity of urine becomes less, so does the proportion of 
sugar. We may have the quantity of urine diminished, and yet the proportion of 
sugar to that quantity remain the same, and, on the other hand, it is asserted (thouo-h 
I have not seen it) that the sugar sometimes diminishes in absolute quantity, while 
the urine remains in the same excess as before. As, however, the sugar absolutely 
lessens, so do the salts, the lithic acid, and the urea, generally increase. The 
colouring matter of the urine is usually deficient, as well as the lithic acid and 
salts; and sometimes the sugar entirely disappears before death. I have seen the 
urine, in diabetic patients, suddenly cease to have a particle of sugar in it; and 
yet the patient has died in the course of three or four days. 

[With respect to the terminations of diabetes, phthisis (as already stated) is the 
most frequent. Besides phthisis, however, I have seen diabetes prove fatal by 
disease of the liver and jaundice, by apoplexy, by a peculiar affection of the sto- 
mach, brought on by improper food, or by over-distension; by acute gastritis 
induced by taking cold fluids when heated; by inflammatory fever excited by ex- 
posure to cold, and rapidly assuming the typhoid character, &;c. Occasionally 
diabetes is said to terminate in incurable dropsy, and in various other alFeclions. 
In short, a great many circumstances which would not afl^ect a sound constitution, 
often prove fatal in this disease. Hence a diabetic individual may be considered 

• See Note to Page 239. 



9S0 FUNCTIONAL DISORDERS OF THE KIDNEY. 

as existing on tlie brink of a precipice; and the general prognosis must be always 
unfavourable/] 

MorbidJippearances. — After death, we frequently find no morbid appearances 
whatever. 1 have several times opened diabetic patients; and, as far as I could 
judge, the wliole of the body was sound. The kidneys have sometimes been 
enlarged a litUe; — sometimes a litUe redder or fuller than natural, and a little flabby; 
but that has been all; and sometimes I have not seen even that. The ureters are 
said to be sometimes florid; but Morbid Anatomy alone certainly gives us no expla- 
nation of this disease. Suppose we find the kidney fuller or larger than natural, 
and the vessels more distinct, that is nothing more than we should expect, from the 
kidney being stimulated to excessive action; and, whatever may be the cause, that 
appearance of the kidney certainly does not explain the saccharine quality of the 
urine. 

Causes. — [It is a remarkable fact, that diabetes seems to be peculiar to mankind. 
Horses and other animals are, indeed, subject to diseases accompanied by a large 
flow of urine; but I am assured that in such cases the urine is never saccharine; 
nor am I aware that sugar has been found in the urine of any inferior animal. If 
such an immunity from diabetes really exists among the inferior animals, its cause 
is very obscure. Can the exemption be referred to the absence of that fertile cause 
of bodily disorder in human beings, the influence of mind?^'] 

Predisposing Causes. — Diabetes is by no means confined to adults; for it fre- 
quently affects children also; but it is not so easily observed in them. It occurs 
much more frequently in men, than in women; and it occurs much more frequently 
in some countries, than in others. Professor Frank says, that he saw but three 
cases of it in Germa^, for twenty years; and that when he practised in Italy, he 
saw but seven cases ill eight years. There are far more cases of it in Edinburgh, 
than in London. When I was a student in Edinburgh, there were always some 
cases of it to be found; but I do not recollect having a case in London, for two 
years. 

Exciting Causes. — Sometimes it is produced by grief. I have seen it produced 
by the long continuance of the depressing passions. It is sometimes occasioned 
by chills; — by the exposure of the body to heat and cold alternately; — especially 
when the body is in a state of perspiration. It sometimes appears to arise from 
strains of the loins. Whether whiskey has any power in producing it, 1 do not 
'mow; but it is far more common in ScoUand, than in England. I suppose they 
drink as much whiskey in Ireland, as in Scotland; but whether the disease is 
■:^qually prevalent there, I do not know. Dr. Latham says, that he has seen the 
{'isease come on after boils; and I have heard others, I think, confirm the observa- 
tion. Excess of venery appears likewise to be a cause of it. Some authors men-* 
tioi^ this most decidedly, as the cause of the disease; and, in some instances, I 
have asked the question of young men; and they have replied that they had in- 
dnlcJ-'-d to great excess. Whether they had or had not, I cannot say; because 
r?'jple feel diff'erendy as to what is excess. I saw it, however, in one man, who 
had committed no excess of this kind; for he said he had never " known a woman;" 
but he died of the disease; and it is very possible he had committed excess of a 
less creditable kind. I rather think this was the case, from the great length of the 
prepuce. Sometimes there is no evident exciting cause at all; and, in some cases, 
it is evidently constitutional and hereditary. One German writer mentions having 
seen seven cases of the disease in one family. Dr. Gregory'^said that he saw three 
cases in one family; and Dr. Prout knew a mother, an uncle, a brother, and a sister, 
all afl'ected with the disease. 

« Dr. Prout, on the Nature and Treatment of Stomach and Urinary Diseases. Third 
Edition; Pages 33 and 34. 

b Dr. Prout on the Nature and Treatment of Stomach and Urinary Diseases. Third 
Edition; Page 34. 

c See Note to»Page 239. 



FUNCTIONAL DISORDERS OF THE KIDNEY. 9Sl 

Patliology. — Some declare the disease to be situated in the kidney; while olhers 
maintain that it is situated in the stomach. Many of the symptoins are as easily 
explained on one supposition, as on the other. The tliirst and the dryness of skin 
are referable to the loss of fluid. So, again, the costiveness, the emaciation, the 
hunger, the debility, and the sensation of sinking at the stomach, are all referable 
to the mere loss of so much substance, as must be lost in the production of sugar. 
But the absence of sugar in the blood, and the very frequent absence of dyspepsia, 
or any thing connected with the stomach, except the hunger (wliich the excessive 
loss will explain), make it appear to me most probable that the disease is situated 
in the kidney. 

[^r\\e proximate cause of diabetes has much puzzled physiologists; and a great 
deal has been said and written on the subject, which it would be useless to repeat 
here. According to the principles* advanced in this volume,"* the proximate cause 
of. diabetes lies partly in the assimilating organs, and partly in the kidneys; and 
may be thus stated: — 

When crystallized sugar is taken into the stomach by a diabetic individual, it is 
reduced to a low state, remains more or less unassimilated, and passes through the 
system to the kidneys; by which organs (being already crystallizable) it is separated 
unchanged. 

When organized saccharine principles, — as farinaceous matters, &c.,' — are taken 
into the diabetic stomach, they are (in the first place) reduced to the form of low 
sugar; part of which is assimilated, as in the healthy stomach; while another part is 
modified, or remains unassimilated. The portion that is assimilated is applied to the 
purposes of the economy; the portions modified and unassimilated, pass together 
through the system to the kidneys; by which glands the portion modified is dis 
organized, and finally appears in the urine as crystallizable sugar, along \pihth# 
portion originally remaining unassimilated in the stomach. The same renmks are 
applicable to gelatinous, and in extreme cases, perhaps, to albuminous and olea- 
ginous aliments. The secortcZari/ assimilating processes in diabetic individuals, par- 
ticipate in the derangements of the primary processes just detailed; — that is to say, 
the gelatinous tissues are either reduced to sugar, and thus not assimilated at all; 
or they are imperfectly assimilated; or they are mal-assimilated; in all which con- 
ditions, the saccharine principle derived from the gelatinous and other tissues, may 
be supposed to pass through the system to the kidneys; by which organs, like 
similar matters brought from the stomach, the various modifications of the saccharine 
principle are further disorganized, and converted into crystallizable sugar."' 

Such are the modes in which the phenomena of diabetes appear explicable on 
our principles. P shall not trouble the reader with corroborative details; but shall 
mention only one circumstance illustrative of the subject, on account of its practical 
importance. When, in diabetic individuals, the disorganizing function of the kid- 
neys is suspended; or when these glands are partially diseased, the urine, besides 
albuminous matters and more or less of crystallizable sugar, often contains the 
saccharine principle in imperfectly developed forms. Hence the urine, almost 
without perceptibly becoming vinous, passes at once into the lactic or acetous fer- 

* The principles alluded to, as far as they are involved in the present question, maybe 
thus briefly recapitulated; — 1. The assimilation of the saccharine principle is a distinct 
function. 2. The cellular tissue represents the saccharine aliment, 3. A secondary as- 
similating process, analogous to that in the digestive organs, is constantly going on in all 
parts of the body, 4, An important function of the kidneys is of a disorganizing character; 
that is, consists in the reduction of organized into crystallizable compounds, 

•> "On the Nature and Treatment of stomach and Urinary Diseases; being an Inquiry 
into the Connection of Diabetes, Calculus, and other affections of the Kidney and Bladder 
with Indigestion. By William Front, M. D." Third Edition, 

'^ These views seem lo be almost demonstrated by the important observations of Mr. 
M'Gregor; who found, that sugar is not only developed from vegetable and animal matters 
in the stomach; but that it exists in the blood, saliva, «&.c., and even in the alvine evacua- 
tions of a diabetic patient, 

d Dr. Prout. 



982 FUNCTIONAL DISORDERS OF THE KIDNEY. 

mentation; and acquires, from the quantity of lactic and acetic acids developed, the 
strong acrid smell of sour milk.*''] 

Diagnosis. — The diagnosis is sufficiently easy. It may be made by measuring 
tfie quantity of fluid, by weighing it, and by analyzing it. We obtain, in diabetes, 
a brown treacly extract; which, on tasting, we find to be sweet. No one can object 
to taste it; for it is not urine, but sugar. When the fluid is evaporated, there is 
nothing left but "hard-bake;" which tastes just as well as any other "hard- 
bake." But although the disease is made out easily enougli, when we suspect its 
existence, and it really does exist, yet it is a disease which is continually over- 
looked. It comes on so insidiously, that many persons have it for a length of 
time, before the medical attendant suspects its existence. The patient complains of 
being weak and languid; does not know what is the matter with him; and the 
quantity of urine may not be such as to attract his attention; — so that frequently no 
light is thrown on the disease. I have known so many cases of this kind passed 
over, that when I see a patient complaining of weakness, and can discover no evi- 
dent cause, I always question him as to the quantity of urine. Not long ago, I 
saw a patient who must have had diabetes for some years; but that circumstance 
never struck my mind. He had disease of the heart, which was killing him; and 
ir was not till I saw him three or four months afterwards, that he spoke of the 
quantity of his urine. The disease of the heart explained every symptom of which 
he complained; but, upon being told that there was something wrong in his urine, 
I evaporated a portion, and found it was diabetic; and he then stated that, for seve- 
ral years, he had made an excessive quantity of urine. No disease is more easily 
passed over; — unless the patient chances to mention, that he makes a larger quan- 
tity of urine than usual. When we see a patient emaciated, complaining of thirst, 
with a good appetite, and a dry skin; while we can see no reason for these symp- 
toms, either in the chest or abdomen, — it is well always to inquire into the state of 
the urine. 

Prognosis. — [The general prognosis in diabetes, must be considered unfavour- 
able. Among the favourable symptoms in this affection may be enumerated a 
moderate flow of urine, of a specific gravity not higher than 1*035; the appearance 
in the urine of lithic acid, either in its amorphous or crystallized form; the recent 
appearance of the disease, and absence of thirst; the retention or gain of flesh and 
strength; and (more than all) immunity from organic disease, especially of the 
lungs. On the contrary, when the flow of urine is permanently excessive, and of 
high specific gravity; or when this secretion is pale-coloured, opalescent, and 
serous; when the thirst, emaciation, and debility are extreme; or when organic 
disease, particularly of the lungs, is present, the chance of recovery is much dimi- 
nished. But when (as is too frequently the case) several, or all of these unfavour- 
able symptoms coexist, the chance of recovery is not only diminished, but absO' 
lutely hopeless."'] 

Treatment. — Perhaps this is the most singular disease in the animal economy; 
for the nature of it is not known; and the treatment which is found useful is as 
singular as the disease itself. The remedies are directly opposite. There can be 
no doubt that repeated venesection has sometimes lessened the symptoms very 
much; and it is sometimes borne remarkably well. There are on record a suffi- 
cient number of cases to establish the fact, that bleeding is occasionally very useful 
in the disease; not bleeding to syncope, — not violent bleeding; but repeated bleed- 
ings, — taking from eight ounces to a pint. I have employed this method; and 
have seen it borne in a remarkable manner. In many cases, the urine diminished, 
and the quality improved, while venesection was going on. But though there can 

" This phenomenon is often exhibited by the chylous urine; — a disease in which the dis- 
or??anizing function of the kidneys is either destroyed, or suspended. (See Page 1050.) 

•* Dr. Prour, on the Nature and Treatment of Stomach and Urinary Diseases. Book 1; 
Chapters; Section 1; Subdivision 3. (Third Edition; Pages 36 to 38.) 

•= Dr. Pront, on the Nature and Treatment of Stomach and Urinary Diseases. Book 1; 
Chapter 2; Section 1; Subdivision 4. (Third Edition; Pages 38 and 39.) 



FUNCTIONAL DISORDERS OF THE KIDNEY. 983 

be no doubt of its utility, yet it has frequently failed. Some prefer the application 
of leeches to the epigastrium; and some, cupping on the loins. 

Jlnimal Diet. — Then, again, rump-steaks eaten abundantly (which is a practice 
directly opposite to bleeding) have also answered as good a purpose. Many per- 
sons have their urine improved, by being confined to animal diet; but still, we should 
imajrine that this would not go to the root of the complaint, wherever it may be. 
It is like giving phosphate of lime in softness of the bones, and taking carbonate 
of soda to remedy acidity of the stomach; — it is merely alleviating, not curing the 
disease. But we find it very difficult to make a person adhere to animal diet. He 
becomes so disgusted with it at last, that he says he would rather starve than eat 
meat every day. I never found a patient able to continue it for a length of time. 
Still, as there is great weakness, it may be well to make a patient live on meat as 
much as possible; and we find as strong evidence in its favour, as in that of 
bleeding. 

j^Dr. Francis Horne was the first to point out the advantages of an animal diet, 
in the treament of diabetes; but the dietetic treament was not reduced to a regular 
system, or its effects thoroughly understood, till the publication of the interesting 
treatise of Dr. RoUo.* Tins author illustrated the beneficial effects of animal diet 
by a variety of cases, in one of which a complete and apparently permanent reco- 
very was accomplished; and since his time, a diet more or less purely animal has 
constituted an essential part of every successful method of cure. Dr. RoUo dwelt 
strongly on the necessity of enforcing for some time a strictly animal diet, into which 
no article of vegetable food was to be admitted. It has been found, however, exceed- 
ingly difficult to secure the observance of an absolute animal diet even in private 
practice, and still more in hospitals; and in recent times it has even been maintained, 
that the rigorous observance of such a diet is not essential; and that some articles 
of vegetable food, more especially bread, may be safely allowed in moderate pro- 
portion. The difficulty of enforcing a rigorous animal diet, must be readily con- 
ceded; the craving for vegetable aliments soon becomes overpowering, particularly 
where the patient is tantalized by the sight of others indulging in them without 
control. But some doubt may be entertained whether the rigour of RoUo's dietetic 
system can be relaxed at all without prejudice; even although several eminent 
authorities, and among the rest Dr. Prout, have decided the question in the affirma- 
tive. It is at least not unworthy of remark, that those who allow a moderate pro- 
portion of vegetable aliment, admit their practice to have been unsuccessful; while 
others, who maintain, with Dr. Bardsley, that a fair proportion of cases may be 
cured, have adopted in their practice a rigorous animal diet; and insist, like Rollo, 
that they who deny from their own ejiperience the curability of the disease, had 
forfeited all claim to do so, from having permitted a departure from his injunctions 
in this respect. 

It is universally conceded that, if vegetable food is to be allowed at all, bread is 
the only admissible article; and that it should be fermented bread, and somewhat 
stale. Among animal articles, the flesh of adult animals is preferable to others; it 
ought to be cooked (in preference) by broiling or roasting, and with as little salt as 
possible, lest thirst be excited; it should be taken tliree times a day, at most, — the 
largest meal being that of dinner; and the last meal must be taken at least two or 
three hours before bed-time. In the middle walks of society, a greater variety of 
articles and modes of cooking is advisable; otherwise an animal diet soon becomes 
irksome; but, in admitting variety in these respects, digestibility is always an im- 
portant condition. Rollo and some of his imitators have thought, that there is an 
advantage in the meat being as fat as possible; because it is less digestible than in 
its ordinary state. But the reason for this preference is far from conclusive; and 
experience has not confirmed tiie statement, that much fat tends to restore the 
lieallhy constitution of the urine. Others, aofain, have thought that cheese may 
form a moderate proportion of the food; on tlie ground, that in a state of health it 

» Cases of Diabetes Mellitus. Bv John Rollo, M. D. 



984 FUNCTIONAL DISORDERS OF THE KIDNEY. 

is comparatively indigestible, superabundant in azote, and highly productive of urea 
and lilhic acid. Here, too, ulterior experience contradicts early theory. The sto- 
mach being apt (in many cases) to be easily disordered, indigestible substances 
ought not to be preferred; as the urine generally abounds in urea, food producing 
this principle in abundance is not eligible; and in point of fact cheese, even where 
well digested, does not appear to possess any advantages over muscular fibre. It 
ouglit not, therefore, to constitnte a large proportion of the food as some propose; 
but may be allowed in small quantity for variety's sake, wherever it is found easily 
digestible. The quantity of the food should be carefully regulated. Exaggerated 
notions are often entertained of the quantity of food which diabetics consume; and 
in general, though they have unusual appetite and craving before meals, they will 
be satisfied with even less than the allowances of a stout man engaged in an active 
employment. If bread is allowed, sixteen ounces of that article, and twenty ounces 
of meat (weighed raw), will generally prove sufficient; or it will become so in no 
long time, if the morbid condition of the urine should begin to yield to treatment. 
As thirst is commonly a more urgent symptom than hunger, so it is likewise 
more difficult to control. The regulation of the drink is, however, one of the most 
essential articles of treatment. For it must be observed, that extensive indulgence 
in liquids is (on the one hand) injurious by impairing digestion, or even causing 
some of the food to pass into the intestines undigested; and (on the other) it has a 
much worse effect upon the urine, than merely increasing its quantity by simple 
dilution; since the density is commonly found to be maintained, though the quan- 
tity be greatly increased. The patient must, accordingly, be often exhorted to 
curb the longing for drink as much as possible; and great care should be taken ia 
regulating its quality. It is found that thirst is slaked with a less amount of fluids, 
when a considerable proportion of the drink consists of such animal infusions as 
weak beef-tea or mutton-tea; to which may also be added milk in moderation. 
Except these articles, pure spring water, and probably also such waters as contain 
calcareous salts in excess, no other ordinary articles of drink are allowable. The 
water of Bristol Hot- Well, and other calcareous springs, has been found (by Dr. 
Marsh, Dr. Prout, and others) to be less apt to increase the quantity of urine, than 
ordinary waters. Beer and other fermented liquors, much as they are longed for 
by the patient, — also wine and spirits, which he often asks for on account of the 
sense of languor and oppression that assails him, — tea as being in some measure 
diuretic, and all acidulous drinks, must be carefully shunned.^ An important rule 
is, that he should drink little at a time. Another rule not less essential is, that 
little liquid should be taken at meals, and the thirst controlled as long after meals 
as possible; because under these precautiofis digestion goes on more perfectly, and 
thirst subsequently is less difficult to appease. Advantage has been found by some 
in using all the drink warm, because less is required to slake the thirst. While it 
is desirable that the desire for drink should at all times be controlled as much as 
may be conveniently accomplished, great and sudden reductions ought never to be 
attempted; especially when the disease is somewhat advanced. 

It is of imperative consequence, that violations of system as to diet be scrupu- 
lously avoided. The undue gratification of the thirst, the indulgence in such pro- 
hibited articles as beer, spirits, vegetables, pastry or confectioneries, is infallibly 
followed by an increase in the quantity and density of the urine, when it has been 
reduced in these respects by previous care in eating and drinking; and one stolen 
enjoyment is dearly purchased by many days of aggravated thirst and exasperation 
of every symptom.''] 

« When the patient has been in the habit of taking' fermented liquors, I [Dr. Prout] have 
been accustomed (for some years past) to recommend sound porter, in preference lo wine or 
spirits. The quantity must be determined by the circumstances of the patient; but the 
minimum quantity should be rarely surpassed. With Yety few exceptions, I have seen 
more relief from thirst, and more support g'iven by- porter in diabetic cases, than by any 
other means whatever, — Dr. Prmd, on the Nature and Treatment of Stomach and Urinary 
Diseases. Third Edition-, Page 44. 

b " Library of Medicine;" Volume 4; Pages 258 to 3G0. 



FUNCTIONAL DISORDERS OF THE KIDNEY. 9S5 

Opium. — There can be no doubt that opium has a great power over the disease; 
it increases the quantity of lithic acid, — ilie quantity of urea^ and lessens tliat of 
the sugar. I have seen this proved repeatedly; — nay, so great is its influence, that 
a very great quantity will diminish the urine, as rapidly as it will diminish the 
sugar in the urine, I once, findino- a man dying of tlie disease, gave him opium 
so freely, that it induced stupor, and some degree of delirium; and, in the course 
of sixty hours, the quantity of urine was reduced from eight pints to two, in the 
twenty-four hours; and, from being very heavy, it lost the greater part of its mor- 
bid specific gravity; and absolutely lost the whole quantity of sugar. Indeed, 
urea was produced in excess; — the urine contained more urea than it does in health. 
The man died, a few days afterwards, of phthisis; but the quantity of opium pro- 
duced the effect I have stated. In general, by giving opium, in increasing doses, 
we lessen the amount of urine, and likewise the quantity of sugar. Of course, the 
opium may be increased in this disease, as it may in any other; and one man, who 
began with half a grain, three times a day, at last took as much as two scruples, 
three times a day. It never confined his bowels; which it usually does where 
patients take a large quantity. His urine became natural; when, through a mis- 
take on the part of those who made up the prescription, he had forty grains of blue- 
pill, which he took three times a day. Thus there was an absence of the opiu?n, 
and the presence of a sivong purgative, — a strong mineral poison^ and instantly 
the sugar was brought back into the urine, in the original quantity, and the urine 
also was increased as before. The opium was renewed again; but I never made 
an impression on the disease afterwards. Whether the benefit would have con- 
tinued, I do not know.'' 

It is said that other narcotics answer as well as opium; but I do not know 
whether that is the case. However, there was one man who, by repeated bleed- 
ings, appeared cured; but I did not see him afterwards. I do not know that I ever 
yet cured a case of this disease; and I dare not say that he was cured by opium, 
by animal diet, or by any other means. Of course, I am speaking of saccharine 
diabetes; for " diabetes insipidus,'''' may be effectually removed. 

Other Remedies. — The steam-bath and the hot-bath have been strongly recom- 
mended; but I have used them without any material benefit. Iron has also been 
recommended; — particularly the phosphate; but I employed the sesquioxide, and 
it appeared useful; though I have never seen it cure the disease. I have not had 
sufficient experience of the disease in children, to say whether it may or may not 
be cured. I saw a child, about two years ago, making an excessive quantity of 
urine; and I think this urine was said to be saccharine; but this state lasted only a 
few days. Alum, catechu, and astringents, are said to be of service; and it is al- 
leged that they have sometimes cured the disease. But what I would recommend, 
if the patient's strength would bear it, would be venesection, and a confinement as 
much as possible to animal diet; and there is no reason why we should not give 
opium, and at the same time phosphate of iron. These all act in a way that we 
do not understand; we are not sufficiently acquainted with the disease to say that 
they will not do good; and if I found a remedy serviceable, I would recommend a 
patient to use it. It is right always to make a patient wear plenty of clothes; to 
keep the surface as warm as possible. Warm clothing, and exercise to sweating, 
have been recommended; but I have known persons perspire profusely in the 
disease, without any good being done. 



SECTION m.— EXCESS OF UREA IN THE URINE. 

There is an affection very similar to diabetes, and sometimes mistaken for it; 
and that is, where the urea is in excess, I do not know that the disease has been 

» In the '• Lancei" for December 1, 1832, (No. 483, Page 319,) will be found a case illus- 
trating the efticacy of Muriate of Morphia in this disease. 



986 FUNCTIONAL DISORDERS OF THE KIDNEY. 

Roticed by Jiny one except Dr. Prout; but I have seen several cases of ii; all of ' 
which have done well. 

Symptoms. — There is debility; lowness of spirits; pain in the loins; thirst; an 
excessive quantity of urine; a diminution and frequently a loss of sexual power; 
often irritation at the neck of the bladder; and a frequent desire of making water. 
The urine is pale, and likewise heavy, — perhaps the specific gravity is from 1*025 
to 1'030. It is acid; but soon grows alkalescent. On evaporating the urine, we 
find no sweet extract; and if we add strong nitric acid to the fluid, we have a pre- 
cipitation of the urea. This state of the urine is frequently seen where the phos- 
phates are in excess. Equal quantities of nitric and muriatic acid must be added, 
in order to produce crystals. 

Treatment. — The remedy for this state (as for diabetes) is opium," and likewise 
iron.^ I have seen these cases yield to the exhibition of one or both these reme- 
dies. Dr. Prout has cured many cases, which were thought to be diabetes, till he 
examined the urine, and found no sugar in it. The patient complains of the symp- 
toms I have narrated;'' and if we find it to be this disease, it may yield to the 
remedies I have just named. If the patient's health be improved, the disease may 
cease spontaneously. It is by no means a formidable disease, — like the formation 
of sugar." 

Just as, with respect to the solids, we have an excess of development, or an 
alteration of natural structure,*^ so the same is observed occasionally in the Jluids, 
The natural constituents become changed in their proportions; and just as, in one 
part of the body, we have cartilage, or bone, where it ought not to exist, — so, with 
regard to the fluids, we find them containing something which ought not to be 
tliere; but still something which is natural to the body; or we find them containing 
something in excess. Again, as, with regard to structure^ we sometimes have a 
new structure altogether, — a structure that ought not to be in the body at all; — 
such as melanosis (if we choose to call that a structure), and scrofulous disease, 
which is a foreign substance; — so occasionally, in the fluids, we find things that 
ought not to be there at all. Of these sugar in the urine is an instance. We have 
changes in the fluids analogous to transformations in the solids;^ and we have 
further changes, which are analogous to new formations.^ 



SECTION IV.— SERUM, CHYLE, AND FAT IN THE URINE. 

Before describing that disease in which there is sugar in*the urine, — which is a 
new formation altogether, and not found in any part of the body, — I ought, for the 
sake of uniformity and consistency of plan, to liave mentioned some other affec- 
tions; — those in which there is merely a transformation, if I may so term it; — in 
which we find in the urine things which are natural to the body, although they 
ought not to be present in the urine. 

Serous Urine. — One of these articles is serum; the presence of which is easily 
ascertained by the application of heat. It coagulates (as we know albumen does) 
at 160 degrees; or it will coagulate on adding a small portion of acetic acid, and 
then prussiate of potass. I spoke of this as occurring sometimes in inflammatory 
dropsy, sometimes where there is no inflammation to be discovered, and sometimes 
where there is no disease of the kidney to be ascertained.^ When serum exists in 
the urine, the urine may be of its natural quantity, or it may be below it, or it may 
be in excess. Generally the urine when made is pale; sometimes it is, when fiiot 
made, a little opaque. I need not say any thing more about this; as I described it 
so fully when treating of dropsy.'' 

Chylous Urine. — Fibrin sometimes exists in tlie urine; — not as a deposit from 
the ureters or bladder, but really as the product of tlie kidneys. At least, it was 

* See Page 985. ^ See the previous paragraph. ^ See Page 977. 

•• See Page 176. ^ See Page 181 

e See Page IGl. ^ See Page 15y. 



CALCULOUS DISEASES. 987 

SO in a case which I saw. I have seen only one case, but that I repeatedly ex- 
amined; and I found it was the fibrin of chyle; — there being fibrin in cJiyle, as 
well as fibrin in blood. The case to which I have just alluded, was very remarka- 
ble. The woman was otherwise in very good health; but soon after she passed 
urine, a coagulation took place; and there was a quantity of something exactly like 
*' blanc mange;" — as much as would fill a tea-cup. Occasionally it coagulated; 
so that she could not make water. I showed the discharge to Dr. Proul; who 
examined it, and ascertained that it was chyle. She went on, in this state, for two 
or three years; and, in the midst of it all, she gave birth to a cliild; — it seemed to 
make no difference in that way. I have every reason to believe she is now alive. 
Dr. Prout has seen six or seven cases since that time. I wished to make some 
observations upon her; and begged her not to take any food for twenty-four hours; 
— in order that I might see if it would check the formation. There was this change 
produced; — the coagulum approached nearer to blood. It had a fine pink colour; 
and tlie more she fasted, the more it approached to red; — it was more and more 
converted into blood. There was no fresh food taken to form fresh chyle; and 
consequently the chyle became more like blood. Around this coagulum there was 
a fluid, which was very serous, — contained a good deal of albumen in solution; 
and, of course, there was urine; but the fluid scarcely smelt of urine, till it was 
concentrated. One hundred grains of the fluid, on evaporation, gave only half a 
grain of urea. Nothing was done in this case; but Dr. Prout told me that, by the 
long-continued exhibition of opium, two or three times a day, he had been success- 
ful in curing this disease. The quantity of substance was altogether deceptive to 
the eye; for, on evaporating this large coagulum and examining it, there was very 
little solid matter; and therefore the loss to the system was by no means so great 
as, at first sight, we must have imagined. 

Discharge of Fat. — Fat has occasionally been found in the urine. When speak- 
ing of a discharge of fat from the intestines, I stated that, in some cases mentioned 
by authors, fat was found in the urine;'' and in the case of a lady whom I know, 
but whom I do not attend, the gentlemai:w under whose care she is assures mOj that 
a large quantity of fat is discharged along with the urine. 



CHAPTER III. 

CALCULOUS DISEASES. 

SECTION L— URINARY SEDIMENTS. 

Concretions are of a mixed nature. They may consist merely of the natural 
constituents of the urine; and may therefore be analogous to those diseases of the 
solids called " transformations;'"' — in which things naturally found in the body are 
present. Or tliey may be new substances, — such as ought not to exist in the body 
at all; — being analogous to those which are termed '-new formations," or "-non- 
analogous changes of struclure."° Before entering on the subject of urinary con- 
cretions, however, it is necessary to make some general remarks on the nature of 
urine and its constituents. 

Jicidity of healthy Urine. — Healthy urine, when it is first made, is acid. It 
will stain litnuis-paper; and, if the bladder be not very retentive, and if persons be 
not very particular (as is sometimes the case with old gentlemen}, ilieir dress will 
be stained; — it becomes red on account of the acid in tiie urine. Chemists say, in 

^ See Pages 930 and 931. ^ See Page 184. 

«= See Page 189. 



988 CALCULOUS DISEASES. 

general, that the nrine is acid when first made; but Dr. Prout contends that it is 
not pure uric acid, but lilhate of ammonia, that stains litmus-paper red.* 

a. Jlmorplious Sediments. 

Lithic-acid Deposits. — Bui the urine sometimes contains nitric acid; and we 
know that, if nitric acid be added to lilhic acid, erythric acid is produced. It is of 
a very fine scarlet hue. If to this erythric acid pure ammonia be added, a purpurate 
of ammonia is produced; and if we treat this purpurate with potass, and then 
again with sulphuric acid, a new acid is formed, — called " purpuric acid;" so 
that erytliric and purpuric acid do not exist naturally in the urine, but are the 
result of other changes. If nitric acid be formed (by disease) in the urinary 
secretion, purpuric acid may be formed; and then (as ihere are soda, potash, and 
ammonia, in the urine) we may have the purpurates of soda, potash, and ammonia; 
and if these are added to the lilhate of ammonia, then the lilhate of ammonia which 
may exist in the urine, becomes of a fine pink or red colour; and we have a pink 
or red sediment. Therefore, the pink and red sediments are essentially lithale of 
ammonia, which is formed in excess, — so as to be insoluble at a common tempe- 
rature; and they are deposited in the urine because they are in excess, or because 
the acid is in excess; — they are super-lithates. The lilhate of ammonia, and the 
other liihates, are ivhite of themselves; but, from the presence of the purpurates, 
they acquire a red or pink colour; and if the yellow matter of the urine be absent 
(as in heciic), then, instead of being red, they become pink. All this, however, 
is comparatively unimportant. 

In pyrexia, nitric acid appears to be formed in the urine; and the lithates (par- 
ticularly the lilhate of ammonia) are in excess; and, in consequence of the excess 
of lilhic acid, or of lilhate of ammonia, and the formation of the purpurates by 
nitric acid, a copious red sediment is produced; and though it is originally owing 
to the nitric acid, yet it is a lithale (generally the lilhate of ammonia) which has 
been rendered red by the presence of the purpurates. 

Causes. — All this may be produced by the sympathy of the kidney with any 
other organ that is affected. From mere catarrh; — slight inflammation of the mu- 
cous membrane of the air-passages, we may have this effect produced. In fever, 
and in inflammation, the same occurrence takes place. If there be organic disease, 
especially of the liver, it has a tendency to produce pink sediment; — that is, it 
causes an absence of the yellow matter; and consequently the sediment is pink. 
Very trifling things will produce this state, in some people. Anxiety, strong 
exercise, a little pie-crust or pastry, or the slightest derangement, may cause a red 
or yellow sediment. Hence Dr. Prout has called this — " the sediment of health;"* 
though it is seen in disease. He means that it occurs from such slight causes, that 
it is hardly worth while to consider it as an indication of disease. All is not right, 
but still it will liappen every day; and, indeed, by far the most frequently when 
the person is in a stale which we cannot denominate " indisposition." Generally 
the redder or the pinker the urine is, the more scanty is its quantity. 

Deposition occurs iv hen the Urine cools. — The temperature of the urine, when 
in the body, is sufficient to keep these mailers suspended; and therefore it is gene- 
rally passed clear; and it is not till the fluid is cool, that the sediment appears; and 
even then, if the person make water a short time afterwards, the heat of the fresh 
quantity of urine, causes the sediment of the former to be dissolved again; though, 
of course, a second cooling occurs. For tliis reason we observe this sediment far 
more frequendy in cold, than in warm and hot weather. In hot weather, though 
the urine perhaps contains every thing necessary for such a deposition, yet it does 
not produce it; but in cold weather, if it so happen that the urine is not in excess 

a " On the Nature and Treatment of Stomach and Urinary Diseases. By William Prout, 
M. D." Third Edition. Introduction, Section 8; Pages 74 and 75. 

!> Dr. Prout, on Stomach and Urinary Diseases. Book Ij Chapter 3; Section 8; Subdivi- 
sion 1. (Third Edition; Page 196.) 



CALCULOUS DISEASES. 989 

(as it so frequently is), — if we are not chilled, — if we are in a warm room, — if we 
do not diminish the perspiration, the quantity of urine remains the same as before; 
and then, on making water, in a cold room, we are almost sure to have this sediment; 
although in summer, in the same circumstances, we should not; for the external 
heat would then be quite sufficient to keep these ingredients in a state of solution. 

Varieties in the Colour. — There is great variety in the colour of the sediment. 
Sometimes it is red; sometimes it is reddish; sometimes it is brown (tlie colour of 
a ripe hazel-nut); and so on; — fainter and fainter, till the sediment is nearly while, 
or perhaps quite so. 

Lithic-Acid Deposit shows Jlcidity. — AVhen we see red or pink sediment, the 
urine is generally more acid than in heahh; and when it approaches more to yellow, 
it is less acid. It shows that there has been less nitric acid; and that less of the 
purpurates have been formed. A less change, therefore, has been produced on the 
lithate of ammonia by the purpurates; and therefore we have a fainter colour. This 
is all very intelligible: but, it is necessary to show it, in order that it may be fully 
understood. In those states of the body in which there happens to be nitric acid 
formed in excess, we have the purpurates; and the purpurates, being present and 
united with lithates, produce a red or a pink colour; — ^just as it may be. In the 
case of red or pink sediment, therefore, the urine is acid; but if it so happen that 
nitric acid is not formed in abundance, then the purpurates are not produced in so 
much abundance; and therefore they cannot change the colour of the lithates (which 
is naturally white) to a red or pink hue. Hence, whenever this sediment is red 
and high-coloured, we generally find the urine very acid; and in proportion as it 
is paler, — goes through a faint brown and approaches to white, — in that proportion, 
generally, is the urine less acid. It may even be deficient in the natural quantity 
of acid; and be rather alkalescent. The urine, when there is acid, is high-coloured; 
but when the sediments are pale, and the urine is not acid, then the urine generally 
is pale also. 

Oxalate of Lime. — Besides the nitric acid, oxalic acid has been found in the 
urine, in the form of a sediment; not a powdery, but a crystallized one; and is in 
union with the oxalate of lime. Once only has Dr. Prout seen a powdery sedi- 
ment; — what he calls "an amorphous uncrystallized sediment of oxalate of lime," 
and then it was mixed with ammonia. We shall see, with regard to oxalate of 
lime, that one calculus consists entirely of it; and the tendency to produce oxalic 
acid, it is said, has been sometimes traced to eating sorrel; which contains that 
particular acid. But of that I will speak presently. 

Fhosphalic Deposits. — If the sediments of the urine be absolutely white, then 
they are not the lithate of ammonia, but the phosphate of lime, the phosphate of 
magnesia, or the phosphate of ammonia, or more than one of these. In this state 
of things, — when there is this absolutely white sediment of the phosphates, — the 
urine is 720t acid. On the other hand it is alkaline; or it becomes so very soon 
after it is passed. It is rare, certainly, for the urine to be quite alkaline at first. 
Sometimes the urine is all but alkaline; and it is no sooner passed, than it emits a 
strong smell of ammonia. The best test for alkalies is, not turmeric-paper, but 
litmus-ppiper which has been exposed to acid. Reddened litmus-paper is the most 
delicate test; for the smallest quantity of alkali brings back the purple hue. When 
the sediments are white, and depend upon the phosphates, the urine differs, in other 
particulars, from the urine made when the sediment depends upon the lithate of 
ammonia. The urine, instead of being high-coloured, is pale, — with a faint greenish 
hue; and, instead of being scanty, — as is the case with acid urine, — it is generally 
abundant; and, verv soon after it is made, it undergoes such a high degree of de- 
composition, that it becomes very offensive, and smells of ammonia. Still there 
is one exception to this; and that is, when lithate of soda has been deposited. I 
have had one case of this description; and, I suppose, others have had many. 
There was a white sediment in the urine; but it did not depend upon the phos- 
phates; and therefore the quality of the urine was like that which is seen where 
there is red sediment. The lithate of soda, if not coloured by the purpurates, is 



990 CALCULOUS DISEASES. 

perfectly white. It so happened, in this case, that the lithate of soda was deposited 
pure; but as it was nota pliosphate, the urine was not of that quality which occurs 
when the phosphates are deposited. It was not abundant, but scanty; it was not 
alkaline soon after it was made, but acid; for it tinged litmus-paper red. 

Diagnosis. — One set of sediments consists of lithates deposited in abundance; 
and they are generally tinged with the purpurates.* Another set are always white: 
and they are phosphates.'' In one set we have acid urine,'' in the other alkaline;^ 
namely, where there is an alkaline phosphatic disposition. In one set the urine is 
scanty,^ in the other it is abundant;^ in one it is high-coloured,^ in the other it is 
pale, and frequently of a green hue." If it so happen that the purpurates are not 
formed, we may have a pure lithate of ammonia; and the deposit will then be 
white;^ iust as if it were a phosphate.'' 

Cause. — This state of the urine — where the phosphates are deposited, and where 
the urine is abundant, and disposed to alkalescency (not staining litmus-paper) — 
does not show an inflammatory state. The other secretion of urine* shows an 
inflammatory condition; but this is connected with an irritable state of the system, — 
a state of debility. 

Alternation of Lithates and Phosphates. -^However, these very states run into 
each other. We may have persons passing one description of urine, with one 
kind of sediment, and then the other, alternately; and we may have persons verging 
from one to the other; — so that there is no certainty. Persons are in a sort of 
mixed transition-state; where matters are much confused. Most probably, ihey 
begin with acid urine, and the lithic deposits;* and yet they are actually passing 
into the other condition," which is the worst state of the two. The sediments are 
sometimes seen to be mixed. In the sediment, we have occasionally lithic acid, 
the lithates, and the phosphates also at the same time; — so that the whole state of 
the patient may be one of transition. Sometimes these conditions alternate; so 
that we may be very much puzzled, perhaps, in the treatment of the case. 

Excess of Urea in Phosphatic Urine. — Where the urine is abundant, pale, 
green, and alkalescent,'' and the phosphates are deposited, it is observed also that 
urea is in great abundance; but Dr. Prout considers that it is imperfectly formed; — 
that it is the urea which gives rise to the abundance of ammonia.*^ The way in 
which this operates he conceives to be the following. In these cases the urea is 
secreted in abundance. Urea, we know, is a compound; and, being badly formed, 
it undergoes some change, and afllords ammonia. As there is not a correspondent 
quantity of phosphoric acid, this ammonia precipitates the lime; and then, by uniting 
with the phosphate of magnesia, a triple salt is formed; which salt is called the 
*' ammoniaco-magnesian phosphate."** This is, of course, a phosphatic sediment; 
and we may easily know this triple sediment, by its white glistening particles. 
The urine, in these cases, is alkalescent; because there is such an abundance of 
imperfect urea, — giving rise to so much ammonia. However, though the abundance 
of ammonia (from the diseased urea) may be the cause of the deposition of this 
phosphatic sediment, yet the same effect will be produced from a deficiency of acid 
in the urine. If there be not sufficient phosphoric and sulphuric acid, the lime 
will be precipitated; and, not only the lime, but likewise the ammonia and mag- 
nesia; — so that we have the "ammoniaco-magnesian phosphate." Sometimes it 
is said that an excess of lime is the cause of the mischief. That, however, is rare. 

Thus the urine may err through an excess of acid, of one kind or other (gene- 
rally the nitric*); or from a deficiency of the acids.'' 

b. Crystallized Sediments. 

Lithic Jlcid. — The sediments are sometimes mere powders (called "amor- 
phous"^); but sometimes the matters deposited are in a crystallized state. In the 

a See Page 987. '' See Page 989. 

^ Dr. Prout, on Stomach and Urinary Diseases. Third Edition. Introduclionj Section 8; 
Page 89. 

« See Page 988. 



CALCULOUS DISEASES. 991 

latter case they may, in the first place, be red. These red, granular, crystalhzed 
sediments (called " crystallized," to distinguish them from powdery ones) are spi- 
culaled crystals. AVe may see them in the urine. There will frequently be red 
crystals, with numerous spiciilce, at the bottom of the vessel. Some of them, by 
chance, mav be swimming; and some may be sticking at the sides. These are 
very nearly pure lithic acid. From the great quantity of nitric acid, most proba- 
bly^ the lithic acid is precipitated. Sometimes the lithic acid is absolutely in ex- 
cess, so that it is not held in solution; and therefore crystals are deposited. But 
this is not necessarily the case. The phosphoric acid will sometimes do this, and 
sometimes the sulphuric; but frequently it is muriatic acid; and sometimes it is 
even said to be carbonic acid. It must be an acid of little strength, to precipitate 
the lithic acid; because any strong 2.q,\(\ will produce decomposition. The urine — 
when it deposits this spiculated, crystallized, red sediment — is usually very transpa- 
rent; and of a fine, reddish colour. 

Triple Phosphate. — If the crystallized sediment be ivhife, it is usually the triple 
phosphate of magnesia and ammonia; and is called the " ammoniaco-magnesian 
phosphate." The urine, in this case, is just the same as if the sediment had 
been in powder. It is alkalescent, abundant, pale, and greenish; and soon becomes 
ammoniacal, and undergoes decomposition.'' 

Oxalate of Lime. — We may have crystals consisting of oxalate of lime;* and 
then the crystals are of a dark green colour; and the urine is found to be acid. But 
this is a very rare occurrence; and one which I have never seen. The crystallized 
deposits are said never to be found together; while \\\q powdery concretions (the 
amorphous deposits) sometimes are. 



SECTION II.— URINARY CALCULI. 

If it happen that the crystals just described are larger, or that more solid matter 
is heaped together, we give to them the name of "concretions." It is merely the 
same thing on a large scale: — perhaps the union of several of these, deposit over 
deposit; and a great quantity of solid matter. We may be prepared to understand 
these concretions, from what I have now said respecting sediments; — both powdery 
(" amorphous") and crystallme. 

Lithic v6[cid. — In the first place, we have a concretion which is merely lithic 
acid; and is of a brownish-red or fawn colour. Concretions of this kind are some- 
times smooth, but sometimes they are tuberculated, — rather rough. On dividing 
themj we find that they consist of concentric laminas within. If they are broken, 
instead of being divided with the saw, the fracture is imperfectly crystallized, and 
of a deep fawn colour, like the rest. Sometimes they are not in concentric lami- 
nae; but form an amorphous irregular mass, of a pale colour; but when they are 
pale, they are generally mixed with a litde phosphate of lime, or even 2 liule oxa- 
late. If we apply heat to this calculus, it becomes white, and burns away; leaving 
a minute quantity of white-ash, which is generally alkaline. This calculus is 
quite soluble in potash; and we may precipate it again by acid. It descends in 
the form of a white powder. If we add nitric acid as well as apply the heat, it is 
dissolved; and, on drying it, we have a fine carmine colour, which is erythric 
acid.** I before stated, that when nitric acid is added to lithic acid, a fine scarlet 
colour is produced;* and therefore if we take such a calculus as this, and add strong 
nitric acid to it, we obtain a red colour. 

Lithate of .Ammonia. — The calculus just mentioned (lithic acid) is rarely found 
pure. It is generally mixed with the lithate of ammonia; and it is then clay- 
coloured, — rather paler than the other. It has,' however, the same general charac- 
ter. It is sometimes smooth, and sometimes tuberculated; sometimes it has con- 
centric plates, and sometimes it is an amorphous irregular mass; but it is more 

* See Page 989. 



992 CALCULOUS DISEASES. 

rarely found in the latter slate, than the calculus of pure lithic acid. The most 
common calculus of this description, is not pure lithic acid, nor pure lithate of 
ammonia, but a mixture of both. If lithate of ammonia exist in a calculus, either 
in a pure or in a mixed state, it decrepitates by heal; and if we add potash with the 
heat, ammonia is soon given off. It is soluble in the alkaline carbonates; whereas 
a calculus of pure lithic acid is not; and therefore we may easily distinguish the 
one from the other, by chemical means. A calculus consisting of pure lithate of 
ammonia, occurs generally before puberty. It is small, and rather uncommon. 
The calculus of lithate of ammonia is not only continually found mixed with lithic 
acid, but often with oxalate of lime. 

Oxalate of Lime. — The next calculus which is found in acid urine, is " oxalate 
of lime." This, for the most part, is very easily known. It is brown, rough, 
exceedingly hard, and generally exceedingly rugged. From the irregularity of its 
surface, it is called " a mM/6erri/-calculus." Sometimes it is nearly black. On 
applying heat, a white efflorescence appears upon it. Oxalate of lime no longer 
remains, but jowre lime; and this, being alkaline, will stain turmeric-paper. Occa- 
sionally this calculus has been found smooth; but in that case it must be of a very 
small size. Generally it is a most formidable-looking calculus; — such as would 
make one shudder, when we remember that it is formed in the human bladder. 
It is known by its ruggedness and dark colour. 

Cystic Oxide. — There is another calculus which exists with acid urine; and it 
is called " cystic oxide." It is so very rare that, perhaps, we may never meet with 
it; but I will describe it. It is of a yellowish-white colour, and smooth externally. 
Internally, it is a confused, crystalline, glistening mass. In point of size, it is 
small. If heat be applied, a peculiar odour is emitted; and it is soluble both in 
acids and in alkalies. 

Phosphate of Lime. — We now pass to the consideration of other calculi; which 
exist with urine generally deficient in acidity, and sometimes bordering very closely 
on alkalescency. These are the phosphates; and the first calculus of which I will 
speak, is that composed o^ phosphate of litne. The colour is of either pale brown, 
or white. It is very smooth and polished; and has regular laminae, which are very 
separable from each other. It is rare and small; and it is thought, by Dr. Prout, 
not to be a true urinary calculus; but to be formed in the prostate gland.* It is 
not fusible by the heat of a blow-pipe; and, when dissolved, may be again precipi- 
tated. Although this calculus is not dissolvable by heat, yet we may dissolve it in 
muriatic acid. 

Triple Phosphate. — There is another phosphate which, unfortunately, is very 
common. It may be known in a moment. It is the " triple phosphate;" — con- 
sisting of phosphoric acid, magnesia, and ammonia. It is white; has no laminae; 
and is easily pulverized or broken. This calculus consists of the same substance 
as the white sand I mentioned.'' It glistens; and consists of a number of minute, 
white, sparkling crystals. The surface is uneven; — being covered with minute 
asperities. If we apply heat or potash to this calculus, ammonia escapes; and 
therefore our chemical knowledge will enable us to say what it is. If we apply 
intense heat to it, it will at last melt, but this is effected with great difliculty. It 
is more soluble in acids, than the phosphate of lime; and may be precipitated again, 
in the form of minute shining crystals. 

Fusible Calculus. — We have another calculus which is very common; but not 
quite so common as the last of which I spoke. This is a compound of the last 
calculus with the last but one; — consisting of phosphate of lime, united with the 
phosphate of magnesia and ammonia. It passes under the name of " \\ie fusible 
calculus;" because it so easily melts under the blow-pipe. It is exceedingly white 
and very friable; — breaking under our fingers, like so much chalk. If we rub it 
on our sleeve, the coat is immediately dirtied, — as it would be by chalk. Generally, 

* Dr. Prout, on Stomach and Urinary Diseases. Third Edition. 
8; Pages 108 and HI. 
" See Page 990. 



CALCULOUS DISEASES. 993 

it is not laminated; bin if it be separable into laminae, we generally find between 
ihem the triple phosphate,* in the form of shining crystals. When it is not lami- 
nated, but in a mass like chalk, it sometimes attains a very large size. It is very 
soluble in the acids; — particularly diluted muricdic acid. It is a calculus which 
frequently gives the surgeon a good deal of trouble, — coming to pieces when he 
applies the forceps. We may easily separate the lime from this calculus. By 
adding oxalate of ammonia, tlie lime goes ti) the bottom; and then, again, the mag- 
nesia may be separated by adding pure ammonia. 

»dll€rnating Calculus. — We do not often have calculi in forms so simple as 
those that I have now mentioned; but, very frequendy indeed, we have what is 
called " an alternating calculus;" that is, a calculus consisting of these various 
substances in different layers. la by far the greater number of these cases, we 
shall find that the 2/2??er substances are those which I first mentioned; — lithic acid,^ 
or (more properly speaking) a compound of liiiiic acid and ammonia,^ or oxalate of 
lime;'' and then, in the outer parr, we find the phosphates.* The layers of these 
alternating calculi may be very various; but the nucleus, — the internal portion, 
generally consists of lithic acid, or oxalate of lime. When a patient has a " mul- 
berry-calculus, nature at last throws the phosphates around it. It becomes white 
externally, and loses a great portion of its roughness; so that the patient does not 
suffer so much as before. The external crust generally consists of a " fusible 
calculus." Sometimes we have laminae of all the three ingredients; but still the 
external crusts generally consist of the phosphates. When calculi are thickened 
in this way, they are often very large. As to the chemical qualities, they depend 
upon the layer examined. If we inspect the outer layer, we find all the characters 
of the phosphates; and ivithin there are all the characters of lithic acid and liihale 
of ammonia. 

Mixed Calculus. — We have another compound calculus; in which the materials, 
instead of being in alternating layers, are all mixed together. A mass of this kind 
generally consists of lithate of ammonia* and the phosphates;* and, of course, the 
colour will vary with the composition. Accordingly as lithic acid predominates, 
or the phosphates, so will the calculus incline to a clay -coXowi^ or to a white colour; 
and the proportions are quite indeterminable. A ""mixed calculus," of this de- 
scription, is generally very hard; — seldom laminated, and seldom large. 

Carbonate of Lime. — There is another calculus, called "the carbonate of lime 
calculus;" because it consists of pure carbonate of lime. It is very rare, and very 
friable. It has all the characters of chalk; and effervesces with the acids. 

Xanthic Oxide. — This calculus is so very rare, that it has been seen only once. 
It is called "xanthic oxide." The substance of this calculus is very peculiar. By 
the addition of nitric acid it becomes yellow. 

Fibrinous Calculus. — There are some concretions of the bladder, v/hich have 
turned out to be nothing more than fibrin. 

Prostatic Calculus. — Besides these vesical C2i\Q,w\\, we have calculi in the pros- 
tate gland. They are found in two situations; — first, in the natural cavities of the 
gland; and then they are of a yellowish brown colour, and more or less round and 
small. Sometimes, I believe, these come from the kidney. I have passed thou- 
sands of these at different times; — about the size of pins' heads. 1 have coUecled 
some, and shown them to Dr. Front; who says they came from the prostate. But 
calculi are sometimes found in an abscess of the prostate; and these are much larger 
and highly polished. They are chiefly phosphate of lime;'' and Dr. Prout believes^ 
that the "phosphate of lime calculus," found in the bladder, is in reality ^prostatic 
calculus.* 

« See Page 992. »> See Page 990. 

•= Dr. Prout on Stomach and Urinary diseases. Third Edition. Introduction: Section 8: 
Page 111. ' 

d The following is Dr. Graves's excellent Table of Calculi (slightly modified):— 
I. Animal Calculi. 

1. Lithic (or Uric) Acid. 
VOL. I.— 63 



994 CALCULOUS DISEASES. 



SECTION III.— CALCULOUS DIATHESES. 

It appears that there are four elementary kinds of calculi, and four distinct calcu- 
lous dispositions; to which dispositions Dr. Prout gives the name of "diatheses." 
In the first place, there is the diathesis to form lithic acid,^ its compound (lithate of 
ammonia"), and a mixture of the two.*" This is the most common calculus we have. 
Nearly all the calculi taken from children, if they have not been allowed to remain 
long, consist of lithic acid, or its compounds, or a mixture of the two; and in the 
majority of calculi taken from people, of whatever age, it forms the nucleus. Then 
there is a disposition to produce oxalate of lime:" and that appears to be a distinct- 
ive diathesis. Then there is a disposition to form cystic oxide;"" but this is very 
rare. Then there is a disposition to form the various phosphates which I have 
mentioned.'' This last succeeds to the others. It i^s usually after the three first 
diatheses have ceased, that the disposition to form the phosphates comes on. 

Their comparative Frequency.- — So common is the disposition to produce the 
*^ lithic acid calculus,"* that it is said to predominate in rather more than one-third 
of all the calculi examined. At least two-thirds originate from it in the first instance 
Those which are of a deep fawn-colour, are well laminated, and have quite a crys- 
talline fracture, are nearly pure lithic acid; in fact, it is red crystallized gravel. If, 
with this diathesis, the calculus is of a pale-brown or clay colour, with an earthy 
fracture, then it is a compound of lithic acid and ammonia;'' and generally there is 
a little mixture of the phosphates, and even a litde oxalate of lime; and the more 
there is of the phosphates and the lithate of ammonia, instead of lithic acid, the 
paler the calculus becomes. The rarest of these calculi is the pure " lithate of 
ammonia."" The '*mi«/6er?'i/-calculus"'' is found to constitute rather less than one- 
seventh of all the calculi which are examined; but it is contained in about one- 
fourth of all the calculi that occur. Of two hundred and seventy-four calculi which 
were examined, only one was found to be of " cystic oxide;"*^ and in three collec- 
tions out of five, none were found. 

The "phosphates"" constitute about one-fourth of the calculi; and one-half of 
this one-fourth are the " mixed phosphates;"*" that is to say, a mixture of the dif- 
ferent phosphates. But this estimate of one-fourth is not very accurate; because it 
has been taken from the external appearance of the calculi; whereas, if these had 
all been sawn through, it is most likely that, tvithin, a number of other ingredients 
would have appeared. 

The ^^alternating calculi"* (those which consist of a layer of different sub- 
stances, — the lithate of ammonia, the oxalate of lime, and the phosphates alter- 
nately) form a very large proportion. In these alternating calculi, we sometimes 
see lithic acid and its compounds externally; and perhaps a foreign body for a 
nucleus. We see, irithin, alternations of lithic acid* and its compounds, and a 
"mulberry calculus"" without; — that is very common. We see alternations of 
lithic acid within, and the phosphates without. We see alternations of the lithic 
acid calculus within, then the " mulberry calculus," and the phosphates without. 
Again: we see alternations of the "mulberry calculus" within, and lithic acid and 

2. Liihaie (or Urate) of Ammonia. 

3. Xanthic Oxide. 

4. Cystic Oxide. 

5. Fibrin. 

II. Simple Saline Calculi. 

6. Phosphate of Lime. ('• Bone-earth" calculus.) ) ^ F„sih1p Calculus 

7. Phosphate of Ammonia and Magnesia. \ «• -^ usiDle Ualcuius. 
9. Oxalate of Lime. (" Mulberry" Calculus.) 

10. Carbonate of Lime. 

III. Compound of Saline Calculi. 

11. Alternating. (Composed of Layers.) 

12. Mixed. (Substances irregularly Mingled.) 

» See Page 990. '' See Page 991. « See Page 993. •» See Page 993. 



CALCULOUS DISEASES. 995 

the phosphates without. AVhen, however, these ahernatin^ calcnli are found, the 
phosphates exist externally; and therefore it appears that the disposition to form 
phosphatic calculi, does not precede the disposition to form Iithic acid calculi, or 
oxalate of lime. It appears that the disposition to form the phosphates, either takes 
place originall3% or follows the disposition to form the oxalate of lime, or Iithic 
acid calculus; but it is not succeeded by any other diathesis. This very interesting 
and very remarkable fact, was noticed by Sir Gilbert Blane, in 1812; in a paper 
published in the "Transactions of a Society for the Improvement of Medical and 
Chirurgical Knowledge."* He states'* that Iithic acid is generally the nucleus in 
calculi; and that the other depositions are merely the result of irritation. I am 
not aware that this statement of Sir G. Blane's was attended to for some time; but 
it has now, by very extensive observations, been proved to be correct. Dr. Prout 
says, that he never met with one patient in whom the phosphatic deposition was 
decidely followed by any other.*' It usually occurs when irritation takes place. 

a. Lithic-^dd Diathesis. 

Depends on the Kidney. — The disposition to form Iithic acid, evidently appears 
to reside in the hidney; for these calculi are seen in that organ. Indeed, there is 
no reason whatever for believing that this description of calculus is formed in the 
bladder. It appears to be truly a renal calculus. If this diathesis be not very in- 
tense, there is merely an amorphous sediment;^ — such as we all have occasionally. 
Some people frighten themselves about it; but, unless the quantity be very great, 
there is no occasion for alarm; — especially if the sediment does not appear when 
the urine is first made. If it be so abundant as to be deposited before the urine 
cools,'' — if it come from the bladder in the form of powder, then there may be 
danger; and if it not only occurs when the urine is first made, and is warm, but 
takes place constantly, then (I believe) the individual is almost sure at last to have 
gravel or stone; — that is to say, he will pass concretions; or have a concretion so 
large, that it will not pass. 

Prognosis. — With respect to the lithic-acid sediment,® there is more danger in 
proportion as it becomes paler. When it is of a bright red colour, there is not 
much occasion for alarm; but when it is white, there is some degree of danger; 
because it shows a disposition to deposit the phosphates. I do not say that it 
ahvays shows danger; because occasionally, when it is white, it is merely liihate 
of ammonia; and it is white because it is not tinged with the colouring matter; — in 
the way I mentioned before.^ Very frequently, however, the intensity of it arises 
from the phosphates being deposited; and when that is the case, there is consider- 
able danger. 

Symptoms. — Some people will pass crystals with very little irritation; but if 
irritation be produced by the sediment, then there is generally a mixture of amor- 
phous and crystallized sediment;® and when the irritation is very great, it is gene- 
rally because a large quantity is passed in both these forms. In these circum- 
stances, there is generally more or less pain in the kidney; irritation about the 
neck of the bladder; a frequent desire to make water; and more or less feverish- 
ness. The urine is acid and scanty; it has a high specific gravity. Persons com- 
plain of these symptoms, from time to time; and then they will discharge a large 
quantity of red or reddish sediment. The urine is very acid; and we should 
always lest it. This state of things frequently comes on in persons who have a 
calculus already in the bladder. Sometimes a calculus is formed in the kidney, 
and may remain there; and give the patient no trouble. A person may have a 
stone formed in the kidney, without being aware of it; and we may be surprised 

• Volume 3; Page 338. »> At Page 358. 

«= Dr, Prout, on Siomach and Urinary Diseases. Appendix; Observations on Table 2 
(Third Edition; Page 481.) 

-» See Page 988. • See Pages 988 and 991. 

' See Page 990. 



996 CALCULOUS DISEASES. 

to find it there after death. Sometimes it will only cause an aching pain in the 
loins; and will not shorten life. But occasionally these calculi produce very great 
mischief. No doubt they continually pass in the form of minute concretions; and 
the patient is not at all aware of it; and they will lodge in the bladder, and there 
grow to the size of which they are found. Sometimes they pass from the kidney, 
after having obtained a size so large as to give great pain, as they pass through the 
ureter, 'i'his pain in the back, on their attempt to leave the kidney, is attended 
with vomiting, and perhaps with a great degree of feverishness. Inflammation 
may be setup, or it may not; and then, after a time, all these symptoms cease, 
perhaps suddenly; and, in a day or two, if the stone be very large, we have signs 
of a calculus in the bladder. 

The infundibula of the kidney are sometimes filled with these calculi. We see 
them sticking there; and sometimes the kidney will become blocked up with them. 
The pelvis is sometimes filled with them; the infundibula become greatly dis- 
tended; and sometimes the ureter is blocked up with them; — so that the pelvis of 
the kidney is distended into a mere bag. It is said that, in the museum of the 
College of Surgeons, there is a calculus weighing seven ounces and a half, which 
was taken from a kidney, and which caused no symptoms during life. This is 
analogous to what I stated with regard to the gall-bladder; where a large number 
of stones will sometimes exist, without being productive of any symptoms.* These 
lithic-acid calculi are continually found in the kidney; and are of all sizes. It is 
probable that, in ail the instances where they are found in the bladder, they have 
descended from the kidney. 

Lithic-acid calculi (using the term generically) sometimes occur in great num- 
bers. No fewer than two thousand have been voided, by one individual, in the 
space of two years; and one hundred and twenty have been known to come away 
in three days. It is the calculus which, of all, gives the least irritation. 

Causes. — Children and dyspeptic individuals are most subject to that state of 
body, in which there is a disposition to form these calculi. The disposition appears 
to be less between puberty and forty years of age, than before. There is cer- 
tainly sometimes an hereditary tendency to it; for it occurs in members of the 
same family, — descendants of each other. It is said to have occurred frequently in 
those who have cutaneous complaints; but cutaneous diseases are so very common, 
that I do not know whether the examples are sufficienUy numerous, to authorize 
us in supposing that there is any connection between the two. Something appears 
to depend upon local situation; for some places are remarkable for the abundance 
of persons with this sort of calculus; but it is not known in what the peculiarity 
consists. Undoubtedly there is some connection with a gouty disposition. Per- 
sons disposed to gout, frequently become the subjects of this sort of calculus, and 
this kind of deposition in the urine. Excess in eating or drinking, is always men- 
tioned among the causes; and so likewise is indolence. 

Treatment. — As to the treatment of the disposition to form this calculus, and 
this kind of sediment, it consists in antiphlogistic measures; for this state of body 
is certainly, for the most part, inflammatory. 

Diet. — An individual so circumstanced, should take very litile animal food; — 
sometimes, perliaps, none at all. In many cases, the latter restriction may be ne- 
cessary. At any rate, animal food should be taken in great moderation; and equal 
moderation is required in eating altogether. In general, it is necessary to abstain 
from wine, spirits, and strong malt-liquors; though mild malt-liquors may be ad- 
missible. It is not merely necessary to abstain from Rhenish wine and claret; but 
from all strong wines, and every thing that is sour. It is necessary to avoid vine- 
gar, sorrel, oranges, and lemons; — in short, every thing that is acid. It is like- 
wise necessary that the patient should be moderate in the exercise he takes; and 
that he should keep an open state of the bowels. 

Remedial Jlgents. — With regard to medicine^ colchicum is found to be bene- 

« See Page 696. 



CALCULOUS DISEASES. 997 

ficia]; together with light preparations of mercury; — mercur}' in a moderate quan- 
tity; — so as not to debilitate the frame; but to keep down, as much as possi!)le, an 
inflammatory condition. In connection with colchicum and mercury, neutral salts 
(such as tartrate of potash) will be very proper. Alkalies are advisable here, — 
particularly magnesia; — both on account of its being- an nlkali, and from the tend- 
ency it has to open the bowels. A saline draught is an excellent mode of giving 
an alkali; because, although we thus give a neutral salt, yet it contains a vegetable 
acid, which is always decomposed within; so that we have the benefit of the alkali 
which was combined with it. For this fact we are indebted to Sir Gilbert Blane.* 
He was the first who pointed out the impropriety of giving saline draughts, where 
an alkali was not required; and the advantage attendant upon their exhibition when 
it was. Dr. Prout, and others who are best able to give an opinion upon it, de- 
clare that this is the case;" and they frequently give a saline draught, for the pur- 
pose of administering an alkali. It is judged advisable, in these cases, to take care 
that the water which the patient drinks be not hard, — does not contain salts of 
lime; although water, for the most part, is one of the best beverages which peo- 
ple, in these circumstances, can take. I stated" that neutral salts should be given 
from time to time. 

Patients, in this condition, sometimes discharge a quantity of powder, like "ful- 
ler's-earth." It is certainly true that, in this state, a vast secretion of lithic acid,^ or 
lithate of ammonia,'' occasionally takes place in the kidney; and then the irritation 
is altogether relieved. It comes on in fits; — ^^just like the gout. Some have at- 
tempted to bring on a secretion of this earth, by artificial means. For this purpose, 
some give turpentine and opium, in small doses; and some give onions and leeks 
steeped in gin, wild carrot, and other herbs. Dr. Prout says, that he has seen 
great benefit produced by these substances.^ I mentioned, when speaking of dia- 
betes, that opium has undoubtedly the power of increasing the quantity of lithic 
acid;^ and therefore it has been employed where a copious discharge of lithic acid 
was required all at once; — a liberation^ if I may so say, of the sediment. But a 
purgative should be given in conjunction with the opium; because, although the 
latter may do partial good by exciting a discharge of lithic acid, yet it may do 
harm by confining the bowels; — to which state they are much disposed. In such 
a case as this, if the patient be very bad indeed, — if he have violent pain in the 
kidney, great feverishness, pain down the ureter, and about the neck of the bladder, 
— we must treat it as nephritis and cystitis; — particularly by cupping him on the 
loins. We shall find it serviceable to put him in a hot-bath, to purge him well, and 
to give him colchicum, alkalies, and opium, 

h. Oxalate-of-Lime Diathesis, 

Symptoms. — In cases where the disposiiion is to form oxalate- of -lime, or "mul- 
berry-calculi,'"^ the urine is likewise acid. A state of the system, similar to that 
last described, s takes place; and a similar mode of treatment is required." The 
"mulberry calculus," like the lithic acid, occurs in both sexes; and at all ages up 
to fifty. It is about fifty that it is most frequenUy seen; but it is, I believe, never 
formed after sixty years of age. The "lithic-acid calculus" and its compounds, 
occur in persons who are very dyspeptic, and who are disposed to be feverish and 
irritable; but the " mulberry-calculus" is continually produced in persons who have 
nothing else the matter with them; and, when produced, it may be discharged. 
The "lithic-acid calculus" and its compounds (as I stated) have been formed to 

» " Transaction^ of a Society for the Improvement of Medical and Chirurgical Know- 
ledge." Volume 3; Pages 339 to 341. 

b Dr. Prout, on Stomach and Urinary Diseases. Book I; Chapter 3; Section 3; Subdi- 
vision 6. (Third Edition; Page 221 ) 

«= See Piges9S7 and 991. d gee Page 091. 

e Dr. Pront, on Stomach and Urinary Diseases. Book 1; Chapter 3; Section 3; Sub- 
division 6. (Third Edition; Page 228.) 

f See Page 985. s See Page 994 to 99G. 



998 CALCULOUS DISEASES. 

the amount of two thousand (of all sizes) in one individual;^ bnt the "mulberry- 
calculus" seldom occurs more than once in a patient's life; or if it does return, — 
that is to say, if another be produced, — it is generally afier a very long interval. 
The urine, in this state of things, is pretty good, and remarkably clear. The 
amorphous sediment of the oxalate-of-lime,'' is a very rare thing indeed; and as to 
the crystallized sediment of oxalate-of-lime,'' that is still more rare. A calculus of 
this description, often acquires an immense size in the bladder; and it does not ap- 
pear to be produced accidentally. The lithic-acid or the phosphatic calculus,** will 
be produced accidentally, when there is a clot of blood, or a foreign substance has 
been introduced into the bladder; but this depends upon a peculiar state of the sys- 
tem, which is not understood; — a peculiar diathesis, which appears unconnected 
with external circumstances. It sometimes/o//oios the deposit of a lithic-acid cal- 
culus, and is sometimes succeeded by it; but nothing is more common than to find 
it alone. It sometmies happens, that oxalic acid ceases to be formed, and lithic 
acid is produced in abundance; and then the deposition in the external part of the 
calculus is liihate of ammonia,*' instead of oxalate-of-lime. I have myself known 
several persons discharge a calculus of this kind. They have been perfectly well; 
but have suddenly been seized with violent pain in the kidney; which has con- 
tinued some days, — perhaps only for some hours, and sometimes only a {e\v 
minutes. The pain has shot down towards the bladder, and then ceased; and 
after a few days, in passing their urine, they have been surprised by something 
making a noise in the pot-de-chamhre. Sometimes there has been violent irritation; 
Avith all the ordinary symptoms of a stone in the bladder^ The stone has escaped, 
and then they have been perfectly well, and have had no return. I know several 
persons, in whom this happened many years ago; and who, ever since, have been 
in perfect health. 

Treatm,ent. — The treatment here, as the urine is acid, is exactly the same as for 
the lithic-acid diathesis;'' — that is to say, if there be any inflammatory state of the 
system, we must suppress it by the ordinary antiphlogistic means. If no inflam- 
matory state can be discovered, still we must put the patient on an antiphlogistic 
plan. Dr, Prout suggests the propriety of changing the oxaliC'd.c\i\ diathesis for 
that of the Hthic-dic'id, by exhibiting muriatic acid. It is merely a suggestion; and 
I do not know that it is founded upon practical experience. 

c. Cystic-Oxide Diathesis, 

The cystic-oxide diathesis is a very peculiar calculus; and the state of the body 
in which it is formed, is not known. This calculus is generally supposed to origin- 
ate in the kidney. 

Treatment, — The treatment of the case, would depend upon the circumstance 
of the urine being acid or being alkaline. If it be acid, we must treat it in the 
way I have mentioned;'* if it be alkaline, then we must treat it as I shall hereafter 
mention.^ 

Prognosis unfavourable. — Dr. Prout thinks that, in this diathesis, the prognosis 
is unfavourable;^ for, in most instances, the kidney has been found diseased; and, 
in others, there has been an inveterate hereditary tendency to disease of the urinary 
organs. It appears to be a very exclusive diathesis; for it is found with no other 
deposition in the urine. There is no other calculous matter ivithin this, as a 
nucleus, or without it; — except the phosphates, which are the eff'ect of irritation. 
The calculus is sometimes incrusted with the phosphates; but that is the result of 
mere irritation,' — not of a disposition to disease. 

* See Page 996. ^ See Page 989. 

« See Page 991. ^ See Pages 991 and 992, 

« See Page 1000. 

f Dr. Prout, on Stomach and Urinary Diseases. Book I; Chapter 3j Section 4. (Third 
Edition; Page 239.) 



CALCULOUS DISEASES. S99 

d. Phosphaiic Diathesis. 

Symptoms. — We have now to consider a far worse state of the system; — that 
in which the phosphates are deposited:'' and which has been called " the phos- 
phaiic" or " the eartliy diathesis." Here every thin^ is the reverse of what I 
stated to be the case, wiiere the tendency is to liliiic acid or oxalate of lime.'' The 
urine is not scanty and high-cohnired, but copious and pale; and often it is green- 
ish.'' On looking at the urine, we may tell what is the state of the paits. We 
may say that the individual has a phosphatic calculus in the bladder, or is deposit- 
ing phosphatic sediment. Tiie urine is of lower specific gravity, than in the cases 
I have already considered;'' and lower than it is naturally. It is in these cases that 
the urine very soon putrefies. Sometimes we cannot keep it a day before it is quite 
putrid; — smelling strongly of ammonia." Frequently, at the top of it, we have an 
iridescent and white pellicle; which consists of the phosphates, with (I presume) 
a little mucus. The sediment may be either pulverulent (or " amorphous"),^ — 
being a mixture of the phosphate of lime and triple phosphate; or it is crystallized;^ 
and then we have the triple phosphates only, in white glistening crystals. The 
two chief calculi found in the bladder, are the "triple phosphate" (the ammoniaco- 
magnesian phosphate),* and that with a mixture of the phosphate of lime;* and in 
that case it is white, is not crystallizable, is friable, leaves a white mark on any 
thing it is rubbed against, and is very fusible. ^ 

This phosphatic disposition, and these phosphatic concretions, are very rarely 
original. They generally occur subsequently to the formation of other calculi; 
and subsequently, in general, to the lithic-acid or oxalate-of-lime diathesis.^ Tiie 
way in which it usually takes place, is this; — the red sediment becomes a fainter 
red; and, from the phosphates being more and more formed, it becomes paler and 
paler, till we have a clay-colour; and then, at last, the phosphates only are formed; 
— the lithic acid and lithate of ammonia being no longer deposited. The urine 
then becomes more abundant, — does not show such strong signs of acidity; and, 
at last, there is no acidity whatever. On the contrary, perhaps, it is even alkales- 
cent; though that is rare when it is first made. Ultimately, however, (as I have 
already said,) it very soon putrefies;" antl in that case it is very alkalescent; — 
affecting turmeric-paper a short lime after it is voided, and depositing spiculae of 
the triple phosphates.'* 

The two sediments of the phosphates, — the sparkling glistening crystals,' and 
that in which there are no glistening crvstals, but with which the phosphate of 
lime is mixed, ^ — sometimes alternate. The same individual will, for a day, or a 
week, or perhaps a fortnight, deposit glistening crystals of the triple phosphates; 
and then, at other times, those which do not glisten at all; and sometimes the latter 
alternate with lithic acid; but then the lithic acid is very pale, — verging to the 
phosphates; — and sometimes, before it gives way to them, ihere is an alternation of 
the two. If there be a great deal of crystallized phosphate, then the urine is very 
alkalescent. The urea is very copious; and crystals are sometimes formed, before 
the urine is discharged from the bladder. This deposition usually takes place after 
the urine is made; but, in bad cases, it will take place before it is voided; and the 
instant the urine is made, the deposition subsides to the bottom of the vessel. 

In the second phosphatic secliment, — -that in which there is a mixture of the 
triple phosphate and the phosphate of lime,' — although the symptoms are similar, 
as well as the state of the urine, yet they are both far worse than in the first state. 
In this condition of the body there is no inflammatory state. There are no marks 
of inflammation; but there is a morbid irritability. There is a bad expression of 

* See Page 993. b gee Pages 995 and 997. 

•^ See Pages 989 and 991. " See Pages 995, 997, and 998. 

e See Page 989. f See Page 991. 

g See Page 992. (" Fusible Calculus.") ^ See Page 990. 

J See Pages 990 and 993. 



1000 CALCULOUS DISEASES. 

countenance; — showing distress, — shoeing something wrong in the system. The 
patient is generally snllow and languid; and experiences pain in the loins. There 
is generally more or less dyspepsia, and some abdominal derangement. Very fre- 
qnenily, there is a want of sexual power and desire; and when a person complains 
of that, it is always right to examine the urine. In many cases, we shall find 
diabetes; in many others, an excess of urea; and in others, again, not only an ex- 
cess of urea, but likewise a deposition of the "triple phosphate."* The urine 
will vary on different days, and at different times on the same day; — being at times 
copious, and at others less so. 

Causes.—Mauy of these cases have arisen from an injury of the loins; and they 
arise, too, from the depressing passions, — from any thing that exhausts the vital 
powers. In some instances, they appear to have arisen from masturbation, or from 
excessive venery. Any local irritation, whetlier in the bladder or in the urethra, will 
produce them; and therefore this diathesis is rarely found in the kidneys. We 
generally find no marks of disease in the kidney; but usually in the bladder. When 
a lithic-acid calculus descends to the bladder, it usually produces irritation; and then 
the phosphates are produced. The bladder is often diseased, from various causes; 
and frequently it is inflamed; — so that these calculi appear to be far more frequently 
formed in the bladder, than anywhere else. They have been formed from an 
irritation in the urethra, reaching to the bladder; but generally it is an irritation of 
the bladder itself that produces them. Urine having this deposition, has continue 
ally been seen after an injury to the spine. After these injuries, therefore, and in 
diseases of the spine independent of mechanical violence, surgeons expect to find 
such urine; and, on examination, they generally do. Stricture of the \irethra will 
induce this description of urine. It seems not only to act by irritating the Madder, 
but it also affects the kidneys; — causing them to give origin to urine imperfectly 
acidified. Great irritation, — whether it occurs in the bladder or in the urethra, — 
gives a tendency in the kidneys to produce urine with a deficiency of acid; and if 
it be deficient of acid, the phosphates are usually deposited in the way I before 
mentioned;*" — from the decomposition of the urea, and the production of other 
things. 

Treatment. — In this diathesis, we must not keep the patient low, or bleed him. 
On the contrary, we must give meat, if he will bear it; and even allow malt-liquors. 
Although, perhaps, wine may (in general) be too irritating, yet acescent wine is 
good. The tendency is to alkalescency; and, if it do not disagree with the stomach 
and intestines, wine should be taken. Acids themselves are proper; especially 
citric and muriatic acid. Mercury acts here as a poison. If we give mercury, in 
nine cases out often we shall find the urine become more alkalescent, the patient's 
pulse will become irritable, and all the symptoms about the urinary organs will be 
aggravated. Opium is required freely, — in order to lessen the irritation. The 
sulphate of quinine, or ar decoction of bark, has been exhibited with the greatest 
advantage; and iron is frequently useful, though occasionally it is too stimulating. 
These things must be exhibited with regard to individual cases, as well as on gene- 
ral principles. Saline purgatives, of whatever kind, are improper; for as they 
consist of an alkaline earth and a vegetable acid, and the latter is decomposed in 
the system, we are actually giving an alkali;*" which makes things worse. Saline 
substances produce great irritation; — such as cannot be borne. It is best to give 
mild aperients (such as " confectio sennre," and castor-oil), in moderate doses; so 
as not to irritate, but merely to prevent an accumulation in the intestines. A small 
quantity of muriatic acid will be found sufficient; — five drops will produce a spe- 
cific action on the urine; but ten or twenty may sometimes be required. There 
is no difficulty in ascertaining whether one particular treatment is proper or not; 
for the state of the urine will always determine that point. It is always right to 
employ litmus-paper, stained red; for, in proportion as the urine is alkalescent, it 

« See Pa£:e 902. " See Pas:e 990. «= See Pa^e 997. 



CALCULOUS DISEASES. 1001 

will restore the oris^inal colour; and (as I mentioned before^) it constitutes a far 
more delicace test than turmeric-paper. 

^^scerlain the Condition of the Urine. — It is the state of the urine which deter- 
mines all tlie treatment. Whether there are signs of a calculus in the kidney or 
not, — whether there are signs of a calculus in the bladder or not, — wliether there 
are any of the sediments which I have now mentioned'' or not, — whether the per- 
son is oroing to be lilhotomized, or has been already submitted to that operation, 
— the urine should be carefully examined; for we have to treat the case in all these 
circumstances. Where a calculus has been removed, we still have to remedy the 
condition of the system which gave rise to it; because that condition does not cease 
on the extraction of the stone. We should examine the urine which is passed 
first in the morning; because that is the least liable to be influenced by accidental 
circumstances, and therefore the most likely to show the actual state of the system. 
It should be put away for twenty-four hours; — in order that we may make a per- 
fect examination. In many cases, we may ascertain the point immediately; but 
the urine should be allowed to remain and cool; and the sediment, if there be any 
formed, will then be deposited. This kind of treatment is continually required 
after lithotomy, or the removal of stones in any other way; and, from the want of 
making a careful distinction, — from the habit of giving alkalies when there is any 
thing the matter with the urinary organs, infinite mischief is done. It is far better 
for nothing to be done, than to do something wrong; and mistakes, till very lately, 
were made every day, — almost every hour, in the treatment of these cases. 



SECTION IV.— CALCULI IN THE BLADDER. 

Symptoms. — The formation of calculi is called " lithiasis" (from 'Kidoq, a stone). 
When there is a stone in the bladder, the symptoms produced are usually a par- 
ticular pain at the end of the penis;— a pain which the patient describes as " a 
benumbing pain," and which is increased upon exertion. This pain makes the 
patient pinch the penis as hard as he can; and if he feel a sudden call to make 
water, he usually puts his hand to the end of the penis; and children are in the 
habit of pulling the prepuce. There is a frequent desire to make water, and the 
stream suddenly stops; — the desire to make water, however, being still urgent. 
Sometimes a change of posture will cause the urine to flow again. Sometimes the 
urine, instead of suddenly stopping, will come away drop by drop; — the discharge 
being attended with great pain, and perhaps w'ith blood. There is pain in the 
bladder itself, especially on motion; and likewise pain and tenesmus on evacuating 
the intestines. If the calculus be large, or very rough, tliere is pain in the neck of 
the bladder, pain and numbness of the testis of the same side, and pain of the inner 
part of the thigh, along the course of the anterior crural nerve, and sometimes down 
to the foot; — so that there is actually pain in the sole of the foot. All these symp- 
toms are rendered worse by exercise. 

Diagnosis. — Pain at the end of the penis, pain increased on motion, and in- 
creased whenever the desire to make water comes on, a frequent desire to pass 
urine, a voiding of it drop by diop, tenesmus, and the presence of blood in the 
urine, — all these symptoms may occur when there is no stone whatever. In the 
course of my life I have had every one of these symptom.s, two or three times over, 
from mere inflammation about the neck of the bladder. The sudden stoppage of 
the stream, is the sign most to be depended upon. Disease of the prostate, and 
inflammation at the neck of tiie bladder, will cause many of the other symptoms. 
Dr. riebcrden says that the pain on voiding the urine is felt after making water, 
in the case of stone in the bladdery and worse before passing it, in the case of 
diseased prostate; and that in the latter case it is not increased on motion.'' I 
believe this is a general fact. The obvious reason why the pain is increased on 

^ See Page 989. *• See Pages 995 to 1000. 

•^ " Medical Commentaries;" Chapter 75. 



1002 CALCULOUS DISEASES. 

motion, in the case of a stone in the bladder, is this. The stone is movable, and 
may therefore come forcibly in contact with different parts of the organ, by motion; 
whereas the prostate is fixed. However, the prostate is rarely diseased, except in 
the case of old men. Dr. Heberden says, that even pain and swelling of the testes 
are sometimes observed in disease of the prostate.^ But we may always ascertain 
whether the prostate is diseased, by passing our finger up the rectum, and observing 
whether it is enlarged; and the certain way of ascertaining whether there is a stoue 
in the bladder, is to sound the patient. In the latter case there is frequently secreted 
a large quantity of ropy mucus; which may be drawn out to a considerable length, 
and which subsides to the bottom of the vessel, in the form of a white tenacious 
mass. Occasionally, a small fragment of a calculus comes away; and when all 
the symptoms have become violent, — whatever deposition there formerly was in 
the urine, — whatever was the diathesis before, it now becomes phosphatic.^ The 
urine becomes pale and copious; it loses its acidity, and has great alkalescency; 
and if there be any deposition at all, it consists of the phosphates. In this state of 
things, the agony becomes constant; the patient becomes emaciated; and death 
ensues. The phosphatic diathesis and the sufferings are proportionate to each other. 

Morbid Appearances. — After death, the bladder is found to be diseased. The 
mucous membrane becomes diseased; the muscular fibres are enlarged; and per- 
haps even the kidneys are affected. 

Cessation of the Symptoms.— This state of things may generally be prevented 
by the removal of the stone by a surgical operation; and sometimes it fortunately 
ceases, from a sac being formed in the bladder. The muscular fibres give way, 
and the inner coat protrudes between them. Not that the muscular fibres rupture; 
but the inner coat gets between the bundle of fibres; and we see externally, on one 
part of the bladder, a small protuberance; — consisting simply of mucous membrane 
internally, and peritonaeum externally. Sometimes, if the calculus be rough, the 
symptoms are diminished by the deposition of the phosphates. Although the 
phosphates are in general produced by irritation, yet they fill up the interstices 
between the prominences of the calculus, and so render it smoother than it was 
before; and, in this way, the symptoms are sometimes alleviated. 

Symptoms sometimes Absent. — But it is to be remembered that, although a 
stone may produce all these symptoms, yet it does not necessarily give rise to 
them. If the calculus consist of lithic acid, it may be small and quite smooth; and 
then it may give very little trouble. Indeed, such a calculus has been found after 
death, when its presence was not at all suspected. The health is sometimes very 
good, in such cases; and if that be the case, and the patient does nothing calculated 
to injure him, a calculus of that kind may not increase. A calculus may continue 
in the bladder for many years without any increase; — provided the person does 
nothing unfavourable; — that is to say, does not commit any excess, — does not 
increase the feverishness; — provided he adopts a moderate antiphlogistic plan. Dr. 
Prout knew a case, in which the presence of a stone in the bladder was ascertained 
by sounding; and, five or six years afterwards (at the time he mentioned it to me), 
the patient experienced little or no trouble from it; and frequently, for weeks toge- 
ther, the patient forgot that he had a stone in the bladder, or any thing the matter 
with him. But the case had been well managed; and the patient had been put on 
a moderate antiphlogistic regimen, — such as I before mentioned.*' Dr. Prout also 
mentioned to me, that he knew a case where four renal calculi existed in the blad- 
der five months, without producing any severe symptoms; and then a little irrita- 
tion occurred at the neck of the bladder, which led to their removal; and yet one 
of them was nearly an inch in length. These, however, were lithic-acid calculi.'^ 
The oxalate-of-lime calculus^ (if it be of any size) causes extreme suffering, and 
so also do the phosphatic calculi;^ and for them an o})eration is indispensable. No 
regimen will answer the purpose here; — provided things have not gone so far, that 
a surgeon would not listen to the operation. Of course, the nature of the opera- 

« "Medical Commentaries;" Chapter 75, " See Page 999. 

^ See Page 995. ^ See Page 991. ^ See Page 993. 



CALCULOUS DISEASES. 1003 

tion must be determined by the surgeon; — whether it is to be the removal of the 
stone by cutting, or its reduction within the bladder, or dilatation of the urethra, or 
any other plan. 

Discharge of CaJciiJi from the Urethra. — In the male, calculi of really consi- 
derable size are sometimes discharged; and instruments have been formed to dilate 
the urethra; — so as to bring them away without any incision; but these are lithic- 
add calculi. Nature very frequently discharges them herself. This occurrence 
takes place far more frequently in (he female, however, than in the male^ and much 
larger calculi have been brought away, both by nature and by artificial dilatation. 
One which weighed as much as twelve ounces has been discharged by a female. 
These are very extreme cases. On account of the shortness of the urethra, it is 
very common for females to pass calculi, by an efTort of nature; and it does not 
appear that females are, by any means, so subject to the complaint as males. 

Vesical Irritation favours the Deposition of Phosphates. — When the suffer- 
ing has been very great, and an operation has at last been performed, it is gene- 
rally found that the calculus is, externally, of a phosphatic kind; but an entire 
phosphatic calculus is rarely seen. In this state of things (when the phosphatic 
diathesis exists) the kidney is at first affected only functionally. From irritation of 
the urinary organs, it secretes morbid urine, — urine which has no excess of urea; 
together with a tendency to a phosphatic deposition; but, at last, actual structural 
disease of the kidney takes place. If the kidney could be preserved in a state of 
functional health, — if it could be made to secrete proper urine, ii is probable that, 
although a stone existed in the bladder, it would not increase, even around an acci- 
dental nucleus. But the accidental nucleus produces irritation; that irritation is 
communicated to the kidney; the kidney secretes morbid urine; from this morbid 
nrine deposition takes place; and so the calculus increases. The moment the urine 
becomes unhealthy, then a deposit takes place; and the mischief goes on increasing. 
Frequently, at its origin, the disease does not depend upon any external circum- 
stance; but there is a real disposition to these morbid deposits; which disposition 
gives rise to them, and tliey go on increasing, till a calculus is formed. But if, 
by chance, any thing — such as a piece of bougie or a drop of blood — gets into the 
bladder, — so as to form a nucleus, this, by inducing irritation, will cause a calculus 
to form round it. If, by art, we could keep the urine healthy, it is supposed that a 
calculus would not be formed; — that the nucleus would not serve for any thing to 
collect around. 

Calculi do not increase regularly. — It does not appear that a calculus goes on 
increasing regularly. The urine is not always equally morbid; the irritation is not 
always equally felt; and external circumstances are not always equally unfavour- 
able. The patient neglects himself, from time to time; or some unfortunate occur- 
rence takes place. Sometimes a calculus has been known to increase very much, 
and the state of the urine to become more and more morbid; and then, again, the 
process has been exceedingly slow. ■ There is another reason to make us suppose, 
that the deposition is not constant. Many calculi have a laminated structure; and 
between the laminae they appear to have suffered some diminution. There is a 
space there; and they frequendy look as if they were worn by water moving 
around them. The occurrence of separate lamince, indeed, is considered to prove 
their irregular deposition. 

Age most favourable for Lithotomy. — It is not only where there is great suffering, 
or where the urine has become phosphatic, that an operation is proper, provided 
the case is not too far gone; but if the patient be below puberty, — even although 
the sediment is not phosphatic; but is red, and consists of lithic-acid and lithate 
of ammonia, — tlien it is considered that the calculus should be removed. If the 
individual be below puberty, there are many chances to one of the calculus in- 
creasing, and giving further trouble; and, thougii the patient may not be suffering 
much, it is generally best to extract it. 

JMortality from Lithotomy. — Lithotomy is considered to be less dangerous in 
children, than in adults. It was found at Norwich to be four times less so. Gene- 



1004 DISEASES OF THE BLADDER. 

rally speaking, the ratio of mortality, from lithotomy, is about one in seven and 
three-quarters; but in Norwich it is said to be less than anywhere else; so that, for 
forty years, Dr. Marcet found that the average of mortality there was but one in 
eleven and tliree-eighths: — before puberty one in eighteen; and after that period 
one in four and three-quarters. Nearly one-half of the cases of stone in the bladder, 
are found to occur before puberty; and then there is an increased number again 
after forty; and but one female was affected with stone in the bladder, for twenty- 
three males. Some ascribe this to the quiet habits of females, — to the circum- 
stance of their not being subject to laborious exercise; and others ascribe it to the 
shortness of the urethra. The latter circumstance must have great influence; but, 
in all probability, there is less disposition in them to tfie disease. 

These are the only considerations for the medical practitioner. "With the per- 
formance of the operation, I have nothing to do. AH that we have to give an 
opinion on, is the condition of the urine; — taking into consideration, when contem- 
plating an operation, the suffering and the age of the patient. 



CHAPTER IV. 
DISEASES OF THE BLADDER. 

SECTION L— CYSTITIS. 

Symptoms. — The urinary bladder is, of course, subject to inflammation; and 
this disease is called "cystitis."* The symptoms are a burning and throbbing 
pain in the hypogastrium; tenderness on pressure; a very frequent desire to make 
water; and a most horrid pain at the neck of the bladder, while the urine is pass- 
ing: — so that the patient, perhaps, can only void it on his knees. The urine is 
made in a very small quantity, perhaps every ten minutes; and it is often high 
coloured, — perhaps bloody. There is also tenesmus. 

Causes. — This affection is induced by turpentine, cantharides, and other things 
which peculiarly irritate the urinary organs; hiU more particularly by gonorrhoea. 
The inflammation of the urethra spreads inwards; — producing inflammation of the 
bladder. 

Treatment. — The treatment is simple, but requires to be put into practice 
vigorously. 



SECTION II.— CYSTORRHCEA. 

Symptoms. — The bladder is subject to chronic inflammation; and it is still more 
subject to an affection of the mucous surface; in which affection there is a great 
discharge of ropy mucus, — such as occurs when a calculus exists in the organ, 
and causes great suffering. There is not only this quantity of ropy mucus secreted; 
but the mucous membrane itself becomes hypertrophietl. As much as several 
pints of this ropy mucus have been known to be discharged in a day; but it is 
very common indeed for a pint to be discharged. It subsides to the bottom of the 
vessel, and is quite white. It sometimes blocks up the urethra; so that a little 
difficulty is experienced, from time to time, in making water; and at last it is 
really purulent. This affection is called "cystorrhosa.'"' 

• From " cystis," ths bladder (from xvo-ti?, a hag)-^ and "itis," injl^ammation. 
^ From Kva-Tii, the bladder; and ^boo, to JIovj. 



DISEASES OF THE BLADDER. 1005 

Morbid Appearances. — After death, if the disease prove fatal, there is fre- 
queiilly a thickening of the mucous membrane to a great amount. The muscular 
fibres are seen distinctly; and, in some parts of the bladder, are very much deve- 
loped. It would seem, indeed, that those muscular fibres described by Sir Charles 
Bell, and which run from the extremities of the ureters, become hypertrophied; — 
so that, at the orifice of the bladder, there is a triangle; the sides of which run from 
the mouth of one ureter to that of the other, and from both to the mouth of the 
bladder. We sometimes may pass our finger down half an inch; — so great is the 
development. 

Treatment. — The treatment of a case of this kind must be antiphlogistic; — so 
far as the patient's strength will allow. The frequent application of leeches is 
proper; and if there be no excessive irritation, but more discharge than any thing 
else, turpentine in small quantities has been occasionally used with advantage; and 
so has " uva ursi." We may put an ounce of the latter to a pint and a half of 
water, and boil it down to a pint. Cubebs, likewise, have been occasionally ser- 
viceable. These cases, however, taken altogether, are very bad; and, in a large 
number of instances, a stone exists in the bladder; or there is a stricture, which 
gives rise to this irritation; as well as to hypertrophy, or disease of the prostate. 
If the urine be alkalescent (deficient of acidity), it may be well to give acids and 
narcotics, in order to lessen the irritation; and, for this purpose, we may give coni- 
nm, opium, and hyoscyamus. But when the mucous membrane becomes hyper- 
trophied, and there is secretion to such an amount as this, we can do litde more 
than afibrd temporary relief. 



SECTION III.—STRUCTURAL DISEASES OF THE BLADDER. 

Hypertrophy. — So greatly disposed to hypertrophy are the muscles of the blad- 
der, tliat no other muscles of the body (it is said) are so increased by exercise; — 
that is to say, if any difficulty exist in the passage of the urine, or there be any 
irritation about this part, — so as to make the bladder contract frequently, no other 
muscles grow to the same amount. Indeed, in some cases, the inner part of the 
bladder looks like the inner part of the heart. The muscular fibres and the mucous 
membrane are so developed, that, at first sight, we might think it was the right 
ventricle of the heart. Tlie mucous membrane is often softened, both when it is 
hypertrophied, and when it is not. Sometimes the villi and the follicles are so 
apparent, that we perceive them instandy; though naturally they are so minute, 
that we cannot see them. The cellular membrane is frequently hypertrophied, so 
that the bladder will become hard; and if a sound be passed into it, the hardness is 
discovered. The mucous membrane is sometimes enlarged; — so that it presents 
the appearance of a polypus. 

Fungous Excrescences. — Sometimes fungous excrescences, of a cancerous or 
encephaloid nature, take place. I formerly mentioned a case of this kind, where 
encephaloid deposit gave rise to heemorrhage, which destroyed the patient."* 

Scirrhous Tumours. — Scirrhous tumours are found in the bladder. 'J'hey are 
sometimes original; and sometimes connected with disease of other parts; — with a 
diseased rectum, or a diseased uterus. 

Cysts. — A cyst has sometimes been found in the organ. It is almost always 
connected with its internal surface; and, in that case, is most probably a mere sac- 
culus.'' A sacculus, however, may be formed originally; and it may become so 
very large, as to be the same size as the bladder itself. The bladder has sometimes 
been divided into two chambers, by adhesions extending across. 

» See Page 204, b The diminutive of " saccus," a base. 



1006 DISEASES OF THE BLADDER. 



SECTION IV.—PARALYSIS OF THE BLADDER. 

Symptoms. — The bladder is frequently the subject of palsy. When a person 
labours under paraplegia (a loss of power of the lower extremities),* he is generally 
unable to retain his urine. At first he is unable to make water; so that it continu- 
ally requires to be drawn off. This we see in paraplegia from accident. After a 
time, however, the " detrusor urinae" muscle loses its power, and then the sphinc- 
ter also becomes paralyzed; so that the patient cannot retain his urine.* 

Causes. — These parts are much disposed to become diseased in old men; — ^just as 
the uterus and theovaria are disposed to fall into disease in old women. When the 
prostate and the parts of generation have done their duty, they fall into a diseased 
condition; — just as similar parts do in women. The bladder suffers with the rest; 
so that old men are frequently unable to sit like young ones, and will be obliged from 
time to time to go out of the room. Sometimes this will occur from accidental cir- 
cumstances. I have known paralysis of the bladder occur from an opiate injection. 
This is worth knowing. From having a suppository, or an injection of opium, 
the bladder has become paralyzed; so that it has been necessary to draw the water 
off; and this has occasioned much alarm. On a repetition of the injection, the 
bladder has become so torpid, that actually retention of urine has occurred. Some- 
times it is produced by a torpid state of the system, — where the head is oppressed. 
It is a thing which frequently occurs in fever; and sometimes, without any obvious 
reason, the bladder loses its power; — ^just as any other part of the body may do. 

Treatment. — If there be no disease of the spine, no organic disease of the blad- 
der, no inflammation,- — nothing more than the simple paralysis, without our being 
able to trace it to any thing more than torpidity, — then cantharides is one of the 
best remedies. So perhaps, is electricity; and any thing else that is stimulating. 

Stillicidium Urinse.— The bladder may be in this state while the urine is drip- 
ping away; for when the organ is distended to a certain amount, the urine will pass 
\guttatim) involuntarily. This is called " stillicidium urinae."" The patient will 
tell us that he cannot hold his water; while, in fact, the bladder is full, and can 
hold no more. It is therefore necessary, in these cases, to ascertain the condition 
of the bladder. Very frequently it happens, that this form of paralysis takes place 
temporarily. If a person do not make water in proper time, he loses the power of 
voiding his urine, and distension is no longer felt. The muscles have no longer 
power to empty the bladder, and it remains greatly distended; although the urine is 
constantly coming away. When we are told, therefore, that a person cannot hold 
his water, we have to ascertain whether he is not holding too much, and cannot 
hold any more. 



SECTION v.— DISEASE OF THE PROSTATE. 

Symptoms.' — With regard to disease of the prostate itself, we may be continually 
consulted upon it; as it occurs so frequently in old men. From the pressure, there 
is frequently a great difficulty in making water; and sometimes it acquires so very 
large a size, that there is difficulty even in going to stool. There is pain there; 
and the abdomen, at last, falls into a state of disease; and death is frequendy the 
consequence. 

Morbid Appearances. — After death, we shall find the prostate full of large cells. 
It is very much hardened; and perhaps it has acquired an immense size. This 
may be ascertained during life, by the introduction of the finger into the rectum. 
Calculi frequently come from the prostate; and they are sometimes found, in very 
large quantity, in the cells of that gland. Occasionally they will grate against a 
sound, when it is passed on towards the bladder. They are generally small, — 

« See Page 672. ^ See Page 974. 

« " Siillicidium" is derived from " slilla " a drop; and " cado," to fall. 



DISEASES OF THE BLADDER. 1007 

sometimes exceedingly so; and are always, I believe, found to consist of phosphate 
of lime.* 

Treatment. — With regard to the treatment of disease of the prostate, we have 
chiefly to resort to surgery; — drawing the water off regularly. On account of the 
great pain, however, it is sometimes necessary to employ narcotii^s; and I think it 
Avould be worth while, in such cases, to give iodine a fair trial: — to rub in 
iodine and hydriodate of potassa externally, and to give it internally. I have not 
had many opportunities of treating such cases, because they generally fall to the 
surgeon; but I have treated them occasionally; and temporary benefit has ensued. 
I have had two or three patients, in whom there appeared to be a temporary allevi- 
ation of the complaint; and if any thing would afford temporary relief, it would be 
iodine. I do not know whether it would cure a case of this description; but I 
should expect to do more good by it than by any other remedy. 

• See Page 993. 



BOOK VIL 
DISEASES OF THE FIBROUS TISSUES, 



CHAPTER I. 
GOUT. 



I HAVE now finished the consideration of diseases of the urinary organs; — so far 
as it is incumbent on me to treat of them. I will now speak of an affection, which 
is very much connected with disease of the urine; although it is another complaint. 
I refer to gout. When persons have the gout, I am never surprised if they have 
stone; — gout and stone so frequently go together; though gout is a disease which, 
in the first instance, affects the joints. 

Etymology and Synonymes. — It is called "tlie gout''^ from the Latin word 
^'gut'ta,^^ or the French word "'goiitte;''^ — which, in its turn, comes from the Latin 
word ""gutta,^^ — a drop. It is so called because it was supposed to arise from a 
deposition of drops from some morbid fluid in the joints. In Latin, it is now gene- 
rally called "arthritis," — "inflammation of the joints."* In the classics, it is 
spoken of under the head of " podagra," when it affects ihefeet^^ "chiragra," when 
it affects the hands?" and "gonagra," when it affects the knees;*^ but all these 
^'agra^^ are comprehended in the term ''arthritis.^^ Although this term means 
" inflammation of a joint" from any cause, yet it is now apjjropriated solely to gout. 

Mode of Invasion. — When this afleclion makes its first attack, it generally begins 
at two or three o'clock in the morning; — ^just at the time that a fit of asthma com- 
mences; as, indeed, do some other diseases. Usually it first attacks the ball of 
the great toe. The patient wakes in the most excruciating pain. He then be- 
comes feverish; and continues in this state till the next midnight; when the pain 
remits. The following morning, he finds his toe swollen and reddish; and he has 
exacerbations of the pain for several days and nights. The disease then fre- 
quently declines; the patient perspires freely. The cuticle of the part attacked, 
desquamates; there is violent itching for some days; and then there is an end of 
the business. 

Peculiarity of the Pain. — The pain, in gout, is not only very severe, but is also 
of a very pe(;uliar kind. Sydenham, in writing of his own sufferings, compares 
them to the gnawing of a dog; and patients who have suffered from it extremely, 
say they can distinguish between the pain of gout and that of rheumatism. 

Progress. — After a time, sooner or later, the same thing occurs again. Perhaps 

* From a^B^ov, a joint; and " itis," infiammation. 
^ From Troup — TTo^oif the foot; and ayja, a seizure, 
c From ;^£jj, the hand; and ay^a, a seizure. 
* From yeyy, the Jcnee; and aj/ja, a seizure. 



GOUT. 1009 

the disease attacks the balls of both great toes; perhaps it flies from one to the 
other; and perhaps it affects the hands, the knees, or the wrists. So also it will 
shift its place, during the same attack; — runninor from one knee to the other, 
from one wrist to the other, from one ankle to the other, from the hand to the 
feet, and vice versa. The more frequently it comes, the less probability is 
there of its being confined to the fingers or toes; and the more likely is it to 
spread to the ankfe, to the wrist, or even to the elbow and other joints: perhaps 
the slioulder becomes affected. But it begins at first in the smaller joints, and 
affects them to the last; — going to the others only occasionally. Generally the 
intervals between the attacks grow shorter; — the patient has fits more and more 
frequently; and they often last longer. The joints, at last, may become stiff; and 
deposits will take place under the skin; so that the joints of the fingers and toes 
become enlarged, swollen, and harder than is natural. Occasionally a solid deposi- 
tion of a white substance takes place, and sometimes it is fluid; — so that if we prick 
the part (which is soft) with a needle, we squeeze out a quantity of matter, like 
soft mortar. Not unfrequently there is a nephritic attack;* with a deposition of 
lithic acid, or some compound of it."* Occasionally these things take place with the 
gout; occasionally they take place only during the intervals; but a deposition in the 
urine, and a fit of the gout, — where there is a deposition in the joints, — are frequently 
very closely connected.'^ 

Improves the General Health. — After the attack, people are generally better 
than they were before. They find it does them good; and therefore they are not 
at all sorry that they have had the disease. Many persons long for a fit of the 
gout, when they have not had it before. They say that gout is in the family; and 
that if they had an attack, they should do well. Those who have had it, if any 
thing be the matter with them, are satisfied that they should be a great deal better, 
if they had another attack, and many people try to bring it on. 

Premonitory Symptoms. — Before the attack, there is frequendy indispositioa 
of some sort; — the symptoms that I mentioned under the head of " disorder of the 
digestive organs."*^ There may be languor, or lowness of spirits, or pain of the 
head, or wandering pains {gouty pains) coming and going in the larger or smaller 
joints. Sometimes there are palpitation and giddiness; — functional diseases, ia 
short, in almost every part of the body. 

Varieties of Gout. — If these symptoms exist for some time, — so that the patient 
really feels himself disea.sed, the disease is called " atonic gout," — gout without 
strength,^ — gout where there is not sufficient strength to bring it out. A gouty 
disposition exists; but there is not activity enough in the system to bring it for- 
ward. Sometimes, when the gout has come on in a very satisfactory manner, it 
will suddenly cease. It will not retire to another joint, but will suddenly cease 
altogether; and the patient will have some internal affection; — perhaps apoplexy, 
perhaps violent vomiting, perhaps gastrodynia, or perhaps violent colic. It will be 
some severe internal disorder; and it is then called " ^'e/rocef/en^^ gout." Some- 
times the affection within is of an inflammatory nature; and then it is called " mz5- 
placed gout:" but it is no matter whether we call it " retrocedent" or " misplaced;" 
for inflammation is very often ascribed, by old authors, to some nervous affection, 
or to something else. We have only to consider that, if the gout does not come 
out satisfactorily, it is " atonic gout;" whereas, if it suddenly cease, and an inter- 
nal part is affected in a violent degree, it is " retrocedent gout" or " misplaced 
gout," according to the affection that is going on. 

Symptoms relieved by Gout. — Some persons have had very extraordinary 
symptoms relieved by gout. I knew a gentleman who had had pain of the sto- 

* See Page 969. »> See Pages 991 and 992. 

«= Lithic acid, developed principally during the mal-assimilaiion of the albuminous tex- 
tures, may be considered as the characteristic feature in gout, — Dr. Proid, mi Sfo7nack and 
Urinary Diseases. Book I; Chapter 3; Section 3; Siibdivision4:. {Third Edition; Paoe'2\.0.) 

^ See'Page944:. • From a (privative j; and tovo;, strength. 

' From " retrocedo," to go back. 

VOL. I. 61 



1010 GOUT. 

mach (gastrodynia) for many years. I know not lioio many years it was; for he 
did not attend to it much; but at last a fit of the gout came on; and he has never 
experienced the pain since. Palpitation, after existing for a long time, has fre- 
quently ceased upon the occurrence of a fit of the gout. Strangury, cystorrhoea, 
piles, and almost every disease that can be mentioned, have ceased on the appear- 
ance of gout. Sometimes they alternate with gout; and if such affections be very 
violent indeed, then they may be called "misplaced gout;" for they have come on 
when gout should have appeared. 

Predisposing Causes. — The disease, at first, most frequently commences about 
the end of January, or the beginning of February. There is no universal rule; 
but it occurs more frequently then, than at any other time. It occurs in males, 
much more frequently than in females; — ^just as is the case with regard to " stone."* 
It is also said to occur in robust males, far more frequently than in weak ones. It 
never has been known in eunuchs; — at least, so it is said. If such be the case, 
^outy old gentlemen have an easy remedy. It is also a disease that is very here- 
ditary. This is one of the great hereditary aff'ections. If it occur in females, it is 
generally in masculine females; — those who have a little touch of the male in 
them; — robust, hearty-looking women. I do not say this is the case universally; 
because I have seen the reverse myself. It occurs particularly in men who have 
circular chests, short necks, and what are called " thick heads;" — not in those who 
have large foreheads; but in those who have bulky heads altogether, and who are 
of full habit. It occurs chiefly in those who eat a great quantity of flesh-meat, and 
drink a good quantity of wine. Among those who are predisposed to it, it seldom 
occurs till after thirty-five years of age. I have seen it in persons below puberty; 
and it is said to have occurred in infants; but, more frequently than not, it takes 
place in those who are above thirty-five, who indulge at the table, and who are of a 
plethoric habit. Such are the predisposing causes. 

I mentioned that, for the most part, males suffer from it more than females;'' and 
that where it does occur in the latter, they are very robust. The males who ex- 
perience it are chiefly those who are thick, stout, and of a sanguineous tempera- 
ment; but occasionally it occurs in persons who are extremely thin, spare, and 
emaciated. Although the disease, in a great number of cases, is connected with a 
certain development or form of body, yet, in many instances, it certainly does 
arise independently of any external appearances whatever. Sometimes very deli- 
cate women are subject to it: — persons who appear the least likely to sufl"er from 
it. In those cases in which the external appearances are not such as would lead 
ns to suppose that the patient would have it, there is usually a strong hereditary 
predisposition; and where this predisposition exists, we shall have the disease, — 
whether it is hereditary or not. It will also occur in the most temperate individuals; 
— in persons whose habits are such, and have been such, as to make it very un- 
likely that they shotdd have an attack of gout. The disposition to the disease may 
be exceedingly strong; and persons may become the victims of it, independently of 
the external appearance of the body; and independently of any of those excesses 
which so frequently produce it. 

Increased Frcquencij of the Paroxysms. — I stated, with regard to the progress 
of the disease, that it generally begins in one great toe;'' that, on the second attack, 
it perhaps occurs in both;** and that so it spreads to the other joints;" till, at last, 
after several paroxysms, many joints will be afl^ected.'' And not only does the 
disease become more extensive, but it also bocomes more frequent; so that persons 
at first, perhaps, have a paroxysm every year or two; and then every year; then 
two or three paroxysms in a year; and at last they are scarcely ever without it; — 
they have it on the least exciting cause. I should have mentioned, also, that some 
persons never liave above two or three fits in the course of their life. I know an 
instance of an individual who, when about thirty-five years of age, had an attack 
of regular gout; and, although he is now upwards of seventy, he has never had an 

* See Page If 03. '' See the Previous Paragraph. 

« See Page 1008. ^ See Page 10G9, 



GOUT. 1011 

attack since; though he has taken no pardcular care to avoid it. These are excep- 
tions to general rules. 

Gout formerly desired. — I mentioned that many symptoms will cease, when 
an attack of gout appears; — so that it is a very common thing for persons who have 
sufl'ered in various ways, to suffer no longer after they have had a fit of the gout.* 
This fact made so great an impression on the public, at one time, that gout was 
longed after as a great blessing; and people, with all sorts of complaints, would 
eat and drink, take a large quantity of wine, and do all they could to have a fit of 
the gout. As it is a disease which attacks the rich more than the poor, it was alto- 
gether a fashionable complaint. It was thought a creditable disease; and, at one 
time, every body longed for it, or declared that they had had it. This whim is 
strongly argued against in Dr. Heberden's '* Commentaries;'"' which it will be 
worth while to read; — not only on account of the elegant Latin, but for the excel- 
lent description which he gives of the disease; although, for the most part, he 
adopted poor and inert treatment. 

Influence of Ardent Spirits. — The disease is particularly favoured by indulgence 
in wine. All fermented liquors do not appear to give the same tendency to it; 
and as to spirits, I am inclined to believe that, so far from disposing persons to the 
disease, they have a tendency to prevent it. At least, I hardly know an instance 
in which a person who has committed a great excess in spirits, labours under the 
disease; although wine-drinkers have it every day. It is a very rare complaint 
among the poor. Now and then we see it among them, because there is a pecu- 
liar predisposition to it in some persons; and sometimes it is hereditary, and will 
occur in spite of the absence of all the ordinary causes; but, for the most part, we 
do not meet with it in the lower walks of life. I have seen persons who, from 
their make of body, and from the occurrence of the disease in their progenitors, — 
many members of the family having had it, — were the most likely persons in the 
world to experience it; but who, from indulging in spirits to a disgraceful excess 
(and excess of that kind is always disgraceful) have not suffered from goul; al- 
hough, beforehand, one would have said that they were most likely to have it by 
the time they were forty or fifty. 

Paroxysms induced by slight Causes. — When a person is liable to gout, a 
paroxysm may be induced by the very slightest cause. If he indulge in eating 
and drinking too much, on any particular occasion, a fit of the gout is very likely 
to be the consequence. It will occasionally ensue from mental anxiety. Expo- 
sure to cold — which, in another individual, would induce an inflammatory com- 
plaint — will, in those predisposed to gout, produce a paroxysm. Even accidents 
— such as a sprain of a joint — will become local causes; and the patient will have 
an attack of gout, in that particular part. 

Induces internal Jlffections. — When persons have the disease for a length of 
time, it is very common for internal organs to become seriously diseased. It is 
very usual to see persons who have been the victims of gout become asthmatic, or 
have disease of the kidneys, or have organic diseases of the stomach and intestine?, 
or have chronic bronchitis. Very frequently, disease of the heart supervenes, and 
disease of the head occurs; — so that they die apoplectic. The gout, at last, is not 
confined to the extremities; nor are the internal symptoms merely functional; but 
the organs in the three great cavities of the body become diseased. 

Prognosis. — The prognosis must depend on the origiital disposition, on the part 
of the patient, to the disease; and also, in a great measure, upon the resolution 
which he has to follow up our advice. A great number of persons who have the 
gout, are very disobedient in this parlicular. 

Treatment: Regimen. — With respect to the cure of the gout, in general it is 
necessary that the patient should be very abstemious; — that he should live as low 
as he can to be in good health; and take as much exercise as he can bear; — only 
taking care that his health is not impaired by its violence. It is impossible to lay 

" See Page 1009. ** Chapter 9. 



1012 GOUT. 

down any specific rule; and to say that a man, disposed to gout, should not drink 
wine, — should not drink beer, — should not eat meat, would be wrong. There are 
some gouty patients who would be better, if they left off fermenled liquors; others 
would be better if they went farther, and ate no meat, but confined themselves to 
vegetable diet and milk. There are other cases, again, where this would be ab- 
surd; — the patient could not live without meat; and there are other cases where it 
is necessary to allow a certain quantity of wine. The stomach of many persons 
labouring under gout is so weak, that they cannot digest their food without a certain 
allo,wance of wine; but, generally speaking, the diet I have recommended, and as 
much pleasant exercise as possible without weakening the patient is advisable. 
No doubt, however, there should be extreme temperance: the patient should not 
take more wine, or eat more meat, than is necessary. Many persons will thus get 
lid of the gout altogether, with the most perfect ease; while others, who will not 
get rid of it (and these may be by far the larger number), will have it very much 
mitigated. It is necessary that they should be particular in their food; — that if ihey 
eat any food, they should take that which is the most digestible; such as fresh 
mutton, or fresh beef; without any sauce, or elaborate preparation on the part of 
the cook. They should take simple Sherry or Madeira, and not mixed wines. 
Above all, they should not take acescent wines, such as Champagne; and perhaps 
they had better take brandy-and-water. Many persons, from taking Rhenish 
wines, or Claret, or Champagne, have a fit of the gout directly. In general. Sherry 
agrees best; and therefore we should recommend it; — unless the person knows, 
from his own experience, that some other wine, or a small quantity of brandy 
mixed with water, is better for his constitution. I am supposing that the stomach 
of the patient requires such a plan to be adopted. 

Friction, — Friction is exceedingly useful, when exercise cannot be adopted. It 
would be well for many persons who are lame in the feet, to be rubbed down, once 
or twice a day, like a horse. They would also find it a very great luxury. 

Colchicum and Antiphlo gistics . — In a regular fit of gout, the best medicine 
that can be given, is colchicum. We should exhibit the wine,^ in half-drachm 
doses, every six hours; and it should be mixed with some other purgative; be- 
cause we want its action to be sj)eedy. The sulphate of magnesia makes a good 
combination with it. We may produce purging in twenty-four hours, or sooner; 
and when that takes place, the })atient is generally relieved at once. Any good, 
active purgative will have a beneficial effect; but colcliicum appears to be more 
efficacious than any other. Unless it purges, however, it will seldom have any 
influence. Now and then, the symptoms will all cease after two or tiiree doses; 
but, in the greater number of instances, so desirable a result does not occur till 
purging takes place. It is better to quicken the purgative effect, in order to pre- 
vent it from griping; and the sulphate of magnesia will excite its action so much 
the sooner. Venesection may be advisable in young persons; but, in general, it is 
out of the question. Leeches applied to the pari, are frequently productive of 
very great alleviation; and it is a great comfort, in general, to apply an evaporating 
lotion; — not cold, but tepid. A spirituous lotion thus tepid, does not produce a 
chilly effect. While these remedies are being employed, the diet should be scanty. 

When the paroxysm is over (and it need never last long if treated in this way), 
friction of the parts is always found useful; — rubbing them with a flesh-brush, or 
the hand, and some salt-and-water, or similar stimulants. Sometimes it is neces- 
sary to give wine, or mild tonics, to relieve the languor that is left; but it is by no 
means ctlways necessary. Occasionally, from the great severity of the pain, opiates 
may be required; but it is necessary to use the antiphlogistic measures that I men- 
tioned.'' If all this be done, and the patient's life is continued, the disease becomes 
comparatively trifling. I say " comparatively;" because it is always more or less 
painful. But it is not nearly so painful as it v/ould be, if patients wrapped up their 

■ " Vinum Colchici." * Seethe previous Paragraph. 



RHEUMATISM. 1013 

limbs ill flannel; took no colchicum; and, in the intervals of the disease, indulged 
in every absurd way they could. 

Application of Cold.— li is dangerous to apply cold to the parts, during an 
attack of gout. Some have done it; and Harvey, who discovered the circulation 
of the blood, was accustomed (when an attack came on) to plunge his feet in a pail 
of cold water. I know persons that do this; but no medical man is justified in 
recommending it; for it has frequently happened that some disease has suddenly 
begun within. There has been apoplexy induced; or violent gastrodynia: or an 
affection of the heart: and the patient has died very shortly. If tlie patient chooses 
to do it on his own risk, he may: but he ought to be warned of the consequences 
by his medical friend. 

Gout is a disease which it is not easy to eradicate; but, by the employment of 
colchicum, the disease is rendered much less violent than it was a few j'^ears ago. 
Formerly colchicum was employed with great success; and then it was forgotten 
entirely, till within a very few years ago. When I was a student, no one thought 
of exhibiting colchicum, in any form. It was only spoken of as a thing once used; 
—as an uncertain diuretic, and a violent purgative; and it was thought that it would 
be better, if it were expunged from the Materia Medica. I mentioned the imne of 
colchicum;* but some give the powder, in doses of five grains, every four or six 
hours; and some give the "acelum colchici.'* 



CHAPTER II. 
RHEUMATISM. 



Definition. — The next disease which T will mention, is nearly allied, in many 
particulars, to gout; and is called "rheumatism." As "gout" is named from the 
idea of the dropping of morbid fluid,^ so " rheumatism" is named from a similar 
idea; — the term being derived from the Greek word pfi^^aft^o (from ptto, to flow). 
It is said that gout and rheumatism were not accurately distinguished from each 
other, till the year 1642; — both of them passing under the name of "arthritis." 
Bellonius, who was a physician that suffered much from rheumatism, is said to have 
been the first that made an accurate distinction. 

Symptoms of the acute form. — Rheumatism may occur in an active^ ox \n z. 
dull passive form; and the two varieties require very opposite treatment. In the 
active form of rheumatism, — that which is commonly called " aciite rheumatism," 
— there is heat, pain, and (in most instances) a swelling of the joints. These are 
not the smaller joints, as is the case in gout;° but the large ones; in general the 
wrists, the ankles, the elbows, the knees, the shoulders, and the hips. When these 
parts are affected with it, there is pain; but nothing of that violent kind which occurs 
in gout; — as if a dog were gnawing the joint. ^ It is as violent as a patient could 
wish it to be; but by no means so horrid as gout. The parts are generally hot and 
red; and frequendy, from the pain being situated in the theca of the tendons, I have 
seen red streaks running in the situation of the tendons. There is generally swell- 
ing and pnffiness in some part. Usually, there is feverishness, pyrexia, and a quick 
pulse. Tlie pulse is not hard; but, in general, full and soft. The tongue is not 
foul and dry, but (in general) very white; and the urine is high-coloured, and de- 
posits a laterilious sediment. 

Diagnosis from Gout. — This disease does not, like gout, begin particularly in 
the night;'' but invades at any time; and it does not come on at any particular season 
of the year. It arises from an evident exciting cause; and therefore it may come 

» See Page 1012. »• See Page 1008. « See Page 1009. 



1014 RHEUMATISM. 

on at any time. It does not confine itself to one joint particularly; but leaves one 
and goes to another; and it will attack two or three at the same time. Tliere is a 
shifting about; — it migrates in the most singular manner. Not only is there heat 
and an increased temperature, but heat generally makes the patient worse. Usually, 
too, there is profuse sweating; and the perspired fluid is often exceedingly sour to 
the smell. When the disease goes off, the parts do not desquamate and itch, — as 
they do after gout; but they merely cease to be hot, cease to swell, and cease to be 
inflamed. 

The Chronic Form. — This is the usual state of things when the disease begins 
suddenly as an acute disease; but a similar state of things occurs in the chronic 
form. When the disease has lasted a twelvemonth, the parts are still hot, swollen, 
and painful; and the pain is increased if heat be applied. We find the same symp- 
toms as in the acute affection; only they are less violent. In general, however, the 
sweating does not continue; for after the disease has lasted a few weeks, this symp- 
tom ceases; and the patient, perhaps, forgets it. It is sometimes a little difficult 
to make an accurate diagnosis; — at least it requires a little trouble; and it is well to 
ask about the sweating. If the disease have been acute rheumatism at first, there 
has been sweating; at least, it is unusual for a person not to sweat at the beginning 
of the disease. 

Not confined to the Joints.— k\\howo\\ the joints are the parls particularly affect- 
ed, yet persons frequently have the disease in the back; and then it is called "lum- 
bago."* Frequently it occurs in the back of the neck; and then the patient is 
said to have a " crick in the neck." It may affect the face; and, indeed, it may 
aflfect almost any part of the body, where there are fibrous membranes, aponeu- 
roses, ligaments, tendons, or (perhaps) muscles. There is no danger whatever 
from this disease, except from one circumstance; — which is, that the membranes 
within the chest (the pericardium and the pleura) are liable to be affected. They 
are sometimes attacked during the disease; and when the latter has suddenly ceased, 
or has gone off gradually, inflammation within sometimes takes place. This inter- 
nal inflammation will occur at all periods, and in all possible circumstances; but it 
most frequently takes place about the time of puberty, and in young adults; so 
that, in acute rheumatism, we should never omit observing the state of the chest; — 
just as, in the case of an obstruction of the bowels, it is righi to ascertain whether 
there is a hernia or not.'' Now and then, inflammation occurs within the head, 
and phrenitis is set up; but that is rare; whereas inflammation of the pleura and 
pericardium, particularly the latter, is very common. 

Atonic Rheumatism. — The active form of the disease, I mentioned, may be 
either acute or chronic.'' The chronic form may have active symptoms; but very 
frequently it has not; — the parts are not hotter than they ought to be; but, on the 
contrary, are relieved by heat. This is sometimes the case in the acute form of 
the disease; — that is to say, it occasionally happens that persons, when they are 
first attacked with rheumatism, have no heat; — the pain is not aggravated by heat; 
but the parts are cold, and are the better for the application of heat. It is gene- 
rally, however, in the chronic form of the disease, that the parts fall into this state 
of atony. 

Rheumatalgia. — The disease sometimes appears to consist of little more than 
violent pain. Sometimes people complain of pain apparently in the muscles; but 
it may be situated in the aponeuroses over the muscles. There is simply pain on 
motion; — a pain not at all increased on pressure; and there is no swelling. This 
form of the disease has been called " rheumatalgia." I do not know the necessity 
for giving it this name. Although rheumatism generally affects the fibrous mem- 
branes, yet sometimes it apparently affects the muscular fibres; and sometimes it 
appears to affect the nerves, or their covering; so that it will distinctly run down 
the sciatic nerve; though it is most frequently seen in the nerves of the face. I 
mentioned, when speaking of "tic douloureux," that sometimes, besides the genuine 

» From " lumbus," the loin. ^ See Page 914. «= See Page 1013. 



RHEUMATISM. 1015 

form of that disease, we have another affection called ^^ rheumafic neuralgia," 
which is easily cured.* When rheumatism affects the nerves, it clearly exists in 
their course, and then it frequently assumes an intermittent form. Tliis is parti- 
cularly the case in the head. 

Sometimes Intermittent. — Rheumatism is sometimes intermittent, when it does 
not affect the nerves particularly, but when it affects aponeuroses; and this form of 
the disease most frequently attacks the head. In this case it usually affects one- 
half of the organ; and the pain generally comes on in the evening, about six o'clock; 
and continues, very violently, for a few hours. Occasionally, when it is intermit- 
tent in this way, the parts are hot, swollen, and throb, and the eyes water. But, 
in other cases, this is not felt; and the patient is all the belter for wrapping up the 
head in a flannel petticoat. This is done among the lower orders; and with very 
good effect. 

Thickening of the affected parts. — Occasionally the parts, when long affected 
with the disease, become thickened. V/e may have considerable thickening of 
the joints. The small joints of the fingers will throb, from time to time; and the 
patient will become a cripple, in consequence of the joints being inflexible; — ^just 
as in the case of gout.^ 

Rheiimatic Gout. — As gout generally affects the small, and rheumatism the 
large joints, if rheumatism should affect the small joints, it is usually termed 
"rheumatic gout." Not that it is a combination of the two; though it sometimes 
may be. vVe may have the same appearances both from gout and from rheumatism. ° 

Exciting Cause. — There is, I believe, but one exciting cause of the disease; 
and that is the application of cold, or cold and wet; more especially if the patient 
be fatigued. I do not know that I ever saw a case, in the whole course of my 
life, that arose from any other circumstance. 

Terminations. — I mentioned before, — when speaking of inflammation general- 
ly, — that rheumatism does not terminate in suppuration.^ If suppuration occur, 
it must arise from another inflammation being accidentally present, or being excited 
by it. Neither does it terminate in mortification. There is sometimes effusion 
into the joints; — a considerable secretion of synovia or of fluid in the bursae; and 
sometimes in the tendons. The parts may become rigid; and then, sometimes, 
mortification has been the consequence. 

Occurs in Infants. — Rheumatism will occur in infants, as well as in old people; 
and this is worth knowing. I have seen many cases of the disease in very young 
children; — a circumstance very likely to be passed over. I have also seen disease 
of the heart in very young children; — as a consequence of pericarditis excited by 
this disease. 

Pathology of Rheumatism. — [As certain forms of fever and inflammation are 
always accompanied by more or less of derangement of the assimilating processes, 
both ])rimary and secondary; and such forms of fever and inflammation are not 
only preceded by long-continued derangements of the primary digestive processes, 
but frequently have their origin in such primary derangements; we^ may perhaps 
be allowed to assume, that some diseases to which we apply the terms "yet'er" 
and '''inflammation,''^ are [practically speaking, at least) only severer derange- 

^ See Page 655. '' See Page 1009. 

•= When the lactic and lilhic acids are developed together (as they maybe, and often are), 
the phenomena may be supposed to show, that the mal-assimilation involves both the gelati- 
nous and albuminous textures; aqd that the accompanying disease partakes of a mixed 
character; or, in fact, constitutes what is not improperly termed "rheumatic goui;" — a form 
of disease which, as every one knows, is usually of a much more deep-seated and obstinate 
character, than either gout or rheumatism alone. According to these views, therefore, the 
lactic and lithic acids, considered with reference to rheumatism and gout, may be regarded 
somewhat in the light of materies morborum; or, strictly speaking, the undue presence of 
these acids in the urine or elsewhere, in certain circumstances, maybe viewed as indices 
of the existence of certain diseased actions going on in the primary tissues of the body; and 
which are known by the names of " rheumatism" and " gout." — Prout, on Stomach and Uri- 
nary Diseases. Book 1; Chapter 3; Section 3; Subdivision 4. ( Third Edition^ Pages 210 
and'^n.) 

«» Dr. Prout. 



1016 RHEUMATISM. 

merits of the secondary assimilating processes, modified by the peculiar nature of 
the organs or textures in which such derangements exist; — inferences that will 
enable us to explain the principles on which derangements of ihe primary assimi- 
lating processes, predispose to those peculiar derangements of the secondary pro- 
cesses which we consider to be nearly connected, if not identical, with those forms 
of fever and inflammation usually denominated '♦ intermiitent fevers," ♦'rheuma- 
tism," and " neuralgia;" on each of which affections we' shall make a few remarks. 

The exciting cause of the diseases just mentioned, is generally admitted to be 
malaria; and, if viewed abstractedly, and with reference to their specific nature, 
it is probable that malaria is the only exciting cause of these diseases. These dis- 
eases, however, are so generally associated with other diseases, arising from other 
exciting causes, that we rarely see them in their simple condition; moreover, dis- 
eases (as hectic, &c.) simulating them in many respects, are produced by other 
exciting causes than malaria; so that it often becomes a work of great difficulty, or 
even of impossibility, to distinguish one disease from another, and, consequently, 
to refer each exactly to its true exciting cause. How malaria acts in producing 
ague, rheumatism, and neuralgia, we do not know; but every one who has 
observed these diseases attentively, will probably admit, that the derangements 
of the assimilating organs constitute one of the first perceptible links in the 
series of symptoms; and, moreover, that these derangements of the assimilating 
organs are usually accompanied by the presence of great acidity in all parts of 
the system. Thus, in ague and rheumatism, during the sweating stages of the 
paroxysms, immense quantities of acid (chiefly of lactic acid) are thrown off by 
the skin; and sometimes by the kidneys. In these cases the saliva is commonly 
acid; and, in the severe and malignant diseases of this type, — occurring in tropical 
climates, — not only the saliva, but the whole assimilating organs, and even the 
blood itself circulating in these organs, have been observed to be in an acid condi- 
tion. Thus, the dark-coloured fluid ejected from the stomach in yellow fever, and 
some other analogous diseases, appears to owe its colour solely to the presence of 
blood, which has been blackened by the large quantity of (lactic^) acid present; and 
which blood and acid must have been thrown off together, from the unnatural fluids 
circulating in the vessels of the stomach itself. Now, the presence of so much lac- 
tic acid cannot be accounted for, except on the supposition that a certain portion of 
what ought to constitute, or actually has constituted, the albuminous (or, rather, 
gelatinous) parts of the system, is decomposed or destroyed; and — as gelatinous 
and albuminous matters or textures cannot be converted into lactic acid alone — that, 
consequently, other unnatural and probably poisonous principles are developed in 
conjunction with the lactic acid; to which in part, as well as to the lactic acid, many 
of the secondary consequences of malassimilation are to be referred. In other 
words, the alimentary matters, which ought to be converted into albumen, by the 
primary assimilating organs; and the albuminous matters of the blood — which, in 
the secondary assimilating processes, ought to be convened into the living gelati- 
nous and albuminous tissues — are, by the deficient or disordered operations of the 
vital processes, converted (in a greater or less degree) into lactic acid, and other 
unnatural combinations. 

Such, then, are the conditions of the assimilating processes, which we" conceive 
to exist in the classes of disease we are now considering; the next question is — What 
constitutes the difference between ague, rheumatism, and neuralgia, when the cause 
and general conditions of the system in these affections are assumed to be the same? 
If our assumption be correct, the only answer of which this inquiry appears to 
admit is, that the circumstances constituting the varieties in question are — differ- 
ence in the degree in which the same organs are aflected; or differences in the seat 
of disease or org^ans affected; or, what is most likely, a combination of both these 
kinds of differences. 

With respect to difference in degree, we do not think that this cause alone is 
sufficient to account for the varied character of the diseases in question. It is ad- 

* Dr. Prout. 



RHEUMATISM. 1017 

mitted, indeed, that difference in degree will, by causing the affection to be generally 
spread over the system, considerably modify the symptoms; but, unless specific 
organs be actually involred, there can hardly be supposed to be any difference in 
the kind of the disease. We are, therefore, driven to the conclusion, that these 
different forms of disease arise from derangements in the secondary assimilating 
processes proper to different tissues or structures. In rheumatism, the same de- 
rangements, to a less extent, appear to exist in the primary assimilating organs; 
but, in this case, the secondary assimilating processes, by which the gelatinous 
portion of the muscular system and its appendages is produced and maintained, 
may be supposed to be more especially implicated; and the loss of power, and the 
great degree of pain usually present in rheumatism, may be referred to the disorder 
of the numerous nerves of motion and of sense; which, as well as the fibrinous 
portion of the muscles, are likevtise necessarily affected by the derangements. 
Moreover, on these suppositions, we may explain the formation of the large quan- 
tities of lactic acid usually present in rheumatic affections; as well as the swelling, 
&c.; for, as all the organs are more or less involved, and their functions paralyzed, 
not only imperfect assimilation takes place in the part affected; but the apparatus 
destined to remove from the scene of operation matters which are unfitted, or no 
longer useful, likewise ceases to act; and hence such unfitted and useless matters 
accumulate, and cause swelling in the part affected.^] 

Treatment of the Acute Form. — Whether the affection be acute or chronic, the 
treatment should be exactly the same. We have only to make two distinctions; — 
to ascertain whether it is the inflammatory form of the disease;^--whether the parts 
are hotter than they should be, and heat does harm; or whether the parts are 
cooler than they should be, and heat does good. In the one case, antiphlogistic 
measures will be required; and in the other stimulants. 

Blood-letting. — Sometimes, where the patient is plethoric, it is advisable to take 
away blood from the arm; and we shall find it buffed and cupped. But there is no 
danger from that circumstance; for if we go on bleeding, we may find the blood 
buffed and cupped, till we have got nearly all the blood out of the body. But vene- 
section is not always required. Free local bleeding generally answers better; but 
there is no objection to general bleeding, if the strength will allow it; and if several 
large joints be affected, it will be better than local bleeding. 

Cold Applications. — With respect to the parts themselves, — whether we apply 
leeches, or cupping, or not, — we shall find it of great use to apply cold water or 
cold lotions, as long as the temperature is higher than it ought to be, and they 
feel comfortable to the patient. There is no danger in applying cold, with these 
limitations. If the patient should be timid, and yet long for cold evaporating 
lotions, they may be applied tepid (as in the case of gout''); but I never saw injury 
arise from cold in rheumatism, where the parts were hotter than they should be, 
and the patient felt hot. 

Colchicum and Mercury. — The two best internal medicines are, without doubt, 
colchicum and mercury. Colchicum here, as in the case of gout, generally does 
no good till it purges;'' and when once it purges the patient thoroughly, the disease 
usually gives way. It should be given in the same way as in gout;** — that is to say, 
with magnesia; that it may produce its effect as speedily as possible. As soon as 
it purges, it is right to desist; and also as soon as its effect ceases. If we give a 
dose of hydrocyanic acid with the colchicum, it is better retained by the stomach. 
We may exhibit one, two, or three minims of the acid. But, every now and then, 
we shall find obstinate cases, which will not easily give way; although the greater 
part of them do; and then it is a pity to go on with the colchicum. We had better 
exhibit mercury, and get the mouth tender. If we do this, in the first instance, 
instead of giving colchicum, the success is about the same. Colchicum may gripe, 
and mercury may make the mouth sore; — so that we may not be al)le to continue 
them. We may then leave off the one (whichever it may be), and exhibit the other; 

* Dr. Proul, on Stomach and Urinary Diseases. Book 1; Chapter 2; Section 3; Sub- 
division 3. (Third Edition; Pages 80 to 83.) 
b See Page 1013. 



1018 RHEUMATISM. 

or if we begin with one of them first, and find it does no good, then we may exhibit 
the other. 

Bark. — As soon as the inflammatory symptoms have gone down, and the patient 
has been properly evacuated, many give bark and quinina. It has been said that 
bailt is a safe and good remedy even in active inflammatory rheumatism; but we do 
not find, in Hay garth's work, any authority for such practice. We find, in his book, 
accounts of the successful treatment Of rheumatism by bark; but then it was not till 
he had evacuated the patient upwards and downwards, and employed the antiphlo- 
gistic plan. After that, it is said that bark prevented the disease from recurring. I 
have not had occasion to use that medicine; for I have found the disease give way 
under the treatment I have mentioned.* 

Narcotics. — It may be right to give narcotics, in order to produce ease; and a full 
dose of opium maybe proper at night. There is no harm in it, provided we adopt 
antiphlogistic measures; — provided we bleed as far as bleeding is indicated, purge 
the patient well, and apply cold. 

Treatment of the Chronic Form. — Exactly the same treatment is proper in the 
chronic form of the disease, if there are inflammatory symptoms; but whether the 
disease be recent or chronic, if the parts are not in this condition, an opposite plan 
should be adopted; and it is right to stimulate the parts. In this case, friction is 
an excellent remedy; and we shall find the hot-bath (particularly the vapour-bath) 
very useful. If the patient find alleviation from warmth and stimulants of all 
kinds, or the parts are colder than they should be, then this plan should be put in 
practice. The hot-bath should be employed, not every other day, but every day; 
and sometimes it should be used, in cases of extreme coldness and extreme pain, 
twice a day. It is here that electricity is of use; as well as friction; together with 
stimulating washes, stimulating liniments, and croton-oil; — which is a good stimu- 
lant when applied externally, and does not purge when so employed. Tartar- 
emetic, and sometimes moxa, have been employed; but only, of course, in very 
severe cases. 

Acupuncture. — It is in this description of the complaint, that we find acupunc- 
ture of great use.*" It is only in the fleshy parts that we can introduce the needle.*" 

» See Page 1017. 

^ Much information on this subject will be learned from Dr. EUiotson's Paper on Acu- 
puncture, in the "Cyclopaedia of Practical Medicine." (Volume 1; Page 32. "J We subjoin 
his observations on the term itself: — "The passing of a needle into the body, is termed acu- 
pwnc^Mre (from 'acus,' a needle; and 'pungo,' to 'prick'). From forgetting that the word 
'■puncture'' has two significations, — that it is used to express both the wound and the act of 
making it, — some have termed the operation ^puncturation.'' But to subjoin the syllables 
^atiurC to the word '■'puncture^ or '■acupuncture^ is as improper as to subjoin them to the words 
^preparatiovb and 'fabrication;'' each of which already ends in 'ation^ and has a similar two- 
fold meaning. An exactly parallel error would be to say 'manufacturaiion? " Dr. Elliotson 
gave the plan an extensive trial in St. Thomas's Hospital; and has published the result of 
that trial, in the Thirteenth Volume of the " Medico-Chirurgical Transactions" (Page 
467). Out of forty-two cases, thirty were cured. 

"=■ M. Bretonneau says, that he has passed needles into the cerebrum, cerebellum, heart, 
lungs, and stomach of sucking puppies, — through, and through, in all directions,— with no 
sign of pain, nor with any particular effect; unless when too large a needle was thrust into 
the heart; and, in one instance of this, a little extravasation took place into the pericardium. 
So far from fearing to acupuncture the heart, Dr. Carraco would have us do so in the worst 
cases of asphyxia. He declares that, in the presence of several persons, he kept several 
kittens under" cold water, till they were apparently dead,— stiff, motionless, frothing at the 
raouth, without pulsation of the heart, and regularly sinking to the bottom of the water, 
every lime they were thrown in; that he passed a needle into the heart; that soon the needle 
began to be gently agitated, then rapidly so; and that one voluntary motion after another 
gradually took place, till life was fully re-established; and that the animals did as well after- 
wards, as if nothing had happened. Death, however, by acupuncture of the brain or spinal- 
marrow,— as a secret mode of infanticide, — is notorious in works on Slate Medicine. 
"Guy Patin,'* says Fodere, " relates that a midwife was executed at Paris, for having mur- 
dered several infants at the moment the head presented at the os uteri; by passing a long 
and very fine needle into the brain, through the temples or the fonlanelles; into the nape of 
the neck; or into the heart or its large vessels. Alberti and Brendel quote similar exam- 
ples. In the "Causes Celebres" we read the horrible story of a woman who, towards the 



RHEUMATISM. 1019 

I should never advise it to be put into tendons and joints; though I have seen such 
things done. In general, it is only in the fleshy parts, — such as the deltoid, the 
biceps, the gastrocnemius, the rectus, or the gluteus muscles, — that it is right to 
put them. The best mode is to roll them by pressing them between the fingers; 
and they will soon pass to the desired length. We may insert them an inch and 
a half in depth; and if the bone is in the way, as in the case of the os femoris, 
there is no harm in the needles coming upon it; though there is no use in it; but 
they may go as far. The success of the operation does not depend on the number 
of needles; but on the time they remain in. If it be comfortable to the patient, we 
may let them remain in a couple of hours; that is, as long as a patient can bear to 
be kept still. There is no pain worth notice when they are introduced; and when 
they are in, there is no pain at all. It should be done every day; and occasionally 
we.find relief as soon as they are taken out the first time; but in other instances, not 
till they have been employed two or three times; or perhaps oflener than that. It is 
only where the parts are not hotter than they should be, that acupuncture is of any 
use. I never saw it do good when heat increased the pain. Acupuncture is not an 
absurd remedy. It is a strong one; but I am quite satisfied it is a real remedy, if 
it be properly applied. 

Mercury. — In the chronic form of rheumatism, we find mercury of the same 
use as in an acute attack.^ Whether the parts are hotter than they should be, or 
not, obstinate cases give way to mercury, when they will not yield to any other 
medicine. Nothing is more common than for persons who are the victims of 
chronic rheumatism (whether it be inflammatory or not), but who are suffering 
great pain, — more especially if the pain be worse at night, — to receive no benefit 
whatever, till they have undergone a course of mercury; and as soon as the mouth 
is sore, they will lose all the pain. Mercury appears equally useful in both kinds 
of rheumatism. 

Guaiacum. — One of the best internal stimulants, in a case of this sort, is the 
ammoniated tincture of guaiacum.^ Guaiacum is a stimulating diaphoretic, and is 
very useful in this form of rheumatism; though it is of no service in the active 
form of the complaint. The tincture made with aromatic spirit of ammonia,'' pro- 
duces great warmth; and the patient remains warm for a longer or a shorter time. 
This is a medicine that may be given in various doses. Some persons are made 
hot with thirty drops; but others will take a drachm; and I have seen some who 
have taken six drachms, three or four times a day. There is no rule for it; but we 
should begin with half a drachm; and, as long as the patient is not warmed by it, 
and does not find it irritate him, we may increase it. Sometimes the warmth will 
last for one, two, or three iiours; and, from a proper course of it, we shall find 
great alleviation. Sometimes it purges; sometimes it irritates the skin, and pro- 
duces the nelUe-rash; but when internal stimulants are necessary in rheumatism, I 
think this is one of thebest. 

Diet. — In the chronic form of the complaint, it is often necessary to support the 
patient well; — to give him wine, and nourish him assiduously. 

Arsenic. — x\rsenic has an excellent eflect in this form of the disease, where the 
joints become cold. It frequently requires to be well persevered in; and (just like 
colchicum) it is borne by the stomach infinitely better, if we give prussic acid a 
little before it, or at the same time.* Arsenic is a medicine which is much dis- 
posed to irritate the stomach and bowels, and to produce gastritis; and, short of 
that, it frequently produces nausea and vomiting; but that may generally be pre- 
vented by prussic acid. The moment we find heat in the stomach and bowels, 
and pain on pressure, it should be omitted. We should ascertain this point every 
day; and when it occurs, the medicine should not be resumed till these symptoms 

middle of the last century, made it lier business to murder all the new-born infants that fell 
into her hands, by acupuncture, — practised at the top of the vertebral column, or in the 
brain; — with the sole intention, as she told the judges, of peopling heaven more and more. 
— Elliotson on Acupu7iclure, in the ^' Cyclopccd/a of Practical Medicine." Volume 1; PagedA. 
» See Page 1017. ^ The " Tinctura Guaiaci Composita." 



1020 RHEUMATISM. 

have gone off. Arsenic also produces soreness of the eyes, and redness of the 
throat; and when any of these symptoms arise, we must desist from exhibiting the 
medicine; and not resume it till they are gone off. Tliere is no particular rule for 
the dose. It is best to begin with two or three minims; and, as long as it is borne 
without doing tlie patient any harm, we may increase it. I have known cases 
where thirteen or fourteen minims were borne; but that is a large dose. In gene- 
ral, seven or eight minims are as much as can be given. I do not know that there 
is any danger in the oedema induced by the medicine; but it shows that it acts on 
the body, and therefore it is better to desist. With regard to the gastritic affection, 
that would be dangerous if the arsenic were continued; but, with a careful practi- 
tioner, no danger can arise from this remedy. In the chronic form of the disease, 
blisters, setons, and moxse may be of use; — just as in any other chronic inflam- 
mation. 

Bark. — ^If the disease assume an intermittent form, we must treat it (in some 
measure) as intermittent fever.* We must give a large dose of quinina or bark, 
either just before a paroxysm is expected, or afterwards; and smaller doses at in- 
tervals." Or we may employ arsenic.'' 

Stramonium. — When rheumatism affects the face, a large dose of some nar- 
cotic, given just when the paroxysm is about to begin, often acts like a charm. It 
is an excellent plan to give a dose of stramonium, at the time the pain is coming 
on, and to repeat it in two or three hours. A large dose is generally required; 
and therefore, in the case of an adult, it is better to give a grain. In two or three 
hours, if there be no alleviation of the pain, and no affection of the head, we may 
repeat the dose. Sometimes the pain will not cease, till we have exhibited two or 
three doses; but I do not know more than one or two cases, in which this plan 
failed. It is certainly one of the best we can adopt. The ill effects of stramonium 
(as I before mentioned**) are dimness of sight, great thirst, and dryness of the 
throat; but these are not at all dangerous symptoms. The most unpleasant symp- 
tom is an affection of the head, drowsiness, giddiness, or delirium. I have fre- 
quently seen these induced, and then go away after a few hours; but if there be 
any hazard, an emetic may be had recourse to. If, however, we increase the dose 
slowly, this effect need hardly ever occur. 

* See Page 273= * See Page 276. « See Pages 380 and 1019. * See Page 958. 



INDEX. 



Abdomen, cysts in the 
"Abdomen," elymolog'y of. 
Abdominal glands, diseases of the 

— signs 

Abernethy's " Hunterian Oration 
Aberration, mental 
Abscess . . • . 
Absorption of morbid secretions 

, physiology of . 

Acanthocephala . 

"Acanthocephala," etymology of 

Acarus scabiei . 

Acephalocyst 

Acetate of lead in hoemorrhage 

, mode of administering 

Achor .... 

"Achor," etymology of 
Acid, lithic 

, uric .... 

Acne . ... 

indurata . 

punctata . 

rosacea 

simplex 

, suppurating stage of 

, treatment of , ^. 

"Acne," etymology of 
Acquired diseases 
Action, diminished 

, increased 

Acupuncture 

"Acupuncture," etymology of 
"Acute," etymology of 
Adynamic fever 
"Adynamic," etymology of 
JEgophonism, cause of 
jEgophony 
jEstrus Haemorrhoidalus . 

Ovis 

yEtinlogy .... 
"^Etiology," etymology of . 

Age 

"Ageuslia,"' etymology of . 
Ague .... 

, action of remedies in 

, adipose tissue affected by 

, ages affected by 

, anasarca in 

, arsenite of potassa in 

— — , ascites in 

— — , bark in 

, bleeding in the cold stage of 





Ague, cause of intermittence in , 


QS7 




— — , causes of . . . , , 


243 


880 


, changes in the type in 


238 


47 


~, cold stage of . . , 


234 


879 




240 


64 


-, congestion in . 


240 


617 


-, danger of arresting . 


28a 


546 


-, diagnosis of . . , . 


268 


97 


-, diseases aggravated by 


24a 


116 




243 




150 


arrested by 


242 


961 


■ — -modified by. 


240 


961 




239 


414 


, duration of ... . 


239 


967 


the paroxysm in . 


237 


141 


, effects of 


240 


767 
417 




254 
240 


— — , effusion in . . . . 


417 


, emetics in . . . . 


282 


991 


, enlargement of the spleen in . 


240 


991 


, hectic combined with 


268 


446 


distinguished from . 


268 


447 


, idiocy in . 


241 


447 


, incidental symptoms in 


235 


447 


, incubation of . , . 


261 


447 


, inflammation in . . 


240 


447 


, leaping , . . . . 


626 


447 


, nervous debility distinguishec 




447 


from . , . r 


2G8 


41 


not contagious . . . . 


260 


40 


, opium in . . . . 


282 


40 


the cold stage of 


271 


73,1018 


, partial affections in . 


237 


1018 


, periodical recurrence of . 


235 


37 


, period of the paroxysm in 


237 


288 


prevented by fire 


259 


288 


smoke . , 


259 


808 


, prevention of . . . 


283 


713 


, prognosis in ... . 


268 


960 


, proximate cause of . 


266 


960 


, return of . . . . 


239 


42 


, state of the blood in . 


266 


39 


, sudorifics in . 


282 


47 


, susceptibility to 


252 


659 


, sweating stage of 


235 


233 


, treatment of . . . 


. 269 


266 
242 






sion of . 


272 


239, 244 


in the paroxysm of 


. 270 


241 


, variety in the paroxysms in 


238 


280 


Asfuish districts, eftccts of . 


. 244 


241 


Air 


. 34,45 


272 


Air-cells, dilatation of the , 


749 


270 


, hcemorrhage from the . 


763 



1022 



INDEX. 



Air.passage?, haemorrhage from the 
Air-tubes, dilatation of the . 

— , diminution of the 

Albumen in carcinoma 

the urine 

"Alexipharmic," etymology of 
Alienation, mental 
Alkaloids, nomenclature of 
"Alphoides," etymology of 
Alterations in the attitude . 

— — breath . 

countenance 



— eye 

— face 

— hand 
-- heart 

— neck 

— orbit 

— respiration 

— surface . 
~ teeth . 

— thorax . 

— tongue . 
voice 



Altered appearances 
Alternating calculus . 
Amaurosis 

"Amaurosis," etymology of 
Ambergris .... 
Amenorrhoea, phrenitis from 
"Amenorrhoea," etymology of 
Ammonia and magnesia, phosph 

in inflammation 

■ , hthate of . 

, urate of 

Ammoniaco-magnesian phospha 
Amorpiious sediments 
"Amorphous," etymology of 
Amphoric buzzing 
Amputation in inflammation 
Anifimia . . . • 

— — , aggravated species of 

, definition of 

, endemic variety of 

, treatment of 



"Anaemia," etymology of . 
Anaesthesia 

"Anaesthesia," etymology of 
Anasarca .... 
"Anasarca," etymology of . 
Anatomy .... 
*'Anatomy," etymology of . 
Ancell's Lectures on the Blood 
Aneurism of the aorta . 

, false 

, rupture of an 

, symptoms of 

, treatment of 

, true 



ate of 



te 



heart 



"Aneurism," etymology of 
Angina occulta . 

pectoris 

trachealis 

"Angina," etymology of 
Anorexia . 

"Anorexia," etymology of 
Anosmia ... 
'Anosmia," etymology of 



762 

747 

748 

197 

160 

935 

546 

273 

4U4 

58 

61 

58 

56 

55 

59 

63 

61 

57 

62 

65 

57 

61 

56 

63 

54 

993 

676 

659 

932 

492 

225 

991,992 

134 

991 

991 

991,992 

988 

188 

714 

134 

217 

218 

217 

218 

218 

35 

680 

659 

147 

173 

17 

36 

84 

8G8 

669 

869 

870 

871 

869 

858 

62 

717 

866 

724 

866 

945 

290 

659 

659 



Anson on scurvy . . 230, 232, 233 

Anson's " Voyage round the World" 230 

Antimony in inflammation 
"Antiphlogistic," etymology of 
Anus, bleeding from the 
Aorta, aneurism of the 

, chronic changes in the , 

, diseases of the 

, inflammation of the 

, transverse rupture of the 

"Aorta," etymology of 
Aortic valves, disease of the 

Aortitis 

Apepsia ..... 
"Apcpsia," etymology of 

Aphonia 

"Aphonia," etymology of , 

Aphthae 

, age liable to 

, in old age 

, treatment of . . . 

"Aphthae," etymology of . 
"Apncea," etymology of 
Apoplectic cells . . . 

cicatrices 

clot 

Apoplexia exsanguinea 

Apoplexy 

, absence of morbid signs in 

, after-treatment of 

, causes of . 

, cerebral softening in . 

, contracted pupil in 

, convulsions in . 

, effects of . . . 

, cff'usion of serum in . 

, extravasation of blood in 

, from ischuria 

, hereditary predisposition to 

, morbid appearances in 

, predisposition to 

, pulmonary 

, sanguineous 

, serous 

, spinal 

, symptoms of 

, treatment of . 



"Apoplexy," etymology of 
Appendages of the skin, diseases of the 
Appetite, loss of . . . 

, voracious 

"Apyrexia," etymology of 
Arabs, elephantiasis of the 



Arachnitis 

simulated by reaction 

Arachnoid, inflammation of the . 
Aristotle, injury done to 
Arrangement, Dr. Elliotson's 
Arrangement?, nosological 
Arsenic, ill effects of 

, mode of administering . 



Arsenious acid 
Arteriotomy in inflammation 
"Arteriotomy," etymology of 
Arthritis .... 
"Arthritis," etymology of . 
Ascaris . . . . 

lumbricoides . 

"Ascaris," etymology of . 



INDEX. 



1023 



Ascites 

, causes of 

, fluid in 

, treatment of 

"Ascites," etymology of 
Asclepiadcs on the duty of a physician 
"Assaloetida," etymology of . 
"Asthenic," etymology of 

Asthma 

■ , ages attacked by 

, complications of . . 

, diagnosis of 

, exciting causes of 

, humoral 

, predisposing causes of . 

, premonitory symptoms of 

, prognosis of 

, spasmodic 

, usually occurs in the night 

"Asthma," etymology of 
Astringents in haemorrhage 
Atonic inflamTnation 

, treatment of 

"Atonic,' 
Atrophy 



' etymology of 
of the heart 



877 
877 
878 
878 
877 
269 
518 
52 

743, 768 
769 
769 
770 
771 
743 
771 
769 
770 
733 
768 
768 
141 
111 
130 
1009 

102, 183 
865 



Attitude, alterations in the 

Aura epileptica 

Auricles, aneurism of the . 

— , contraction of the 

• , departure of the blood from 

the 

. , dilatation of the 

Auriculo-ventricular valves, changes in 

the ... 

Aurigo . . . 
Auscultation 

"Autocrateia," etymology of 
Avenhrugger, memoir of . 

on percussion 

Avenbrugger's " Inventum Novum" . 



B. 



Bacon, Lord, on specifics 

Barbadoes-leg 

Bark (sec " Cinchona") 

in inflammation 

Barking cough . 
Bartholin, incredulity of 
Bartholin i on fever 
" Belladonna," etymology of 
Eellingham, the murderer 
Belloc on chronic laryngitii 
Bellows-sound . 

, double 

, effect of bleeding on 

the . 

, seat of the 

, temporary 

Bezoars 

" Bezoars," etymology of 

Biliary calculi . 

Bilious remittent fever 

Black vornit 

Bladder, calculi in the 

, cysts in the . 

, diseases of the 



21, 



21.7 



58 
597 
860 
841 

840 
846 

833 

891 
707 

66 
704 
703 

21 



26 
471 
272 
134 
736 

24 
294 
396 
557 
723 
839 
848 

845 
847 
• 845 
934 
935 

896,932 
340 

333, 359 
1001 
1005 
1004 



Bladder, fungous excrescences of the 

— ■ , hypertrophy of the 

, inflammation of the 

, irritation of the 

, paralysis of the . 

, scirrhous tumours of the 

, structural diseases of the 

Bladder-tailed hydatid 
Blisters in inflammation 
Blood, bile in the 

, blackness of the 

, changes in the 

, coagulation of the , 

• , in pregnancy . 

, modification of, in fever 

, urea in . . . 

Blood-letting from distant parts 

, in inflammation, 

, red particles diminished by 

Blood-vessels, ossification of 

Blowing respiration 

Boccacio on the plague at Florence 

Boerhaave on loss of memory 

Boils .... 

Bone-earth calculus . 

Bonner, murder of Mr. and Mrs 

Bonnet, alleged impiety of . 

Books recommended by Elliotson 

Bothriocephalus latus 

Bots .... 

" Brachial," etymology of . 

Brain, abscess in the 

, anaemia of the 

, beneficial effect of an accident on 

the 

, changes of consistency in the 

, compressibility of the 

, effect of age on the 

, encephaloid tumours in the 

, encysted tumours in the 

, hydatids in the 

— — , induration of the 

, infiltration of pus in the 

, inflammation of the 

, morbid ap 

pearances in 

, malformations of the 

, melanosis in the 

, osseous tumours in the 

, precautions in examining the 

, red dots in the 

. , scirrhous tumours in the 

, scrofulous tubercles in the 

, size of the 

, softening of the 

j , torpidity of the 

, tumours in the 

Bread, brown 
Breath, alterations in the 
-, fetid 



Breath-sounds, modified 
Broad-worm 
Bronchia, dilatation of 

. , diminution of 

, inflammation of the 

" Bronchia," etymology of . 
Bronchial respiration 
Bronchitis 
, acute 



1005 

1005 

10U4 

1003 

1006 

1005 

1005 

967 

129 

892 

93 



91 
291 
162 

499 
119 
122 
104 
710 
305 
672 
448 
992 
554 
25 
32 
968 
960 
271 
488 
490 

543 

488 
521 
543 
537 
537 
537 
489 
488 
481 

486 
538 
537 
536 
490 
489 
536 
536 
538 
488 
543 
536 
956 

61 
700 
710 
968 
747 
748 
737 

76 
709 
737 
737 



1024 



INDEX. 



Bronchitis, asthenic . 

, pathology of 

■ , treatment of 

, auscultation in 

—— ', chronic 

, age liable to 

, asthma caused by 

, auscultation in 

, dyspnoea in 

, effects of . 

, mistaken for 

phthisis 

, symptoms of 

, treatment of 

■■ , varieties in 



■ , percussion m 

, symptoms of 

, treatment of 

•'Bronchitis," etymology of . 
Bronchocele 

, complicated with cretin 

ism 

, countries affected by 

, diagnosis of 

, effects of 

, extirpation of the gland in 

— , hereditary 

— — , hydriodateof potassa in 

" . , iodine in 

, ligatures of the Vessels in 

, treatment of 

" Bronchocele," etymology of . 

Bronchophony 

Bronchotomy 

" Bronchotomy," etymology of 

*' Bubo," etymology of 

Buffon, alleged impiety of 

Buffy coat, absence of the 

, formation of the . 

Bulimia 

, cases of 

" Bulimia," etymology of 
" Bullae," etymology of 
Bulman, Dr., on hay-asthma . 
Butler's " Charts" 
Buzzing, amphoric 



741 
741 
741 
739 
742 
742 
743 
744 
744 
747 

744 
743 
745 
743 
739 
737 
740 
737 
683 

684 

684 

687 

684 

689 

684 

688 

687 

689 

687 

546 

712 

720, 728 

720 

449 

25 

91 

92 

946 

287 

946 

415 

773 

37 

820 



C. 



" Cachexia," etymology of 

Cadaveric appearances in inflammation 

effects of gravitation 

obstruction 

time 



113 

79 

81 

81 

81 

80 

180, 82 

80 

597 

412 

896, 932 



redness 

softening 

transudation 

Caesar's epilepsy 

"Calamme," etymology of 

Calculi, biliary 

from the urethra, discharge of 1003 

in the bladder . .1001 

■ , absence of symp- 
toms in . 1002 

, cessation of symp- 
toms in . 1002 

, diagnosis of . 1001 

, symptoms of . 1001 

gall-ducls . . 896 



Calculi in the pancreas 
spleen 



-, irregular increase of . 
-, respective frequency of 
-, table of 
-, urinary 



Calculous diseases 
Calculus, alternating . 

, bone-earth . 

, fibrinous 

, fusible 

, mixed 

, mulberry 

, prostatic 

Cancer, cicatrization of 

, derangement of functions in 

, effects of 

, haemorrhage in 

, parts secondarily affected in 

Cancer, sloughing stage of , 

— , symptoms of , 

Cancerous discharge 

ulceration . 

Cancrumoris ... 

Cantharides, solution of 
Capillaries, contraction of the 

, dilatation of the 

in inflammation 

, pathological changes in the 

, turgescence of the 

Carbonate-of-lime calculus 

Carbuncles 

Carcinoma 

, albumen in 



alveolare 



-, characters of 
-, development of 
-, microscopical cha 

racters of 
-, symptoms of 
-, varieties of 



883 
884" 
1003 
994 
993 
932, 991 
987 
993 
992 
993 
992 
993 
992 
995 
199 
202 
201 
201 
200 
202 
201 
199 
199 
698 
130 
84 
84 
83 
85 
84 
993 
448 
195 
197 
206 
206 
208 



, definition of 

— simplex 

, structure of 

Carcinomatous septa . 
Cardiac dropsy 

, causes of 

, signs of 

Cardialwia 

"Cardialgia," etymology of 

Cardinal, the idiot 

Carditis, 

" Carotid," etymolog:y of 

" Cartilage," etymology of 

Cartilaginous transformations 

Catalepsy 

, diagno^'s of 

generally in women 

, periodical . 

, treatment of 

"Catalepsy," etymology of 

Cataphora 

Catarrh 

, causes of 

, dry . 

, symptoms of . 

, treatment of . 

"Catarrh," etymology of 
Catarrhus senilis 



INDEX. 



1025 



" Cathartic," etymology of 
Cause, proximate 
Causes, classification of 

, exciting 

, occasional 

of death 

■ diseases 

, predisposing . 

, procatarctic . 



Cavernous respiration 

Cavitaires 

Cecil on Lord Bacon . 

Cellular transformations 

Cerebellum, deficiency of the 

Cerebral affections from a mental shock 



44 



527 
43 

42 

44 

44 

34 

39 

,47 

44 

709 

961 

24 

185 

539 

530 



physical shock 530 



chlorosis 

dropsy 

exhaustion 

intestinal irri 

tation 

ischuria 

remote causes 

— diseases, localization of 

— hemispheres, deficiency of the 

— system 
-, pathology of the 



tumours 



535 
535 
526 

526 
535 
526 
479 
538 
477 
478 
536 
537 
Cerebritis . . . _ .482 

Cessation of an eruption, phrenitis from the 491 
Cestoidea .... 96J 

*'Cestoidea," etymology of . . 961 

Changes without inflammation . 103 

Chantilly, fish-pond at . . 250 

Charles the First and Harvey . 25 

Chest, auscultation of the . . 707 

, examination of the . . 701 

, manual examination of the . 702 

— — , mensuration of the . . 703 

■ internal capa 

city of the 



symptoms of 



, mode of examining the . 

, percussion of the 

, regions of the 

, symmetry of the 

, visual examination of the 

Chicken-pock 

, diagnosis of. 

, varieties of 



Chigoe 
Chin-cough 
Chiragra . 
"Chiragra," 
Clilorosis . 



etymology of 



-, advanced stage of 
-, appetite impaired in 
-, bathing in 
, breathlessness in 
-, causes of . 
-, change of air in 
-, complications of 
-, deficient nervous energy in 
, diagnosis of 
-, diet in 
-, menstruation in 



, pain of the side in 

, pallor of the skin in 

palpitation in 
VOL. I. — 65 



703 
702 
703 

705 

702 

702 

445 

445 

446 

472, 967 

780 

1008 

1008 

218 



221 
221 
224 
220 
222 
224 
222 
220 
222 
223 
221 
221 
220 
220 



Chlorosis, pathology of 
stages of 

state of the blood in 
bowels 
tongue 
symptoms of 
treatment of 
"Chlorosis," etymology of 
Cholera 

, English 

, symptoms of 

, treatment of 



221 

220 
219 
m . 221 

in . 220 

219 
223 
218 
935 
935 
935 
936 
epidemic . . , . 938 

, contagiousness of . 942 

, historv of . . 941 

'■ , in London . 940, 941 

, morbid appearances 

in . . 939,941 
943 



-, mortality of . 
-, novelty of 
-, state of the blood in 
-, symptoms of . 
-, treatment of . 



-, Indian 
-, infantum 



" Cholera," etymology of 
Chorea 

, causes of 

, duration of . 

, most frequent in girls 

, termination of 

, treatment of 

" Chorea," etymology of 

" Christianity as old as the Creation' 

Chronic diseases 

inflammation 

treatment of 
" Chronic," etymology of 
Chylopoietic viscera, diseases of the 
" Chylopoietic," etymology of 
Cinchona, active principles of 
dose of 
history of . 
mode of administering 
value of 
varieties of 
"Circinatus," etymology of 
Circulation, obstructed 
"Cirrhosis," etymology of 
Classification of causes 
Clavus hystericus 
Clayey soils 
Coagulation of the blood 

time of . 
Colchicum in inflammation 
Cold . 

applications in inflammation 
in the head 
Colic . 

causes of 
from lead 

morbid appearances in 
symptoms of 
treatment of 
"Colic," etymology of 
"Colliquative," etymology of 
" Colloid," etymology of 
Coma without convulsions 
Concretions from bones 



941 
943 
940 
943 
938 
937 
935 
622 
624 
623 
623 
623 
624 
622 
550 

37 
111 
131 

37 
873 
225 
273 
273 
272 
273 
282 
273 
410 
846 
189 

42 
610 
251 

89 

92 
126 
113 
118 
731 
915 
916 
917 
91 G 
910 

9in 

915 
96 
190 
599 
933 



1026 



INDEX. 



Concretions from chalk . ; 


932 


Continued fever, prognosis of 


296 


earthy phosphates 


934 


pulse in 


28.'> 


hair-balls . 


934 


purgatives in 


322 


magnesia 


932 


saline treatment of 


327 


mustard-seeds 


933 


splenic disease in 


295 


sesquioxide of iron 


933 


state of the brain in 


288 


gastro-intestinal . 


932 


breathing in 288 


size of . 


934 


intestines 


in 287 


symptoms produced by . 


935 


muscles 


n 295 


^Confinement, effects of 


312 


stomach 


in 287 


Congenital diseases 


41 


tongue in 286 


'Congenital," etymology of . 


41 


urine in 


287 


Congestion . . . . 


86 


stimulants in 


327 


pulmonary 


846 


symptoms of 


284 


"Congestion," etymology of . 


41 


tonics in 


327 


Congestive remittent fever 


340 


treatment of 


320 


"Conjunctiva," etymology of 


389 


varieties of . 


288 


"Connate," etymology of 


41 


ulceration of the int( 


^s- 


Conquest's operations in hydrocephalus 


511 


tines \n 


294 


Consistence, changes of 


40 


wine in 


326 


Constipation .... 


949 


Continuent diseases . 


38 


Consumption, pulmonary 


785 


Contra-indications 


67 


Contagion .... 


299 


" Convulsion," etymology of 


536 


and infection, difference be- 




Convulsions .... 


591 


tween . 


300 


in cephalic disease 


479 


denied 


304 


infantile . . . 


592 


not from dead bodies 


316 


partial 


600 


occasional . 


301 


" Cornea," etymology of 


473 


of typhus, arguments against 




Coronary arteries, ossification of the 


864 


the 


308 


Corpora striata, deficiency of the 


538 


causes facilitating 




Coryza 


731 


the . 


311 


"Coryza," etymology of 


731 


retarding the 


311 


Costiveness, phrenitis from 


492 


fresh generation of 


316 


Cough 


63, 736 


prevented by bad health 


303 


auscultation of 


739 


of yellow fever . 335 


,359 


barking 


736 


Dr. Stevens's opinions on 


336 


nervous 


738 


"Contagion," etymology of . 


298 


spasmodic 


736 


Contagious diseases . 


42 


Countenance, alterations in the 


58 


communicable to 




Counter-irritants in inflammation 


129 


brutes 


303 


Counter-irritation in inflammation 


125 


communication of 


300 


Cowan, Dr., on physical diagnosis 


19 


incubation of 


302 


Cowhage 


966 


insusceptibility 




Cowper's madness 


594 


to . 302 


,303 


Cow-pox 


438 


recurrence of 


302 


phenomena of 


441 


matter, nature of 


299 


identical with small-pox 


439 


Continued diseases 


38 


Crab-lice 


967 


Continued fever 


284 


Cranial bones, separation of the 


508 


antimony in . 


324 


" Crassamentum," etymology of 


46 


blood in 


291 


Cretinism 


545 


blisters in 


323 


Crick in the neck 


. 1014 


causes of 


298 


" Crisis," etymology of 


289 


cold affusion in 


321 


Critical days . 


289,. 34 1 


complications of 


290 


Crossed effect in cephalic disease 


473 


contagion of . 


299 


Croup . . . 


724 


convalescence from . 


325 


bronchotomy in 


728 


debility in . 288, 326 


causes of . . 


726 


diagnosis of . 


296 


morbid appearances in 


725 


duration of 


289 


nature of 


726 


emetics in 


321 


primary 


725 


excitement in 


288 


recurrence of . 


729 


heat of the surface in 


285 


secondary 


725 


mercury in . 


323 


spasmodic 


733 


morbid appearances 




treatment of . 


728 


in 


292 


varieties of 


725 


opium in 


328 


Culprits and madmen 


556 


perforation of the intes- 




Cutaneous diseases 


363 


tines in 


295 


classification of 


364 





INDEX. 


1027 


Cutaneous diseases dependent on dis- 




Diabetes mellitus 


977 


eases of the system . 


364 


morbid appearances in 


980 


Dr. Elliotson's ar 




pathology of . 


981 


rangement of 


365 


prognosis in . 


982 


transformations 


187 


specific gravity of the urine in 


978 


Cyanosis 


865 


sugar in . 


978 


" Cyanosis," etymology of 


865 


treatment of. 


982 


" Cynanclie," etymology of 


493 


" Diabetes," etymology of 


976 


Cynanche parotidea . 


690 


Diagnosis of diseases . 


19,50 


pharyngea . 


694 


" Diagnosis," etymology of . 


50 


tonsillaris . 


691 


" Dialyses," etymology of 


37 


trachealis . 


716,724 


Diaphoretics in inflammation , 


125 


Cystica 


961 


" Diaphragm," etymology of . 


57 


" Cystica," etymology of " 


961 


Diarrhoea 


926 


Cysticercus cellulosus 


967 


adiposa 


930 


Cystic oxide . 


992 


causes of . 


927 


diathesis . 


998 


definition of 


927 


Cystitis 


1004 


discharge of lymph in 


930 


•* Cystitis," etymology of 


1004 


evacuations in 


927 


Cystorrhoea 


. 1004 


morbid appearances in 


927 


treatment of 


. 1005 


treatment of 


928 


"Cystorrhoea," etymology of . 


1004 


white evacuations in 


929 


Cysts, adventitious 


186 


white, treatment of 


929 


contents of 


186 


" Diarrhoea," etymology of . 


927 


" Cytoblast," etymology of . 


208 


Diathesis 


51 






calculous 


994 


D. 




cystic-oxide . 


998 






heemorrhagic 


142 


Damp , 


115 


lithic-acid . 


995 


DandrifF 


. 403 


oxalate-of-lime 


997 


Day- Blindness 


. 678 


phosphatic . 


999 


Dead parts, separation of 


101 


scrofulous 


194 


Death, negative causes of 


34 


" Diathesis," etymology of 


51 


positive causes of 


34 


Diet in inflammation . 


119 


Debility 


53,317 


Digestive organs, disorder of the 


944 


dropsy from . 


152 


Digitalis in inflammation 


125 


Decline . , 


785 


" Digitalis," etymology of 


396 


Defoe's "Journal of the Plague-Year' 


643 


Dilatation of the air-cells 


749 


Delirium 


482 


appearances 




traumatic 


530 


in 


749 


tremens 


531 


auscultatior 




causes of 


531 


in 


750 


diagnosis of 


532 


causes of 


750 


morbid appearances 


in 534 


treatment o 


f 751 


opium in 


533,534 


air-tubes 


747 


phrenitis in . 


534 


auscultatior] 




stages of 


532 


in 


747 


stimulants in 


534 


capillaries 


84 


symptoms of 


531 


heart 


852 


treatment of 


533 


causes of 


854 


" Delirium," etymology of 


532 


iron in 


858 


" Dementia," etymology of 


562 


signs of 


854 


Democritus, dissections by 


24 


treatment of 


857 


Denmark, Mr., on tic douloureux 


658 


varieties of 


854 


Deposition from cool urine 


988 


Diminished action 


40 


Deposit of lithic-acid . 


988 


Dinner, rest after 


957 


oxalate of lime 


989 


" Diphtheritis," etymology of. 


388 


phosphatic 


989 


" Diplop," etymology of 


189 


Derangement, mental 


538,546 


" Diplopia," etymology of 


54 


of functions 


35 


Discharges, inflammatory 


144 


Descartes, injury done to 


25 


uninflammatory . 


144 


" Desquamation," etymology of 


106 


vicarious . 


137 


Diabetes . . , 


976 


Discolorations of the skin 


467 


animal diet in 


983 


Disease, definition of . 


36 


causes of 


980 


nature of . 


34 


condition of the blood in 


979 


of the cardiac valves . 


ir,:) 


diagnosis of . 


982 


valves, causes of 


835 


fermentation of urine in 


978 


comparative fre- 




insipidus 


976 


quency of 


834 



1028 



INDEX. 



Disease of the valves, effect of the 
Diseases, acquired 
active 
acute 

and disorders 
causes of 
chronic 
congenital 
contagious 
continued 
continuent 
cutaneous 
diagnosis of 
duration of 
endemic 
epidemic 
functional 
general 
hereditary 
intermittent 
local . 
nature of 
non-contagious 
occasionally contagious 
of motion 
organic 
passive 
periodical 
period of 
primary 
prognosis of 
remittent 
seat of 
seats of 
secondary 
severity of 
sporadic 
structural 
temporary 
tereatment of 
universal 
" Dislocation," etymology of 
Disorders and diseases 
Dispensaries . 
Distemper, the 
Ditches, exhalations from 
Dracunculus . 
Drawings 
Drink 
Dropsical fluid, characters of 

shifting of 
Dropsy 

abdominal 

active 

acute . 

cardiac 

causes of 

debility of the heart in 

definition of 

forms of 

febrile 

from debility 

obstruction 
general 
inflammatory 
mechanical remedies in 
mercury in . 
of the abdomen, encysted 



835 

41 

38 

37 

37 

39 

37 

41 

42 

38 

38 

363 

19,50 

42 

41 

41 

36 

37,70 

41 

38 

37, 363 

39 

42 

3G1 

620 

36 

38 

38 

42 

41 

51 

38 

42 

39 

41 

42 

41 

36 

66 

66 

216 

37 

37 

28 

648 

251 

967 

28 

46 

153 

154 

146 

877 

149 

154 

166 

155 

3 70 

146 

147, 153 

154 

152 

152 

147 

150 

173 

173 

880 



Dropsy of the fallopian tubes , 


882 


ovarian 


880 


• characters of the fluid 


in 881 


paracentesis in 


881 


passive 


150 


pathology of . 


147 


pneumonia in . . 


169 


prognosis of . 


154 


pulmonary emphysema in 


170 


pulse in 


155 


renal 


156 


renal disturbance in . 


156 


signs of renal 


158 


state of the kidney in . 


156 


treatment of . 


171 


tubercular disease in . 


170 


Drop-tail 


962 


Drowsiness . . 


53 


Drugs . . 


68 


Dry catarrh - 


745 


gangrene 


104 


Dura mater, inflammation of the 


487 


Dysecaea . . 


678 


" Dysecsea," etymology of 


659 


Dysentery . • . ' 


920 


acute 


920 


causes of . 


922 


chronic 


920, 921 


sulphate of copper i 


n 925 


treatment of 


924 


conjoined with fever 


921 


contagiousness of . 


923 


evacuations in 


920 


formerly prevalent in Lond< 


m 922 


in the Peninsular war 


923 


morbid appearances in 


921 


mortality of 


923 


symptoms of 


920 


tenesmus in 


926 


treatment of 


923 


ulceration of the intestines 


in 925 


" Dysentery," etymology of . 


920 


Dyspepsia 


944 


appropriate food in 


955 


brown bread in 


966 


bulimia in . 


946 


cardialgia in 


947 


causes of . 


949 


cure of 


952 


during pregnancy . 


952 


from abstinence 


955 


smoking 


954 


snuff . 


954 


gastrodynia in 


. 947 


organic disease in . 


950 


pica in . . 


945 


prognosis in 


951 


pyrosis in . 


947 


rest after dinner in 


. 957 


sluggishness of the intestine 


s 


in 


. 953 


symptoms of 


945 


treatment of 


. 951 


" Dyspepsia," etymology of . 


944 


" Dysphagia," etymology of . 


. 498 


Dyspnoea 


63 


" Dyspnoea," etymology of 


56 


Dystoma liepaticum . 


968 



INDEX. 



1029 







"Epidemic," definition of 


381 


E. 




etymology of 


41 






Epilepsy . . . . 


593 


Ear-ache . . 


701 


absence of suffering in 


593 


Earth-worm . . . . 


961 


causes of . 


601 


" Ecchymosis," etymology of 


294 


centric 


604 


" Ecclesiasticus" on medicine 


949 


centripetal . 


604 


speculative know- 




complicated with other disease 


s 597 


ledge 


20 


diagnosis of . 


604 


Echinococcus humanus 


967 


during sleep 


596 


Eck, Dr., on glanders . 


464 


' eccentric 


604 


Ecstasis . . . . 


598 


feigned 


604 


" Ecstasis," etymology of 


598 


form of the head in . 


601 


Ecthyma, characters of 


419 


frequency of attacks in 


597 


treatment of 


420 


hereditary predisposition to 


601 


varieties of . 


419 


hysteria distinguished from . 


604 


" Ecthyma," etymology of 


419 


impairment of the mind in . 


597 


*' Ectopias," etymology of 


37 


morbid appearances in 


603 


Ectozoa • . . . . 


959 


most frequent in males 


601 


" Ectozoa," etymology of 


959 


youth 


600 


Eczema . . . . 


411 


partial convulsions in 


600 


impetiginodes 


412 


prognosis of . 


605 


rubra m 


412 


seat of . . . 


604 


treatment of . 


412 


synorrymes of 


593 


" Eczema," etymology of 


411 


treatment of . 


605 


" Edinburgh Review" on universities 


26 


warning of . 


596 


Education of medical men 


30 


" Epistaxis," etymology of 


512 


Effusion . . . . 


81,95 


" Epizootic," etymology of 


264 


treatment of 


133 


Equinia . . . , 


456 


" Elaterium," etymology of . 


506 


apostematosa 


462 


Elephantiasis . . . - 


470 


catarrhalis 


462 


Emerods 


450 


Ergot of rye . 


103 


" Emmenagogue," etymology of 


225 


" Erethism," etymology of 


697 


Emotions, mental 


47 


Eructations 


946 


Emphysema, false 


749 


Erysipelas 


397 


Empirical treatment . 


67 


bark in . 


. 401 


" Emprosthotonos," etymology of 


628 


causes of . 


399 


Empyema 


811 


characters of 


397 


treatment of 


815 


cold applications in 


. 400 


Encephaloid disease . 


203 


complications of . 


399 


causes of . 


206 


contagiousness of . 


399 


deceptive appear 




gangrenosum 


. 398 


ances in 


206 


incisions in 


481 


nature of . 


203 


metastasis of 


398 


parts liable to 


205 


mortification in . 


401 


secondary 


205 


nitrate of silver in 


400 


softening of 


204 


of the face 


399 


symptoms of 


205 


head, phrenitis fronr 


I 492 


ulceration of 


204 


treatment of 


400 


varieties of 


204 


varieties of 


398 


" Encephaloid," etymology of 


537 


" Erysipelas," etymjlogy of . 


397 


Encysted tubercles 


193 


Erythema 


375 


Endemic diseases 


41 


causes of . 


376 


" Endemic," etymology of 


41 


identical with roseola 


375 


Enteritis 


913 


nodosum 


376 


morbid appearances in 


914 


treatment of 


376 


resemblance of colic to 


915 


tuberculatum 


377 


symptoms of 


913 


varieties of. 


375 


treatment of 


914 


" Erythema," etymology of . 


106 


« Enteritis," etymology of 


. 915 


Essential symptoms . 


49 


Entozoa 


960 


" Exacerbation," etymology of 


39 


classification of 


961 


Exanthemata . 


374 


originally ectozoa 


967 


"Exanthemata," etymology of 


374 


usual situation of 


960 


Exciting causes 


44 


"Entozoa," etymology of 


959 


Excito-motory system . 


477 


" Enuresis," etymology of 


481 


Excretions 


65 


Ephelis 


468 


black 


213 


" Ephelis," etymology of 


468 


undue 


46 


Epidemic diseases , ■ 


41 


Exercise 


47 



1030 


INDEX. 




Exfoliation 


]02 


Fcelor, removal of 


134 


Exhalations, effects of noxiorus 


316 


Fomites 


308 


malarious 


246 


"Fomites," etymology of 


309 


Exhaustion 


53 


" Fontanel," etymology of 


508 


cerebral symptoms from 


526 


Food .... 


. 34,46 


effects of . 


478 


excess of 


949 


" Exostosis," etymology of 


603 


improper 


949 


Explanation of terms . 


39 


Forfarshire ague 


626 


Eye, alterations in the 


56 


Formations, new 


. 189 






Framboesia 


474 


F. 




" Framboesia," etymology of . 


474 






Franklin's " Journey to the Polar Sea" 


685, 686 


Face, alterations in the 


55 


Freckles 


467 


eruptions in the 


58 


Friction sound, pleural 


714 


paralysis of the 


58 


Functional diseases 


36 


Facias Hippocratica . 


57 


Functions, derangement of 


35 


Faeces, black . 


. 213 


Fusible calculus 


992 


" Faeces," etymology of 


43 






Fallopian tubes, dropsy of the 


882 


G. 




Farcy 


461 






in the horse 


462 


Galen on anatomy 


18 


Fasciola hepatica 


968 


pathology 


18 


Fatty matters, discharge of 


930 


reverence lor . 


24 


Fatuity 


544 


Gall-bladder, diseases of the . 


898 


" Fatuity," etymology of 


562 


Gall-stone, passage of a 


952 


Fat-worm 


968 


Gall-stones 


896 


Favus 


417 


constituents of 


897 


" Favus," etymology of 


417 


escape of . 


897 


Febrile dropsy 


154 


internal appearance of 


897 


signs of 


154 


seat of 


896 


" Femoral," etymology of 


271 


symptoms of 


896 


Fetid breath . 


700, 946 


Gall's " Fonctions du Cerveau" 


24 


causes of. 


700 


Ganglionic system 


478 


Fever 


88 


pathology of the 


480 


affections of the nervous sys- 




Gangraena oris 


698 


tem in 


318 


causes of 


699 


continued. (See "Continued 




pathology of . 


699 


Fever.") 


284 


symptoms of . 


699 


critical days in . 


289 


synonymes of . 


698 


East Indian 


333 


treatment of . 


700 


forms of 


233 


Gangrene 


101 


hectic - . . . 


96 


dry . 


104 


increased mental power in 


552 


from ossification of blood- 




inflammation as a cause of 


317 


vessels 


104 


intermittent. (See "Ague.") . 


233 


of the heart . 


862 


phrcnitis in . 


493 


lungs 


759 


proximate cause of 


316 


cases of 


759 


remittent. (See "Remittent 




diagnosis of . 


760 


Fever.") 


332 


seldom the result of 




typhoid . . . , 


329 


inflammation 


759 


state of the abdomen in 


319 


not always fatal 


761 


brain in 


319 


symptoms of. 


760 


capillaries in 


319 


treatment of . 


761 


Fevers, classification of 


233 


"Gangrene," etymology of . 


101 


symptoms of . 


234 


Gaol-fever . . . . 


288 


varielies of . 


234 


Gastricjuice, experiments on the 


902 


Fifth pair of nerves, paralysis of the . 


679 


Gastritis, acute 


904 


Fibrin in dropsical blood 


163 


causes of 


905 


the blood 


89 


morbid appearances in 


906 


Fibrinous calculus 


993 


treatment of . 


906 


Fibrous membranes, inflammation of. 


109 


chronic 


907 


tissues, diseases of 


1007 


" Gastrocnemius," etymology of 


174 


transformations 


187 


Gaslrodynia . . . . 


947 


Fig-pock . . . . 


448 


" Gastrodynia," etymology of . . 


280 


Filing-sound of the heart 


839 


Gastro-intestinal concretions . 


932 


Filth, effects of 


312 


George the Second, death of . 


862 


Fistula in ano . . . . 


901 


Second's aortic aneurism . 


869 


Flea in the ear . . . 


960 


Georget on insanity . 


565 


Fluke .... 


9G6, 968 


Gin-liver . . . . 


889 



INDEX. 



1031 



Glanders 


449, 456 


Haemorrhage, active 


139 


Glanders, causes of . 


464 


arterial 


143 


communicable to man . 456 | 


astringents in 


141 


history of . 


456 


exciting causes of 


143 


in brutes 


461 


from inflammation 


140 


man 


462 


relaxation 


140 


the horse . 


461 


the air-cells 


763 


incubation of 


464 


appear 




treatment of . 


464 


ances in 763 


varieties of . 


461, 462 


auscul 




Glands, enlargement of the mesenteric 876 


tation in 765 


Gleet, bronchial 


744 


case ol 


765 


" Glottis," etymology of 


393 


symp. 




Godrich, Mr., on hydrophobia 


644 


toms of 764 


Goitre 


683 


air-passages 


762 


♦'Goitre," etymology of 


683 


air-passages, 




Goitrous countries 


684 


causes of 


762 


districts, character of 


687 


air-passages. 




Gonagra 


.- 1008 


characters of 762 


" Gonagra," etymology of 


. 1008 


air-passages, 




Goodwin Sands 


248 


diagnosis of 762 


Gordon, Mr., on hay-asthma . 


772 


lungs 


761 


Gout . 


. 1008 


stomach 


912 


atonic 


. 1009 


ice in . 


141 


improvement of health in 


. 1009 


in cancer 


201 


influence of ardent spirits 


son . 1011 


mixed cases of . 


140 


internal affections in 


. 1011 


mode of 


137 


invasion of 


. 1008 


passive . 


139 


longing for 


. 1011 


predisposing causes of 


142 


pain in . 


. 1008 


source of 


136 


paroxysms of 


. 1010 


sulphuric acid in 


141 


predisposing causes of . 


. 1010 


turpentine in 


141 


premonitory symptoms o 


f . 1009 


venous . 


143 


progress of 


. 1008 


"Haemorrhage," etymology of 


136 


retrocedent 


. 1009 


Haemorrhagic diathesis 


142 


rheumatic 


. 1015 


Hair-balls, concretions from . 


934 


symptoms relieved by . 


. 1009 


Hair-worm 


967 


treatment of 


. 1011 


Hallucination . 


546 


varieties of 


. 1009 


"Hallucination." etymology of 


546 


" Gout," etymology of 


. 1008 


Hamularia subcompressa 


967 


Grain, diseased 


103 


Hand, alterations in the 


59 


Greeks, elephantiasis of the 


470 


Harmattan, the 


255 


Green jaundice 


891 


Harvey on the circulation of the blooc 


I 24 


Guinea-worm . 


967 


Hawkesworth's "Adventurer" 


551 


Gotta serena . 


676 


Hay-asthma . 


771 


" Guy's Hospital Reports" 


87 


cases of . 


772 


" Gyrata," etymology of 


407 


"description of 


772 






from ipecacuanha 


777 






history of 


771 


H. 




prophylactics against 


780 






treatment of 


777, 779 


Haematemcsis 


912 


Headache 


948 


causes of 


912 


inflammatory 


484 


treatment of 


913 


sick 


485 


"Hasmatemesis," etymology o 


f . 912 


Heart, abnormal sounds of the 


839 


" Fleematoma," etymology of 


537 


abscess of the . 


862 


Ilasmatosine in dropsical blood 


l(i3 


active aneurism of the 


853 


Hematuria 


970 


alterations in the 


63 


diagnosis of 


970 


aneurism of the 


858 


from disease of th 


3 kidney 971 


atrophy of the . 


865 


suppressed d 


ischarges 972 


bellows-sound of the . 


845 


passive 


971 


bone in the 


865 


treatment of 


971 


case of dilatation of Ihc 


845 


"Ilaematuria," etymology of 


970 


chronic changes in the 


. 861 


Haemoptysis . 


761 


coagula in the . 


866 


treatment of 


767 


cysts in the 


865 


" Haemoptysis," etymology of 


761 


dilatation of the 


852 


Haemorrhage . 


136 


diminished apertures in (he 


813 


acetate of lead ir 


1 . 141 


disease of the . 


B52 



1032 



INDEX. 



Heart, disease of the lining membrane 


Hereditary taint 




35 


of the 


831 


Hernia 




949 


disease of the substance of the 


851 


" Hernia," etymology of 




37 


valves of the 


831 


Herpes, characters of 




410 


diseases of the 


824 


circinatus 




410 


valves of the 


832 


iris 




411 


encephaloid matter in the 


865 


labialis 




. 410 


fatty degeneration of the 


864 


phlyctaenodes 




410 


first sound of the 


837 


prseputialis 




410 


gangrene of the 


862 


treatment of . 




411 


hydatids in the 


865 


zoster 




410 


hypertrophy of the 


852 


" Herpes," etymology of 




410 


induration of the 


861 


Heterologous formations 




189 


inflammation of the 


851 


Hibbert's " Philosophy of Apparitions" 548 


lining mem- 


Hippocrates on the circulation of the 




brane of the 831 


blood 


25 


natural sounds of the . 


836 


optic nerve 


25 


neuralgia of the 


866 


Hippocratic face . 


57 


ossification of the 


864 


Hollinshed on ancient meals . 


955 


palpitation of the 


856 


Home, Sir Everard, on inflammation 


76 


partial dilatation of the 


858 


Hook's prophecy of auscultation 


22 


preternatural situation of the 


866 


Hoo Loo, operation on 


967 


rupture of the . 


862 


Hooping-cough 


780 


scirrhus of the . 


865 


causes of 


782 


second sound of the 


839 


morbid appearances ir 


I 781 


softening of the 


861 


pathology of . 


782 


sounds from dilatation of the 


844 


prognosis of . 


781 


structural disease of the 


864 


symptoms of . 


781 


tubercles in the 


865 


synonymes of 


781 


ulceration of the 


862 


treatment of . 


783 


Heart-burn 


947 


Hopkins, Dr., case of . 


841 


Heat .... 


75 


Hospital-fever . 


288 


Heberden, Dr., on catalepsy . 


616 


Hospitals and Dispensaries compared 


28 


chicken-pock 


445 


large and small 


29 


chorea 


622 


Humoralism . 


317 


epilepsy 


600 


Hunter, John, loss of memory of 


672 


Hectic fever . 


96 


on inflammation 


76 


Hemeralopia . 


677 


pretended catalepsy 


617 


" Hemeralopia," etymology of 


226 


Hydatid, bladder-tailed 


967 


Hemicrania 


485 


" Hydatid," etymology of 


186 


Hemiplegia 


664 


Hydatids 


186, 961 


affection of the brain in 


667 


" Hydragogue," etymology of 


172 


after apoplexy 


664 


" Hydrarthrus," etymology of 


147 


apoplexy after 


665 


" Hydrocele," etymology of . 


147 


causes of 


665 


Hydrocephalus 


500 


coagulum in 


666 


acute 


501 


general effects of 


664 


causes of 


504 


generally occurs in bed 


664 


characters of fluid in 


504 


gradual invasion of 


664 


chronic 


.507 


loss of memory in 


667 


in acephalous 




morbid appearances in 


665 


monsters 


510 


on the left side 


664 


morbid appear 




opposite side affected in 


667 


ances in 


509 


recurrence of 


665 


nature of the 




tumours in 


667 


fluid in 


508 


" Hepatic," etymology of 


43 


quantity of the 




" Hepatization," etymology of 


293 


fluid in 


508 


Hepatitis 


885 


size of the hea 


d in 509 


acute, symptoms of . 


885 


state of the 




termination of 


885 


mind in 


510 


causes of 


886 


treatment of 


511 


chronic 


886 


history of 


505 


treatment of 


887 


morbid appearances 




diagnosis of . 


886 


in 


504, 506 


in hot climates 


. 886 


premonitory syrapton 


s of 501 


morbid appearances in 


886 


prognosis of . 


505 


suppurative, treatment of 


887 


rupture of the brain i 


n 511 


treatment of 


887 


seat of the fluid in . 


504 


Hereditary diseases . 


41 


spurious, diagnosis of 


528 





INDEX. 


1033 


Hydrocephalus, spurious, history of 


528 


Hypertrophy, organs liable to 


181 


morbid ap- 




tissues liable to . 


181 


pearances 


in 529 


treatment of 


183 


symptoms c 


f 528 


Hypochondriasis 


558 


treatment of 529 


Hysteria 


609 


symptoms of . 


502 


affections of the joints in 


610 


treatment of . 


505 


causes of 


612 


with bifid brain 


511 


from sexual desire . 


613 


" Hydrocephalus," etymology of 


501 


general tenderness in 


610 


«' Hydrogogue," etymology of 


172 


pathology of 


612 


Hydrophobia . 


637 


state of the uterus in 


613 


absence of dysphagia ir 


I 640 


treatment of 


612 


animals liable to 


647 


Hysterical irritability 


615 


causes of 


641 


Hysterica passio 


611 


contagiousness of 


642 






diagnosis of 


647 


I. 




dysphagia in 


637 






excision of the part in 


649 


Ice in haemorrhage 


141 


insertion of the poison in 646 


" Ichorous," etymology of 


loa 


intolerance of noise in 


638 


Ichthyosis 


472 


light in 


638 


treatment of 


473 


irritability of mind in 


638 


varieties of 


473 


body of 


638 


"Ichthyosis," etymology of . 


472 


morbid appearances in 


641 


Icterus 


891 


nature of 


642 


Idiocy 


540 


produced de novo 


647 


attended by other deficiencies 


542 


remittent 


640 


causes of 


544 


sensibility of the surface 


in 638 


coexistent with other diseases 


543 


spurious 


647 


deficiency of the brain in 


543 


symptoms of 


637 


diagnosis of 


544 


symptoms of the latter 




distinguished from fatuity 


544 


stage of 


639 


from mental activity . 


544 


transfusion in . 


651 


legal definition of 


540 


treatment of 


649 


not referable to the senses 


541 


voice of a dog in 


648 


prognosis of 


545 


Hydro-pneumato-thorax 


818 


treatment of 


545 


amphoric buzz 




"Idiopathic," etymology of . 


88 


ing in 


820 


Idiosyncrasies 


49 


case of 


820 


"Idiosyncrasy," etymology of 


49 


diagnosis of 


820 


Idiotism 


540 


distinguished 




congenital 


544 


from absence of the lung 


820 


Idiots, early death of congenital 


544 


fluctuation in 


819 


moral qualities of 


542 


metallic tink- 




prone to imitation 


542 


ling in 


819 


Imbecility, mental 


546 


symptoms of 


819 


Impetigo 


417 


Hydrothorax . 


816 


eczematodes . 


418 


pathology of 


816 


kind of pustule in . 


418 


physical signs of 


816 


treatment of. 


418 


treatment of 


817 


Inanition 


46 


" Hydrothorax," etymology of 


816 


Increased action 


40 


"Hyperemy," etymology of . 


77 


•' Incubus," etymology of 


599 


Hypertrophy . 


102, 180 


Indications 


67 


and dilatation, produced 




Indigestion . . . . 


944 


by inflammation 


852 


causes of . 


949 


causes of 


182 


definition of 


944 


general health in 


183 


symptoms of 


945 


nature of , 


181 


treatment of 


951 


of the auricles . 


853 


Individual peculiarities 


68 


heart 


852 


Induration 


102-176 


concentric 


853 


cause of . 


177 


eccentric 


853 


organic 


176 


local bleed- 




treatment of 


178 


ing in . 


857 


Infection prevented by dilution 


302 


signs of 


854 


Inflammation . 


71 


simple 


853 


acute 


111 


treatment of 


857 


ammonia in 


134 


varieties of 


852 


amputation in . 


135 


left ventricl 


3 853 


antimony in 


126 


VOL. I.— 66 









1034 



INDEX. 



Inflammation, appearances after death i 


n 79 


arteriotomy in . 


122 


atonic . 


111 


bark in . 


134 


bleeding in 


119 


blisters in 


129 


causes of 


112 


changes from . 


104 


without 


103 


chronic 


111 


colchicum in 


126 


cold applications in 


118 


course of 


87 


common 


87 


counter-irritants in 


129 


counter-irritation in 


125 


definition of 


73 


diagnosis of 


117 


diaphoretics in . 


125 


diet in . 


119 


digitalis in 


125 


duration of 


93 


excessive depletion in 


129 


extent of bleeding in 


122 


from sympathy . 


110 


general bleeding in 


122 


haernorrh.ige from 


139 


history of 


71 


intermittent 


111 


local bleeding in 


123 


depletion in 


129 


mercury in 


127 


mixed . . 


135 


musk in 


134 


nitrate of silver in 


132 


of fibrous membranes 


109 


mucous membrane 


106 


parenchymatous stru 


c- 


tures 


109 


serous membranes 


108 


organic diseases in 


132 


passive . 


111 


pathology 


82 


prognosis of 


117 


prophylactic treatment o 


f 135 


pratective power of 


71 


pulse in 


121 


purging in 


124 


remarks on 


82 


results of 


94 


sanative power of 


72 


sinapisms in 


129 


softening from . 


902 


specific . 


111 


remedies in 


135 


stimulants in . 


131 


tonic 


111 


treatment of 


118 


varieties of 


106 


venesection in . 


122 


warm applications in 


119 


«» Inflammation," etymology of 


71 


Influenza 


732 


" Influenza," etymology of 


732 


Injuries, mechanical . 


47 


of the head, phrenilis from 


491 


Inoculation, history of 


. 432 


success of 


. 433 


Insanity 


546 



Insanity, abdominal lesions in . 567 

absence of legion in . . 562 

agency of the devil in . 573 

alternating . . . 562 

as to facts . . . 555 

opinions . . 555 

causes of , . . 568 

concealed . , . 574 

corporeal . , .563 

definition of . . 546, 555 

destructiveness in . . 553 

diagnosis of . . 

difficulty in detecting 
distinguished from crime 
duration of . 
feigned . 

from fever . 

injuries of the head 
old age 

mental application 
the cessation of discharges 573 
general . . . 552 

harsh treatment of . . 578 

heat of the brain in . . 565 

hereditary . . 557, 568 

imperfect cerebral develop- 
ment in 
injury of the head in 
intermissions in 
legal 
moral causes of 

management of 
morbid appearances in 
periodical 
physical signs of 

treatment of 
preceding signs of . 
prognosis of . 573, 

propensities in . 

puerperal 

rare in childhood , 
recent researches in 
remissions in 
sentiments in 
shape of the head 
stealing in 

structural . . 

sudden cure of 
suicide in 
termination of 
thickness of the skull in 
thoracic lesions in . 
treatment of 
" Insanity," etymology of 
Intellect, affections of the 
deficiency of the 
Intermittence, cause of 
Intermittent diseases 

fever (See •' Ague") 
cold stage of 
hot stage of 
sweating stage of 
inflammation 
Intestinal irritation, cerebral symptoms 

from 
Intestines, diseases of the 

foreign bodies in the 
Intestines, torpidity of the 
Intoxication, phrcnitis from . 



573 
559 
556 
561 
574 
571 
571 
572 
570 



570 
557 
562 
558 
570 
577 
562 
562 
560 
575 
561 
575 
553 
572 
561 
566 
562 
553 
557 
554 
563 
581 
559 
562 
563 
567 
575 
546 
538 
540 
267 
38 
233 
234 
234 
235 
HI 

526 
913 
932 
953 
491 



INDEX. 



1035 



Introduction . 
Intus-susception 

intestine discharged 
" Todine," etymology of 
Irritability, hysterical 
Irritation 

from purgatives 
spinal 
Ischuria 

apoplexy from 
cerebral effusion from 
symptoms of 
treatment of 
" Ischuria," etymology of 
Itch .... 
after fever 
causes of 
treatment of . . 



17 
919 
919 
68T 
615 
85 
124 
584 
974 
525, 975 
517 
975 
975 
149 
412 
413 
413 
413 



J. 



James the First and Harvey . 


25 


Jaundice 


891 


artificial 


893 


black 


891 


causes of 


892 


chronic 


895 


enlargement of the ducts in 


893 


green 


891 


})athology of 


893 


spasmodic . 


894 


synonymes of . . 


891 


treatment of 


894 


Joints, inflammation of the 


. 1008 


Juan Fernandez, island of 


233 


" Jugular," etymology of 


61 


Juries, well-informed . 


556 


K. 




Kidney, atrophy of the 


973 


diseases of the , 


969 


dropsical 


156 


fiitty degeneration of the' 


972 


functional disorders of the 


974 


granular 


973 


haemorrhage from the 


970 


hypertrophy of the . 


972 


inflammation of the . 


909 


malignant disease of the 


973 


mottled 


972 


organic diseases of the 


972, 974 


paleness of the 


972 


serous cysts in the 


973 


softening of the 


973 


turgescence of the 


972 


King, Dr., on hay-asthma 


778 


Kirrhonosis • . , . 


214 


definition of 


214 


"Kirrhonosis," etymology of , 


214 


Knife-swallowing . ' . 


932 


L. 




Laander . . . . 


299 


Labour ' , 


34 


Lachrymation 


731 



" Laclirymation," etymology of 
Larks' bones, concrelions from 
Laryngismus stridulus 

history of 



Laryngitis 



pathology of 
resembles croup 
treatment of 



acute 



causes of 
in adults 

morbid appearances 
symptoms of 
treatment of 
chronic 

diagnosis of 
treatment of 
Larynx, inflammation of 

nervous affections of the 
organic affections of the 
spasmodic aflteclions of the 

closure of the 
diseases of the 
"Lateritious," etymology of 
Law of mutability 
Lavater treated as a fatalibt 
Lead-colic, . . . 917 

paralysis after 
Leaping-ague . 

attributed to witchcraft 
history of 
pathology of 
symptoms of 
treatment of 
Lectures, advantages of 

at the College of Physicians 
Left ventricle, rupture of the 
Lemon-juice in scurvy 
Lentigo 

"Lentigo," etymology of 
Lepra 

arsenic in 
causes of 
characters of . 
contagiousness of 
dulcamara in . 
internal symptoms in 
treatment of . 
varieties of 
" Lepra," etymology of 
Lethargy 

" Leucophlegmatic," etymology of 
" Leucorrhoca," etymology of 
Lichen 

duration of 
local applications in 
progress of 
seat of 

treatment of . 
varieties of 
Ligature, effects of a . 
Limb, paralysis of a . 
Lime, oxalate of 

phosphate of 
Limited duration of life 
Lining membrane of the heart, disease 

of the 
Lithate of ammonia . 
Lithates and phosphates, alternation of 



731 

933 

733 

734 

734 

733 

735 

716 

716 

718 

717 

717 

717 

719 

721 

721 

722 

716 

735 

730 

733 

720 

716 

235 

33 

25 

,918 

918 

626 

627 

626 

627 

626 

627 

27 

26 

862 

231 

467 

467 

404 

405 

405 

404 

405 

405 

405 

405 

404 

404 

619 

524 

938 

369 

369 

370 

369 

369 

370 

369 

103 

682 

992 

992 

33 

831 

991 
990 



1036 



INDEX. 



Lithic acid deposit . . 988, 990 

acidity of . . 989 

causes of . , 988 

colour of . . 989 

diathesis, affection of the 

kidney with . . 995 
causes of . 996 
prognosis of . 995 
symptoms of . 995 
treatment of . 996 
Lithotomy, age most favourable for . 1003 
mortality from . . 1003 
Liver, diseases of the . . . 885 
encephaloid disease of the . 889 
enlargement of the . . 890 
fatty degeneration of the . 889 
- gin or brandy . . . 889 
hydatids in the . . . 890 
inflammation of the . . 885 
melanosis of the . . 889 
morbid appearance of, in remit- 
tent fever . . . 344 
morbid appearance of, in yel- 
low fever . . . 356 
scirrhus of the . . . 889 
scrofula of the . . . 889 
structural disease of the . 888 
suppuration of the . . 885 
worms in the . . . 890 
Local diseases . . . 37,363 
Locked jaw .... 628 
Long-worm . . . . 968 
Louis on phthisis . . . 794 
tubercles . . .105 
Lumbago . . . . 1014 
" Lumbago," etymology of . . 1014 
l^umbricus . . . . 961 
X>unacy . . . . 546 
Lungs, abscess of the . . . 753 
diseases of the . . 701 
effects of disease of the heart 

on the . . . 851 

functional diseases of the . 768 

gangrene of the . . 759 

htemorrhage from the . 761 

hepatization of the " . . 753 

inflammation of the . . 751 

suppuration of the . . . 753 

Lupus ..... 469 

" Lupus," etymology of . . 469 

Luther and the devil . . . 549 

Lymph, discharge of shreds of . . 930 

M. 

Mackintosh, Dr., on bleeding in ague . 270 

JVIad dog, bite of a . * . 646 

Madness .... 546 

Malaria . . . .245 

ancient notices of . . 245 

brutes affected by . . 264 

ctiemical properties of . 260 

classical allusions to . . 245 

diseases rendered intermittent 

by . . . . 264 

distance to whicfi it extends . 253 

elevated situations cxpf)i:ed to 255 

general health aflfcctcd by . 263 

influence of currents on . 255 



Malaria, influence of fire on 


. 259 


night on . 


257 


c plants on 
'^ rain on . 


258 


257 


sea-water on 


258 


smoke on 


259 


soils on . 


258 


low situations exposed to 


256 


not produced by animal matte 


r 259 


peat, bog 


259 


pnrtial influence of 


256 


physical properties of. 


260 


ravages of 


. 264 


" Malaria," etymology of 


44 


Malformations of the nervous system 




causes of . 


540 


Malignant pustule 


449, 455 


contagiousness of 


456 


treatment of 


456 


Mania and melancholia 


553 


suicidal 


559 


" Mania," etymology of 


553 


Marsh-miasma 


245 


Mastication, imperfect 


950 


Maw-worm . . , 


967 


Meals, ancient 


955 


Measles. (See Rubeola.) 


381 


Meat, best kinds of . 


955 


Mechanical injuries . 


47 


Medical books . 


32 


education in England 


26 


lectures in London . 


27 


men, general education of 


30 


schools in England . 


27 


Medullary matter, deficiency of cerebr 


al 539 


" Melancholia," etymology of 


553 


Melgena 


213 


Melanosis 


210 


age liable to 


212 


diflfused 


212 


distinguished from cancer 


210 


encysted 


219 


in a fluid form 


212 


brutes . , 


211 


nature of . 


210 


on false membranes 


212 


mucous membranes 


213 


serous membranes 


212 


surfaces . 


212 


the skin 


213 


parts liable to 


212 


pathology of . . , 


214 


prognosis of 


214 


varieties of . 


211 


" Melanosis," etymology of . 


189 


Membranous transformations . 


185 


" Memoires du Comte de xMaurepas" . 


582 


Meningitis . . . . 


482 


tuberculous 


506 


spinal 


588 


" Meningitis," etymology of . 


483 


" Menorrhagia," etymology of 


142 


Mental aberration 


546 


alienation 


546 


derangement . 


546 


diseases , 


538 


emotions 


47 


faculties, increased power of . 


552 


functions 


538 



INDEX. 



1037 



Mf^ntal irritation, phrenitis from . 491 

Mercury in dropsy . . .173 

inflammation . . 127 

Mery on anatomy . . . 17 

Mfsenteric glands, enlargement of tlie 876 
"Mesentery," etymology of . . 673 

Metallic tiniding ." . . 714 

Metastasis . . . .116 

phrenitis from . . 493 

"Metastasis," etymology of . . 42 

Methodical nosology ... 69 

"Miasm," etymology of . . 245 

Miliaria . . . .408 

causes of . . . 409 

epidemic . . . 409 

treatment of . . .409 

"Miliaria," etymology of . . 408 

Miliary eruption . . . 408 

Millimetre, explanation of the . 204 

Mind, unsoundness of ' . . 538 

Mixed calculus . . " . 993 

inflammation , . . 135 

Moats, exhalations from . . 251 

Moles . . . ■ . . 468 

Monomania .... 549 
"Monomania," etymology of . 553 

Morbus arquatus . . . 891 

regius . . * 891 

Mortification .... 100 
treatment of . . 134 

"Mortification," etymology of , 100 

Mother-marks . . . 468 

Motion, diseases of . . . 620 

Mouth, aflfections of the . . .690 

gangrene of the . . 698 

inflammation of the . . 695 

phagedasna of the . . 698 

pustules of the . . 695 

ulceration of the . . 697 

Mucous follicles, hypertrophy of the . 900 
membrane, atrophy of . 901 

consistence of . 899 
gelatinous softening of 902 
hypertrophy of . 901 
increased redness of 898 
inflammation of 106,900 
influence of age on 89 8 
decom- 
position on 898 
situation 

on . 898 

the gastric 

juice on 899 

natural appearance of 898 

perforation of . 903 

softening of . 901 

thickness of . 899 

ulceration of . 902 

transformations . . 187 

Mucus, characters of . . . 98 

Mulberry calculus . . . 992 

Mumps . • . .690 

Murder by acupuncture . . 1018 

Murder, propensity to , . 553 

Muscae volitantes . . . 948 

"Muscle," etymology of . . 40 

Musk in inflammation . . 134 

Mustard-seeds, concretions from . 933 

Mutability, general law of . . 33 

Myelitis, spinal . « • 589 



N. 



Ngevi . . . . , 468 

Narcotics, phrenitis from , . 491 

Nausea .... 946 

Neck, alterations in the . . 61 

" Necroscopy," etymology of . . 568 

Necrosis . . . .101 

infantilis . . .698 

"Necrosis," etymology of . • 102 

Negative symptoms . . .50 

Nernatoidea . . . . 961 

"Nematoidea," etymology of . 961 

Nephritis . . , .969 

distinguished from rheumi?.tism 969 

treatment of . . 970 

"Nephritis," etymology of . . 969 

Nervous cough . . . 736 

system, diseases of the . 477 

subdivisions of the - 477 

Nettle-rash . . . .377 

Neuralgia . . . . 652 

causes of . . . 654 

decayed teeth in . . 656 

from malaria . . 659 

morbid appearances in . 653 

of the heart . .866 

rheumatic . ' . . 655 

treatment of . . 655 

" Neuralgia," etymology of . . 117 

Nicolai's spectres . . . 547 

Night-blindness . . . 677 

Nightmare . . . . 599 

Nitrate-of-silver, discoloration of the skin 

from . . . .607 

in inflammation . 132 

Noli-mc-tangere . . . 469 

Nomenclature of alkaloids . . 273 

Non-contagious diseases . ' . 42 

Non-naturals , . . . 45 

Norma . . . . 698 

Nosological arrangements . . 69 

Nosology, general ... 40 

methodical ... 69 

" Nosology," etymology of . .39 

Nyctalopia . . . .678 

"Nyctalopia," etymology of . . 226 

" Nycthemeron," etymology of . 267 



O. 



Obstruction, dropsy from . . 152 

Occasional causes ... 44 

CEdema .. . . .147 

(Esophagus, stricture of the . . 694 

"(Esophagus," etymology of . . 399 

Opium, in inflammaliou . . 128 

"Ophthalmia," etymolr>gy of . . 77 

"Opisthotonos," etymology of . 589 

Optic thalami, deficiency of the . 538 

Orbit, alterations in the . . 57 

Organic diseases ... 36 

in inflammation . 132 

of the peritoneum . 879 

skin . . 469 

induration . . .176 

" Ormskirk Medicine" . . 650 

Orthopnoea .... 63 

" Oi Ihopnoea," etymology of . . 63 



1038 



INDEX. 



Osseous transformaliong 


, 


188 


"Ossification," etymology of 


, 


666 


" Otalgia," etymology of 


. 


4.92 


" OtorrhcEa," etymology of 


. 


492 


Ovaries, dropsy of the 


. 


880 


Oxalate-of-liine 


991 


,992 


deposit 




989 


diathesis 


, 


997 


symptoms of 


997 


treatment of 


998 


Oxide, cystic .... 


992 


Oxyuris .... 


962 


"Oxyuris," etymology of 


. 


962 



Pain .... 
characters of 
effect of pressure on 
Palliative treatment 
Palpitation 

of the heart 
Palsies, local . 

Palsy . . . *. . 

Pancreas, absence of the 
diseases of the 
Pancreatic calculi 
'' PapillsB," etymology of 
Papulae 

progress of 
seat of 

termination of 
varieties of 
"PapultE," etymology of 
Paracentesis abdominis 
"Paracentesis," etymology of 
" Paralysie des Aiienes" 
Paralysis . - 

agitans 

in young persons 
pathology of 
treatment of 
causes of . . 

feeling of heat in 
from disease of the nerves 
lead 

treatment of 
intermittent 
local 
of a limb 
the bladder 

causes of 
symptoms of 
treatment of 
of the face . 
spontaneous cessation of 
surgical treatment of 
temperature in 
treatment of 
varieties of 
"Paralysis," etymology of 
Paralytic symptoms, variety in 
Paraplegia . . . . 

causes of . 
from cold . 

disease of the brain 
morbid a{)pearances in 
spasms in . 



52, 77 
78 
78 
66 
847 
856 
676 
659 
884 
882 
. 883 
409 
366 
366 
366 
366 
367 
366 
879 
173 
566 
.659 
620 
622 
621 
621 
663 
660 
682 
918 
918 
662 
676 
682 
1006 
1006 
1006 
1006 
678 
676 
"674 
661 
674 
659 
536 
495 
672 
673 
673 
673 
674 
674 



Parenchymateux . . 961, 963 

Parenchymatous structures, inflammation 

of . . . . .109 

Parkinson, Mr., on the shaking palsy 621 

Parotitis . . . .690 

contagiousness of . . 690 

treatment of . . 690 

''Paroxysm," etymology of . . 39 

Passions, influence of the . . 480 

Passive diseases . . , . 38 

dropsy . . . 150 

hfemorrhage . . 139 

inflammation . . Ill 

treatment of 130 

Pasture lands, aguish nature of . 249 

"Pathognomonic," etymology of . 49 

Pathology . . . .18 

definition of . .36 

general . . .33 

"Pathology," etymology of . . 36 

Pearson, Mr., on the discharge of fat 931 

Peat-bog, properties of . . 259 

Pectoriloquy . . . . 712 

Peculiarities .... 48 

individual . . 68 

Pediculi pubis 

"Peptic," etymology of . 

Perceptions, false 
Perceval, murder of Mr. 
Percussion . . .21 



character of the sounds in 
history of 
mediate 
mode of . 
Pericarditis . . . . 

anatomical characters of 
connection of rheumatism 

with 
physical signs of . 
symptoms of 
treatment of 
Pericardium, adhesions of the 
dropsy of the . 
hiaemorrhage into the 
organic affections of the 
"Pericranium," etymology of 
Periodical diseases 
Period of diseases 

existence limited 
Peripneumonia notha . 
"Peripneumonia," etymology of 
Peritonseum, diseases of the . 

inflammation of the 
organic diseases of the 
"Peritonseum," etymology of . 
Peritonitis 

causes of . 
chronic 

treatment of 
puerperal . 

treatment of 
Pernicious remittent fever 
Perspiration, offensive 
Pertussis 

"Petecliiae," etymology of 
Peyer, glands of 
"Pliarnuicopoeia," etymology of 
Pharyngitis 
"Pharynx," etymology of . 



967 
223 
547 
557 
62, 703 
705 
703 
706 
704 
824 
824 

825 
828 
827 
829 
830 
829 
830 
830 
459 
38 
42 
33 
742 
751 
873 
873 
879 
60 
873 
874 
875 
875 
874 
875 
340 
476 
781 
235 
329 
68 
694 
399 



INDEX. 



1039 



Philip, Wilson, on inflammation 


83 


''Phimosis," etymology of 


977 


•'Phlebolite," etymology of . 


188 


"Phlogistic," etymology of 


51 


"PhlyctEenodes," etymology of 


410 


Phlyz:icium . . . 


417 


"Piilyzacium," etymology of . 


417 


Phosphate, triple 


992 


Phosphutic deposit 


989 


cause of . 


990 


diagnosis of 


990 


diathesis . 


999 


causes of 


1000 


condition of the 




urine in 


1001 


symptoms of 


999 


treatment of 


1000 


sediments from vesical irri 




tation . 


1003 


urine, excess of urea in . 


990 


Phrenitis . . . . 


481 


after exhaustion 


495 


causes of . 


491 


diagnosis of 


493 


distinguished from apoplex^ 


Y 494 


deliriunr 


1 


trerner 


IS 494 


exhaust 


ion 495 


fever 


493 


mania 


493 


worms 


495 


in infancy . 


494 


milder forms of 


484 


morbid appearances in 


486 


prognosis of 


497 


symptoms of . • 


482 


treatment of 


498 


*>Phrenitis," etymology of 


481 


''Phrenology," etymology of . 


557 


Phthisis (pulmonalis) 


785 


ages liable to 


798 


auscultation in 791, 


792, 794 


bathing in . 


803 


causes of . . 


797 


cicatrization in 


796 


cold shower-bath in . 


801 


complications of 


794 


definition of . 


785 


diagnosis of . 


796 


elongation of the uvula in 


805 


empirical remedies in 


805 


evacuation of tubercles in 


797 


haemoptysis in 


789 


hectic in 


790 


hereditary predisposition to 


797 


influence'of clothing on 


798 


cold on . 


799 


contagion on 


799 


exhaustion on 


799 


food on 


798 


mercury on 


800 


other diseases o 


n 800 



powdery substances 
on 

respiratory exertion 
on 

sedentary occupa- 
tions on 

temperature on 



799 

800 

800 
798 



Phthisis, influence of venery on 
wet on . 
inhalations in 
metallic tinkling in 
pathology of 
pectoriloquy in . 792, 

percussion in . 791, 

pneumato-thorax in 
prognosis of 
prophylactics against 
second stage of 
sponging in 
statistics of 
symptoms of 
third stage of 
treatment of 
urgent symptoms in 
varieties in the symptoms of 
warm climate in . 
warm clothing in . 
*' Phthisis," etymology of 
" Physics," etymology of 
Physiology 

of absorption 
" Physiology," etymology of . 
" Phytoseptic," etymology of . 
Pia mater, inflammation of the 
Pica 

" Pica," etymology of . 
" Pigmentares," etymology of. 
Pills retained in the intestines 
" Pineal," etymology of 
Pitcairn, Dr., on pericarditis . 
"Pituitary," etymology of 
Pityriasis 

capitis 
versicolor . 
" Pityriasis," etymology of 
Plague 

at Florence 

contagiousness of . 450, 

history of . 

in London 

nature of 

not communicated by the dead 

infectious . 
treatment of . 
Plato on theoretical philosophy 
Plethora . " . 

" Plethora," etymology of 
Pleura, diseases of the 
inflammation of 
organic affections of the 
ossification of the 
scirrhus of the , 

tubercles in the 

symptoms of 
treatment of 
Pleural friction-sound 
Pleuritis, acute 

distinguished from rhe 

n)atism 
morbid appearances in 
physical signs of 
treatment of . 
chronic 

compression of the 
lungs in . 



800 
799 
804 
793 
786 
793 
793 
797 
796 
800 
790 
803 
800 
788 
790 
800 
805 
791 
802 
801 
785 
62 
18 
150 
36 
245 
487 
945 
945 
468 
933 
603 
826 
461 
403 
403 
403 
403 
449 
305 
452 
450 
451 
454 
453 
450 
453 
20 
46 
41 
807 
807 
822 
823 
823 
822 
822 
623 
714 
807 

807 
809 
808 
809 
810 

812 



1040 



INDEX. 



Pleuritis, chronic, contraction of the 


chest in . 


813 


displacement of the 


liver in . 


812 


empjerna in 


811 


physical signs of 


811 


» Pleuritis," etymology of 


807 


" Pleurodynia," etymology of . 


585 


" Pleurosthotonos," etymology of 


6-28 


Pleximeter 


707 


Plica polonica . 


475 


" Plica," etymology of 


475 


Pneumato-thorax 


817 


causes of 


821 


disiinguished from e 


m- 


physema . 


818 


operation in . 


821 


signs of 


817 


treatment of 


821 


"Pneumato-thorax," etymology of 


817 


Pneumonia 


751 


abscess of the lungs in 


753 


amendment in 


754 


auscultation in 


755 


causes of . 


756, 758 


critical phenomena in 


757 


expectoration in . 


. 752 


first stage of 


752 


hepatization in 


753 


in dropsy . 


169 


lobular 


757 


morbid appearances in 


752 


of children 


757, 759 


of old people 


757 


"* resolution of 


757 


second stage of . 


753 


of sputa in ■ , 


757 


symptoms of 


752, 757 


third stage of 


753 


treatment of 


756, 758 


usual seat of 


754 


•♦Pneumonia," etymology of . 


751 


«' Pneumo-thorax," impropriety of 


21 


Podagra . . . 


1008 


" Podagra," etymology of 


1008 


Poisons .... 


47 


Polystoma pinguicola . 


968 


Polyuria .... 


976 


"Polyuria," etymology of 


976 


Pompholyx .... 


415 


causes of . 


415 


classification of . 


415 


pathology of 


416 


treatment of . 


416 


"Pompholyx," etymology of . 


415 


Porcupine-family 


474 


Porrigo .... 


421 


contagiousness of . 


421 


decalvans 


421 


treatment of 


425 


treatment of . 


422 


varieties of . 


421 


Portio dura, paralysis of the . 


678 


Position in inflammation 


124 


Positive symptoms 


50 


Poyscr, Mr., on hay-asthma . 


774 


Predisposing causes . 


44,47 


Pregnancy .... 


952 


stale of the blood in 


91 



Pressure, curative effects of . 

Prickly heat . 

Primary diseases 

Prince of Coride, insanity of the 

Princess of Brunswick, death of the 

Procatarctic causes 

" Procatarctic," etymology of 

Profluvia 

treatment of 
"Profluvia," etymology of 
Prognosis of diseases . 
" Prognosis," etymology of 
Prophylactic treatment 
" Prophylactic," etymology of 
Prostate, diseases of the 
Prostatic calculus 
Proximate cause 
Prurigo 

causes of 
duration of 
effects of . 

formicans 

local applications in 
mistaken for itch 
mitis . 

progress of . 
senilis 

symptoms of . 
treatment of . 
varieties of 
" Prurigo," etymology of 
Psoriasis, characters of 
inveterata . 
treatment of 
" Psoriasis," etymology of 
Psydracium 

"Psydracium," etymology of 
" Ptosis," etymology of 
"Ptyalism," etymology of 
Puerile respiration 
Puerperal peritonitis . 

treatment of 
Pulmonary apoplexy . 
diseases 

diagnosis of 
functional 
valves, disease of the 
Pulse, examination of the 
in dropsy 

inflammation 
irregularity of the 
preternatural sounds after the 
rate of the 
variations in the 
volume of the . 
Purgatives, irritation from 
Purging in inflammation 
Purpura 

allied to scurvy 
treatment of, 
turpentine in 
"Purpura," etymology of 
Purring thrill . 
Pus, analysis of 
characters of 
formation of 
PuslulsB 
Pustular diseases 

acute 



78 
370 
41 
582 
862 
44 
44 
144 
157 
144 
51 
51 
66 
66 
1006 
993 
43 
370 
372 
372 
372 
371 
373 
373 
371 
370 
371 
370 
373 
371 
370 
406 
407 
407 
406 
417 
417 
678 
125 
709 
874 
875 
764 
701 
701 
768 
833 
60 
155 
121 
60 
842 
60 
60 
59 
124 
124 
466 
466 
467 
467 
466 
848 
99 
98 
100 
417 
4J7 
425 



INDEX, 



1041 



Pustular, chronic diseases . . 417 

Pustule, malignant . . 449, 455 

Pustules of the mouth . . 695 

Putrefaction, conditions necessary to . 247 
temperature necessary for 248 
Putrid animal matter, effects of . 314 

fever . . . .288 

"Pyogenic," etymology of . .97 

Pyrexia . . . .234 

'•Pyrexia," etymology of . ,39 

Pyrosis .... 947 

"Pyrosis," etymology of . . 947 



Q. 



Quinina defeated by gastric irritation 


280 


dose of . . . 


276 


during inflammation 

the paroxysm of ague 
large doses of 


277 
276 
276 


mode of administering 


275 


sudden discontinuance of . 


276 


time for administering 


276 


value of . 


282 


"Quinina," etymology of 
Quotidian ague 
(iuartan ague 


266 
236 
236 



Remittent fever, 



symptoms of 332, 338 

treatment of 337,350 

varieties of 333, 340 

yellov.'nct;s of the skin in 334 



R. 



Rale, bubbling 
cavernous 
crackling 
crepitant 
dry mucous 
mucous 
sibilant 
sonorous 
subcrepitant 
submucous 
whistling 
Rales .... 

dry . 
Rashes 

Rational treatment 
Rattles 

Rayer's classification of cutaneous diseases 
Reaction, excessive 
"Rectum," etymology of 
Red-gown 
Red-gum 
Redncvss 

cadaveric 
parts liable to 
Red-rash 
Regimen 

Relaxation, haemorrhage from 
Remittent fever . . 332, 

aggravated form of 
bilious 
congestive 
causes of 
critical da3's in 
diagnosis of . 
duration of . 333, 

morbid appearances in 
nature of . 332, 



711 
711 
711 
711 
710 
710 
710 
710 
711 
711 
710 
710 
710 
374 

67 
710 
364 
527 

76 
367 
367 

73 

80 
900 
375 

68 
140 
338 
333 
340 
340 
342 
341 
348 
341 
343 
346 



Removal of a tumour, phrenilis from 
Renal capsules, diseases of the 
disturbance in dropsy . 
dropsy 

ages liable to . 
albuminous urine in 
cardiac disease in 
causes of 

cerebral derangement ir 
changes of the bluod in 
complications in 
infljimmation in 
signs of 
urine in 
"Renal," etymology of 
Resolution 

"Resolution," etymology of . 
Respiration, alterations in 

auscultation of the 
blowing . 
bronchial 
cavernous 
murmur of 
puerile 
pulmonary 
vesicular 
Respiratory murmur . 

organs, diseases of the 
sounds 
Retained secretions 
"Retrocedenf," etymology of . 
"Retrograde," etymology of . 
Revaccination 
"Rhagades," etymology of 
Rheumatalgia 
Rheumatic gout 
Rheumatism . 

acute 
atonic 
chronic . 

acupuncture in 
treatment of 
distinguished from gout 
exciting cause of 
infants liable to . 
intermittent 
not confined to joints 
of the cerebral mcmbran 

scalp 
pathology of 
terminations of 
treatment of 
"Rheumatism," etymology of 
Rhonchus (see Rale) . 
Rigiit ventricle, rupture of the 
Rigors from nervous debility . 
stricture 
suppuration 
Ring-worm 
Risus sardonicus 
"Roderick Random" . 
Rollo'd cases of diabetes mellitus 



Koop . 
Roseola 



duration of 



492 

974 

]5(i 

156 

166 

160 

164 

165 

163 

162 

163 

164 

158 

159 

149 

95 

94 

62 

709 

710 

709 

709 

709 

709 ' 

709 

709 

709 

683 

62,63 

46 

42 

42 

443 

406 

1014 

1015 

1013 

1013 

1014 

1014 

1018 

1018 

1013 

1015 

1015 

1015 

](114 

484 

484 

1015 

1015 

1017 

1013 

710 

862 

268 

268 

269 

410 

57 

227, 228 

983 

724 

374 

375 



1042 



INDEX. 



Roseola, treatment of 


375 


Scarlatina, state of the throat in 


394 


varieties of . 


375 


stimuli in . 


395 


"Roseola," etymology of 


374 


symptoms of 


388 


Rose-rash . . . . 


375 


treatment of 


394 


Rubeola . . . . 


381 


varieties of 


388 


catarrhal symptoms in 


383 


Scarlet fever . . . . 


387 


characters of 


38-2 


Scirrhus . . , . 


197 


diagnosis of . 


383 


formation of 


197 


diarrhoea in . 


387 


hereditary predisposition to . 


203 


exciting cause of 


384 


microscopical characters of . 


198 


incubation of 


384 


parts liable to 


200 


nature of . 


381 


softening of 


199 


nigra 


385 


structure of 


197 


predisposing causes of 


383 


termination of 


203 


progress of . 


381 


ulceration of 


199 


pulrida 


385 


" Scirrhus," etymology of 


687 


recession of . 


386 


" Sclerotic," etymology of 


49 


sequelae of . 


383 


Scorbutic pimples 


369 


sine catarrho 


384 


Scot's " Discovery of Witchcraft" 


549 


treatment of . 


386 


Scott's " Demonology and Witchcraft" 


597 


•'Rubeola," etymology of 


3&1 


Scrofula of the mesenteric glands 


876 


Rupia . . . 


420 


Scrofulous diathesis . 


194 


analogous to ecthyma . 


4ao 


Scurf . . . . . 


402 


treatment of . 


421 


Scurvy 


225 


"Rupia," etymology of 


420 


causes of 


226 


Rupture of the heart . 


862 


condition of the system in 


226 


case of . 


• 8r.2 


definition of . 


225 


intestines 


901 


history of . . 


227 


stomach 


908 


in London 


228 


morbid appea 


r- 


lemon-juice in 


231 


ances in . 


909 


nature of 


233 


peritonitis aft 


er 909 


pathology of . • 


225 


treatment of 


909 


prevention of 


229, 232 


Rye, ergot of . 


103 


reappearance of old wounds in 


226 


spurred . 


103 


remedies for . 


229 






symptoms of . 


226 






" Scutulata," etymology of 


421 


• S. 




Scybala 


932 






Seat of diseases 


. 39, 42 






Secondary diseases 


41 


"Sacculus," etymology of 


1005 


Secretions, antagonism of the 


175 


"Sagittal," etymology of 


567 


deficient 


175 


"Saliva," etymology of 


58 


of the skin, diseased 


476 


Salivation, leeches in . 


127 


retained 


46 


in inflammation . 


127 


Sediments, amorphous 


988 


Sawing sound of the heart 


839 


crystallized 


990 


Scabies 


412 


lithic-acid 


988 


" Scabies," etymology of 


413 


oxalate of lime 


989 


Scald-head 


421 


phosphatic 


989 


Scalp, rheumatism of the 


484 


urinary 


. 987 


Scaly diseases 


402 


" Scrotum," etymology of 


469 


Scarlatina ... 


387 


Self-injury, remarkable case of 


564 


ammonia in 


3:)5 


Semeiology 


49 


anasarca in 


396 


" Semeiology," etymology of . 


39 


anginosa . 


390 


Sensation, derangement of 


546 


belladonna in 


396 


Sensations, uneasy 


52 


bleeding in 


394 


Separation of dead parts 


. 101 


causes of . 


392 


Septa in carcinoma 


195 


cold affusion in 


394 


Serous membrane?!, inflammation of 


108 


confounded with measles 


387 


Severity of diseases 


42 


diagnosis of 


392 


Sex .... 


47 


faucium 


391 


Sexual desire, inordinate 


555 


liability to . 


392 


Shakspere on a gaping pig 


778 


maligna 


390 


antipathies . 


778 


prognosis of 


393 


drowning 


695 


prophylactics in 


395 


fever 


235 


recession of 


395 


hysteria 


611 


repeated recurrence of 


392 


insanity 


553 


simplex 


389 


mental imbecility 


541 



INDEX. 



1043 



Shakespereon periods of life 

Shingles 

Ship-fever 

Shock, mental 

physical 
Sibbens 
Sick-headache 

treatment of 
Sight, loss of . 
Signs, abdominal 

stethnscopic 
Simon Browne's "Dedication 
Sinapisms in inflammation 
"Sinapism," etymology of 
Sinking state 
Sir Andrew Ague-cheek 
Size, changes in 
Skin,discolorations of the 

diseased secretions of the 
diseases of the 

appendages of the 
inflammation of the 
organic diseases of the 
universal blackness of the 
Skulls, thick . 
Sleep • 
Small-pox 

ancient opinions on 
causes of 
cicatrices in 

coexistence of measles with 
complications of 
critical days in 
diagnosis of 
epidemic 
eruption in . 
history of . 
incubation of 
influence of inoculation on 
the atmosphere 
mercurial plasters in 
modified by vaccination 
morbid appearances in 
mortality of 
occurring in the foetus 
pits in 

premonitory symptoms of 
treatment of 
Small-Pox-Hospital 
Srnell, loss of . 

Softening . . . 82, 

cadaveric 

effects of . , 

treatment of 
Soils, clayey . 
retentive 
influence of in the production of 
malaria 
Solidism 

Stil-lunar influence 

Solution of Canthiirides 

"Somnambulism," etymology of 

Sounds of the heart, auscultation of the 

causes of abnormc 

the prct( 

nalur 

recent investi 

on the 

respiratory 



40, 



47 
410 
288 
530 
530 
299 
485 
486 
676 
64 
62 
550 
129 
129 
527 
641 
182 
467 
476 
363 
475 
106 
469 
213 
563 
116 
425 
431 
430 
427 
428 
428 
427 
434 
431 
426 
425 
430 
432 
431 
438 
441 
429 
435 
430 
427 
426 
437 
436 
678 
102,178 
180 
180 
180 
251 
251 



lijalion 



on 



258 
317 
337 
130 
599 
846 

1 839 

r- 

1 841 



836 
62,63 



1 Spasm, a cause of fever 


317 


" Spasm," etymology of 


78 


Spasmodic asthma 


733 


cough 


736 


croup 


733 


Spinal system, true 


477 


Spring-eruption 


369 


Spurred rye 


103 


Sputa, phthisical 


789, 790 


pneumonic 


752, 757 


Specific inflammation 


111 


treatmer 


)tof . 135 


remedies in inflamma 


ion . 1 35 


Specimens 


28 


Sphacelus 


101 


" Sphacelus," etymology of 


101 


Spili . 


468 


'•Spilus," etymology of 


468 


Spina bifida 


590 


Spinal apoplexy 


590 


inflammation, causes oi 


583 


morbid e 


ppearances 


in 


589 


sympton 


is of . 588 


treatmen 


t of . 590 


marrow, absence of the 


539 


diseases of th€ 


583 


inflammation 


Dfthe . 588 


irritation 


584 


causes of 


585 


diagnosis of 


. 586 


symptoms of 


584 


treatment of 


587 


system, true 


477 


pathology of 


479 


Spleen, absence of the 


834 


calculi in the . 


884 


congestion of the 


884 


diseases of the 


883 


enlargement of, in agu 


e . 240 


hypertrophy of the 


883 


induration of the 


884 


inflammation of the 


883 


softening of the 


884 


tubercles in the 


884 


Splenitis, chronic 


883 


Sporadic diseases 


41 


" Sporadic," etymology of 


41 


Squamae 


402 


St. Anthony's fire 


. 397 


St. Vitus's dance 


622 


Stagnant water, effects of 


250 


Stealing, propensity to 


554 


Stethoscope 


707 


mode of using the 


708, 846 


use of the 


708 


"Stethoscope," etymology of 


562 


Slcllioscopic signs 


63 


"SUienic," etymology of 


51 


Sties . 


448 


"Stigtna," etymology of 


367 


Slillicidiimi urince 


. 1006 


" Slillicidium," etymology of 


. 1006 


Stimulants in inflammation 


131 


Sloimicace maligna 


699 


Stomacl), diseases of the 


904 


fibrin cfl'iiscd in the 


910 


lifeiiiorrhage from th 


2 . 912 


inflanunalion of the . 


904 



1044 



INDEX. 



rtlie 



Stomach, palholog-y of the 

pus in the coats of the 
rupture of the 
scinhus of the 
structural diseases of the 
ulceration of the 
Stomatitis 

niercurialis . 
ulcerosa 
" Strabismus," etymolog-y of . 
" Slramoniurn," etymology of 
"Strangury," etymology of . 
Slronjryle 
Strophulus 

causes of . 
exposure to cold in . 
treatment of 
varieties of. 
Structural diseases 
Structure, changes of . 

transformations of . 
Students, medical books for . 
Submucous cellular tissue, hypertrophy 
of the 
scirrhus o 
Suicide 

Sulphuric acid in haemorrhage 
Suppers 
Suppuration 

treatment of 
without an abscess 
Surface, alterations in the 
"Suture," etymology of 
Swedenborg, Baron 
Swelling 
Swinc-pock 
Sycosis 

capillitii 
menti . 
" Sycosis " etymology of 
Sydenham treated as a quack 
Sylvius's abuse of Varolius 
Sympathetic inflammation 
Sympathy 

"Sympathy," etymology of 
"Symptomatology," etymolog, 
Symptoms, accidental 
essential . 
nature of . 
negative . 
positive 
"Syncope," etymology of 
Synocha 

" Synocha," etymology of 
Synochus 

"Synochus," etymology of 
System, cerebral 

excito-motory 
ganglionic 
nervous 
true spinal 



T. 

Table of auscultatory sounds 
calculi 
carcinoma 
colloid disease 
cncephaloid disease 
melanosis 



898 
909 
904,908 
910 
910 
908 
695 
696 
697 

57 
608 

53 
963 
367 
368 
368 
368 
367 

36 
176 
184 

32 



y of 



901 

901 

559 

141 

956 

96 

133 

98 

65 

508 

551 

77 

445, 446 

448 

448 

448 

448 

24 

25 

110 

116,950 

116 

39 

49 

49 

49 

50 

50 

121 

288 

288 

288 

288 

477 

477 

478 

477 

477 



715 

993 
197 
209 
209 
211 



Table of scirrhus 

true spinal diseases 
worms 
Taenia 

armed . 
lata 

solium . 
"Taenia," etymology of 
Taint, hereditary 
Talma, death of 
Tape- worm 
Tajiping 

etymology of 



211 

209 

480 

967 

962 

963 

962 

962 

35 

859, 860 

962,986 

879 



" Taraxacum," etymology of . . 423 
Tciste, loss of . . . -678 
Teeth, alterations in the . . 57 
" Temperament," etymology of . 47 
Temperaments . . . 47' 
Temperature .... 34 
morbid sense of . . 660 
Temporary .diseases ... 66 
Tenesmus, treatment of . . 926 
" Tenesmus," etymology of . . 53 
Terminations of inflammation, treat- 
ment of . . . . 133 
Terms, explanation of . . . 39 
Tertian, double . . . 236 
Tetanus .... 628 
amputation in. . . 636 
cases of . . . 635 
causes of . . . 630 
distinguished from hydrophobia 632 
hysteria . 633 
rheumatism 633 
division of the nerves in . 636 
during ague . . . 633 
n)orbid appearances in . 630 
prognosis of . . . 633 
protection of the tongue in . 637 
state of the nerves in . . 630 
symptoms of . . . 629 
treatment of . . . 633 
varieties of . . . 628 
whirling-machine in . . 636 
" Tetanus," etymology of . . 628 
Tetter, running . . . 417 
Theft, monomania of . . . 554 
" Therapeia," etymology of . . 39 
Therapeutics .... 24, 65 
Thirst . . . .954 
Thorax, alterations in the . . 61 
Thread-worm . . . 962,967 
Three-tailed worm . . . 962 
Thrill, purring . . . 848 
Throat, affections of the . . 690 
Thrush . . . .695 
"Thyroid," etymology of . . 545 
Tic douloureux . . . 652 
Tinkling, metallic . . ,714 
Tin-mattress f )r warming patients . 270 
Tongue, alterations in the . . 56 
Tonsillitis . . . .691 
causes of . . . 691 
debility in . . . 693 
gangrene in . . 693 
treatment of . . 692 
ulceration in . . 693 
"Tonsillitis," etymology of . . 691 
Tonsils, enlargement of the . . 693 
Torpidity of the bowels . . 954 



INDEX. 



1045 



991 



"Torticnllis," etymoloo^y of 
" Tourniquet," etymology of 
Tracliea, organic affections of th< 

diseases of the 
Tracheitis (See Croup) 
Trance 

fatal . 
Transformations, cartilaginous 
cellular 
cutaneous 
fibrous 
membranous 
mucous 
of structure 
osseous 
Transudation, cadaveric 
Traumatic delirium 
Treatment, curative 

empirical . 
of diseases (general) 
palliative . 
prophylactic 
rational 
Trematoda 

"Trematoda," etymology of 
Trichocephalus 

"Trichocephalus," etymology of 
Trichoma 

"Trichoma," etymology of 
"Trichuris," etymology of 
Triple phosphate 
" Trismus," etymology of 
Trousseau on chronic laryngitis 
" Tubercle," etymology of 
Tubercles 

ages liable to 
composition of 
consistence of 
deposition of 
encysted 
formation of 
form of 
in brutes 
dropsy . 
the brain 
the spleen 
organs liable to 
pain in 

predisposing causes of 
seat of 
shape of 
situation of 
softening of 
state of the lung around 
not the result ot inflammation 
Tubercular cavities 
eruptions 
infiltration 
Tumours in the brain 

symptoms of . 
Turgescence . * . . 

of the capillaries , 

Turpentine in haemorrhage 
Tussis . . • . 

Tympanites .... 
"Tympanites," etymology of 
Typhoid fever 

distinction between it and ty- 

phus . . 323 to 331 



589 
271 
730 
716 
724 
618 
619 
188 
185 
187 
187 
185 
187 
184 
188 
80 
530 
66 
67 
66 
66 
66 
67 
961 
961 
962 
962 
475 
475 
962 
992 
589 
723 
189 
190 
192 
191 
191 
786 
193 
191 
191 
193 
170 
536 
884 
192 
194 
193 
190 
786 
786, 787 
191,786 
787 
105 
194 
446 
786 
536 
537 
176 
84 
141 
781 
879 
879 
329 



Typhus 


288 


contagion of . 


307 


gravior 


288 


incubation of 


312 


mitior 


288 


sudden cessation of . 


309 


" Typhus," etymology of 


. 288 



u. 



Ulceration, treatment of 


133 


Universal diseases 


216 


University of London, establishment o 




the . . 


27 


Urate of ammonia . . 


991 


Urea, excess of 


990 


in the blood 


162 


Uric acid 


991 


UrinsB stillicidium 


1006 


Urinary calculi 


932, 991 


organs, diseases of the 


969 


sediments 


987 


Urine, acidity of . 


987 


albumen in the 


160 


blood in the, . 


970 


chyle in the 


986 


excess of urea in the . 


985 


fat in the 


986, 987 


fermentation of the 


978 


in renal dropsy 


159 


retention of 


974 


serum in the . 


986 


suppression of , 


974 


temporary excess of . 


976 


vicarious excretion of . 


975 


Urticaria 


377 


causes of 


379 


chronic 


381 


treatment of 


380 


varieties of . 


378 


"Urticaria," etymology of . 


377 


Uvula, elongation of the 


917 


" Uvula," etymology of 


390 



V. 



Vaccination, history of 


443 


mode of 


443 


perfect . 


441 


repeated . 


443 


Vaccine lymph, recurrence to the cow 




for . . 


442 


Vaccina (See Cow-pox) 


438 


Valves, disease of the aortic . 


833 


auriculo- ventri- 




cular 


833 


pulmonary 


833 


of the heart, bone in the 


833 


cartilage in the . 


833 


corrugation of th 


Q 834 


diseases of the 


832 


lymph in the 


835 


rupture of the 


863 


shrinking of the 


834 


warts on the 


834 


Varicella (See Chicken-pock) 


445 


Variola (see Smull-pox) 


425 



1046 



INDEX. 



Variola, confluens 

discreta 
"Variola," etyrnolog'y of 
Varoliup, discoveries of 
" Vascular," etymology of 
Veal-skin 
Venerea! nodes, phrenitis from 
Venesection in inflammation 
"Venesection," etymology of 
Venous haemorrhage . 

system, congestion of the 
Versailles, canal at 
Vertigo from exhaustion 

treatment of 
"Vertigo," etymology of 
" Vesicle," etymology of 
Vesiculae 

Vesicular diseases 
" Vibices," etymology of 
Vicarious discharges . 
Vinegar in sinapisms 
Vision, yellowness of 
Vis medicatrix 
Vitiligo 

" Vitiligo," etymology of 
Voice, alterations in the 

auscultation of the 

loss of . 
Voice-sounds, natural 
Volition, derangement of 
Vomiting 

W. 

Walcheren, expedition to 
Wallenstadt, lake of 



Warm applications in 
Water-brash . 
W^ter-canker 
Water in the brain 
head 
Water-stroke . 



inflammation 



427 
427 
425 

25 
468 
469 
492 
122 
122 
143 
846 
250 
499 
499 

54 
408 
408 
408 
286 
137 
129 
891 

66 
469 
469 

63 
712 
737 
712 
546 
946 



244 

248 
119 
947 
698 
500 
500 
504 



Willan's classification of cutaneous dis. 



Woods, effects of clearing 
Worm, long . 
Worms 

causes of 

cylindrical 

debility favourable to 

dolichos pruriens in . 

intermediate . 

oil of turpentine in . 

pomegranate-root-bark in 

spontaneous cessation of 

symptoms of . 

table of 

treatment 



X. 



Xanthic oxide 



364 
249 
968 
959 
963 
967 
964 
966 
968 
964, 965 
966 
964 
964 
967 
964 



993 



Yaws .... 




299 


Yellow-fever . 




333,354 


alleged contagion 


of 


335 


anatomical characters 


356 


causes of 




335, 359 


climates liable to 




334 


diagnosis 




357 


nature of 




357 


seasons liable to 




334 


symptoms 




354 


treatment 




361 


Yellow vision 




891 


Yellows 




891 



z. 



" Zoster," etymology of 



410 



THE END. 



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Ill 



11 



.liWI 



6 

The alterations that have been made, though few, are such as has been 
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editorship of one who has proved himself well worthy of the office. 

We find some excellent preliminary observations on the means by which 
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then change of structure, and new formations (as scirrhus, tubercles, cancer, 
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study which renders medicine what the ancients were wont to term it; — 
"«rs divina, — a heaven-descended art.'''' — Dublin Medical Press. 

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as a teacher of the principles and practice of medicine; or the judicious 
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himself. He has not overloaded the text with superfluous notes; but has ap- 
pended just so much as was necessary for the purpose of illustration, and to 
fill up some hiatus. He has also considerably improved the language. We 
strenuously recommend the work to all who feel interested in the advance- 
ment of Practical Medicine. — London Medical Gazette. 

The author has been long honourably distinguished as standing in the 
foremost rank of those who have formed a corps of observation for the pur- 
pose of exploring the recesses in which those terrible foes of the human race, 
phthisis and its allies, had hitherto reigned in almost undisturbed dominion. 
His language is simple and nervous, and remarkably free from technicalities, 
and inflated epithets; while his style is of that pleasant, familiar kind — neither 
too bold, nor too florid — which accords well with the subject, and the occa- 
sion. The medical world is under great obligations to Dr. Rogers, for having 
undertaken the editorship of this work. He has evidently bestowed great 
pains in amending the text^^correcting reporters' mistakes, and supplying de- 
ficiencies; — in every way proving himself a faithful Achates. We cannot 
entertain a doubt, that this work — embodying as it does, the mature experi- 
ence of an able and accomplished physician — will be welcomed by all classes 
of the profession. We predict for it a wide circulation, and the warm enco- 
mium of every one who becomes possessed of it. Less than this will not 
be commensurate with its high deserts. — Dublin Journal. 

The best work for the study of diseases is Elliotson's "Principles and 
Practice of Medicine, by Rogers and Lee." — Lancet. 

We strenuously recommend the work to all who feel interested in the 
advancement of Practical Medicine. — Med. Gaz. 



ENCirCLOPEDIAjOF CHEMISTRIT. 

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